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	<title> - EXAMINING THREATS TO WORKERS WITH PREEXISTING CONDITIONS</title>
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	[House Hearing, 116 Congress]
	[From the U.S. Government Publishing Office]


	EXAMINING THREATS TO WORKERS
	WITH PREEXISTING CONDITIONS

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

	HEARING

	BEFORE THE

	COMMITTEE ON EDUCATION
	AND LABOR
	U.S. HOUSE OF REPRESENTATIVES

	ONE HUNDRED SIXTEENTH CONGRESS

	FIRST SESSION

	__________

	HEARING HELD IN WASHINGTON, DC, FEBRUARY 6, 2019

	__________

	Serial No. 116-1

	__________

	Printed for the use of the Committee on Education and Labor

	[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]



	Available via the World Wide Web: www.govinfo.gov
	or
	Committee address: https://edlabor.house.gov


	__________


	U.S. GOVERNMENT PUBLISHING OFFICE
	35-267 PDF WASHINGTON : 2019

	-----------------------------------------------------------------------------------
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	COMMITTEE ON EDUCATION AND LABOR

	ROBERT C. ``BOBBY'' SCOTT, Virginia, Chairman

	Susan A. Davis, California Virginia Foxx, North Carolina,
	Raul M. Grijalva, Arizona Ranking Member
	Joe Courtney, Connecticut David P. Roe, Tennessee
	Marcia L. Fudge, Ohio Glenn Thompson, Pennsylvania
	Gregorio Kilili Camacho Sablan, Tim Walberg, Michigan
	Northern Mariana Islands Brett Guthrie, Kentucky
	Frederica S. Wilson, Florida Bradley Byrne, Alabama
	Suzanne Bonamici, Oregon Glenn Grothman, Wisconsin
	Mark Takano, California Elise M. Stefanik, New York
	Alma S. Adams, North Carolina Rick W. Allen, Georgia
	Mark DeSaulnier, California Francis Rooney, Florida
	Donald Norcross, New Jersey Lloyd Smucker, Pennsylvania
	Pramila Jayapal, Washington Jim Banks, Indiana
	Joseph D. Morelle, New York Mark Walker, North Carolina
	Susan Wild, Pennsylvania James Comer, Kentucky
	Josh Harder, California Ben Cline, Virginia
	Lucy McBath, Georgia Russ Fulcher, Idaho
	Kim Schrier, Washington Van Taylor, Texas
	Lauren Underwood, Illinois Steve Watkins, Kansas
	Jahana Hayes, Connecticut Ron Wright, Texas
	Donna E. Shalala, Florida Daniel Meuser, Pennsylvania
	Andy Levin, Michigan* William R. Timmons, IV, South
	Ilhan Omar, Minnesota Carolina
	David J. Trone, Maryland Dusty Johnson, South Dakota
	Haley M. Stevens, Michigan
	Susie Lee, Nevada
	Lori Trahan, Massachusetts
	Joaquin Castro, Texas
	* Vice-Chair

	Veronique Pluviose, Staff Director
	Brandon Renz, Minority Staff Director


	------


	C O N T E N T S

	----------
	Page

	Hearing held on February 6, 2019................................. 1

	Statement of Members:
	Scott, Hon. Robert C. ``Bobby'', Chairman, Committee on
	Education and Labor........................................ 1
	Prepared statement of.................................... 4
	Foxx, Hon. Virginia, Ranking Member, Committee on Education
	and Labor.................................................. 5
	Prepared statement of.................................... 7

	Statement of Witnesses:
	Corlette, Ms. Sabrina, Research Professor, Center on Health
	Insurance Reforms, Georgetown University Health Policy
	Institute.................................................. 9
	Prepared statement of.................................... 11
	Gupta, Dr. Rahul, Senior Vice President and Chief Medical and
	Health Officer, March of Dimes............................. 42
	Prepared statement of.................................... 44
	Riedy, Mr. Chad, Resident, Alexandria, VA.................... 23
	Prepared statement of.................................... 25
	Turner, Ms. Grace-Marie, President, Galen Institute.......... 30
	Prepared statement of.................................... 32

	Additional Submissions:
	Adams, Hon. Alma S., a Representative in Congress from the
	State of North Carolina:
	Article: House Health Bill Would Lead To Less Coverage,
	Higher Patient Costs................................... 108
	Prepared statement from MomsRising....................... 110
	Article: National Disability Rights Network Opposes
	American Health Care Act............................... 112
	Jayapal, Hon. Pramila, a Representative in Congress from the
	State of Washington:
	Prepared statement from Asian and Pacific Islander
	American Health Forum (APIAHF)......................... 113
	Underwood, Hon. Lauren, a Representative in Congress from the
	State of Illinois:
	Article: Final Rule on Short-term Insurance plans will
	leave Patients With High costs, Less Coverage.......... 118
	Questions submitted for the record by:
	Guthrie, Hon. Brett, a Representative in Congress from
	the State of Kentucky.................................. 121
	Smucker, Hon. Lloyd K., a Representative in Congress from
	the State of Pennsylvania.............................. 121
	Ms. Turner's response to questions submitted for the record.. 122


	EXAMINING THREATS TO WORKERS WITH PREEXISTING CONDITIONS

	----------


	Wednesday, February 6, 2019

	House of Representatives

	Committee on Education and Labor,

	Washington, DC.

	----------

	The committee met, pursuant to notice, at 10:15 a.m., in
	room 2175, Rayburn House Office Building. Hon. Robert C.
	``Bobby'' Scott (chairman of the committee) presiding.
	Present: Representatives Scott, Davis, Courtney, Sablan,
	Bonamici, Takano, Adams, Norcross, Jayapal, Morelle, Harder,
	McBath, Schrier, Underwood, Hayes, Shalala, Levin, Omar, Trone,
	Stevens, Lee, Trahan, Castro, Foxx, Roe, Thompson, Walberg,
	Guthrie, Byrne, Grothman, Stefanik, Allen, Smucker, Banks,
	Walker, Comer, Cline, Fulcher, Taylor, Watkins, Wright, Meuser,
	Timmons, and Johnson.
	Staff present: Tylease Alli, Chief Clerk; Nekea Brown,
	Deputy Clerk; Ilana Brunner, General Counsel; David Dailey,
	Senior Counsel; Daniel Foster, Health and Labor Counsel;
	Mishawn Freeman, Staff Assistant; Alison Hart, Professional
	Staff; Carrie Hughes, Director of Health and Human Services;
	Eli Hovland, Staff Assistant; Eunice Ikene, Labor Policy
	Advisor; Ariel Jona, Staff Assistant; Kimberly Knackstedt,
	Disability Policy Advisor; Stephanie Lalle, Deputy
	Communications Director; Andre Lindsay, Staff Assistant; Max
	Moore, Office Aide; Merrick Nelson, Digital Manager; Udochi
	Onwubiko, Labor Policy Counsel; Veronique Pluviose, Staff
	Director; Banyon Vassar, Deputy Director of Information
	Technology; Joshua Weisz, Communications Director; Cyrus Artz,
	Minority Parliamentarian; Marty Boughton, Minority Press
	Secretary; Courtney Butcher, Minority Coalitions and Member
	Services Coordinator; Rob Green, Minority Director of Workforce
	Policy; John Martin, Minority Workforce Policy Counsel; Sarah
	Martin, Minority Professional Staff Member; Hannah Matesic,
	Minority Legislative Operations Manager; Kelley McNabb,
	Minority Communications Director; Alexis Murray, Minority
	Professional Staff Member; Brandon Renz, Minority Staff
	Director; Ben Ridder, Minority Legislative Assistant; Meredith
	Schellin, Minority Deputy Press Secretary and Digital Advisor;
	Heather Wadyka, Minority Staff Assistant; and Lauren Williams,
	Minority Professional Staff Member.
	Chairman Scott. The Committee on Education and Labor will
	come to order, and I want to welcome everyone to the hearing. I
	note that a quorum is present. The Committee is meeting today
	to hear testimony on examining threats to workers with
	preexisting conditions.
	Pursuant to committee rule 7(c) opening statements are
	limited to the chair and the ranking member. This allows us to
	hear from our witnesses a lot sooner and provides all members
	with adequate time to ask questions.
	I recognize myself now for the purpose of making an opening
	Statement.
	Today we are here to examine the threats to affordable
	healthcare for workers with preexisting conditions. I want to
	welcome our distinguished witnesses for agreeing to be here
	today and to testify on an issue that affects roughly 133
	million Americans across the country.
	On March 23, 2010, President Barack Obama signed the
	Patient Protection and Affordable Care Act into law. Over the
	last 9 years, this historic legislation has improved the lives
	of countless Americans by making insurance more affordable and
	more accessible, while strengthening the quality of health
	coverage and enacting lifesaving consumer protections.
	The Affordable Care Act's success is even more remarkable
	in the context of the persistent attempts to repeal and
	sabotage the law. Since it was passed the House Republicans
	called more than 70 votes to repeal all or parts of the ACA.
	Those efforts were punctuated by the American Health Care Act,
	a bill passed by House Republicans in 2017, which gutted
	protections for patients with preexisting conditions. According
	to the CBO, the repeal bill would have resulted in 23 million
	fewer Americans with health coverage, would have raised
	premiums by 20 percent the first year while providing less
	comprehensive benefits, and would have jeopardized many of the
	consumer protections found in the ACA.
	The Trump Administration has taken an equally aggressive
	approach to undermining the law. For example, the
	Administration has expanded the use of junk plans that roll
	back consumer protections, raise the costs for most consumers,
	and have a troubling record of fraud and abuse.
	On June 19, 2018, the Department of Labor finalized a rule
	to expand association health plans. Under the rule,
	associations can sell coverage to small businesses and self-
	employed individuals without meeting certain ACA standards that
	would otherwise apply, such as: the requirement to cover
	essential benefits, the prohibition against charging higher
	premiums based on factors such as gender or occupation, and the
	age rating limit, which prevents insurers from charging
	unaffordable premiums to older people.
	Extensive research has shown that association health plans
	create a few winners and a lot of losers. A report published by
	the Government Accountability Office in 2000 found that they
	are likely to increase costs for most workers who are not in
	association plans and make it harder for older, sicker workers
	to get affordable care. The prevalence of fraud in these plans
	is equally concerning. A 2004 Congressional Budget Office
	report identified 144 ``unauthorized or bogus'' plans from 2000
	to 2002. Those plans covered at least 15,000 employers and more
	than 200,000 policyholders, and left unpaid medical bills over
	$252 million.
	On August 3, 2018, the Departments of Health and Human
	Services, Labor, and Treasury jointly moved to expand the use
	of short-term health plans. The Departments issued a final rule
	to extend the allowable duration of short-term plans from 3
	months to up to 12 months, with renewability up to 36 months.
	Under the rule the short-term plans do not have include Federal
	consumer protections, including protections for patients with
	preexisting conditions. Because of the risk of confusion and
	overall lack of consumer safeguards, not one single group
	representing patients, physicians, nurses or hospitals voiced
	support for the rule expanding the use of short-term plans.
	The Administration's final and most dangerous attack on the
	ACA is its unusual decision to side with a group of Republican
	attorneys general in a lawsuit against the Federal Government
	seeking to strike the ACA in court. So the Trump Administration
	is effectively arguing that the ACA's consumer protections
	should be invalidated, along with the rest of the law.
	If this ultimately prevails, as it did in the district
	court in Texas, the result would be catastrophic. All
	Americans, whether insured through the ACA marketplace or
	through their employers, would lose the consumer protections we
	all take for granted, including elimination of lifetime and
	annual caps. The prohibition on lifetime and annual coverage
	limits, which protects workers from incurring unreasonable out-
	of-pocket expenses. Before the ACA, more than 90 percent of
	non-group plans had annual or lifetime caps on coverage, and a
	majority of the employer-provided plans imposed lifetime
	limits.
	Cost-sharing protections, the requirement that plans offer
	to limit out-of-pocket costs to an affordable percentage of a
	worker's income, elimination of preexisting health condition
	exclusions, the requirement that all health plans cover
	patients with preexisting conditions at the standard rate. Last
	night I was pleased to hear the President's comment that he
	wants to protect patients with preexisting conditions and end
	the spread of AIDS. As I said, the actions of the
	Administration have jeopardized those protections and people
	with HIV or AIDS who would be excluded from coverage based on
	preexisting conditions if those initiatives succeed. Preventive
	services without cost-sharing, the protection that allows
	workers and families to access vital preventive care without
	paying out-of-pocket expenses. That protection would be
	eliminated.
	While I appreciate that my Republican colleagues are now
	voicing support for many of these protections, their words have
	not translated into actions. On January 9, Democrats voted on a
	resolution to empower the House counsel to intervene in the
	Texas case to defend the ACA and protect people with
	preexisting conditions. Only three House Republicans voted to
	support the resolution.
	There many different views within the Democratic Party and
	across the political spectrum regarding the best path forward
	to further expand affordable care. But we must all commit, both
	with our words and deeds, to maintaining the lifesaving
	consumer protections enacted in the ACA and we must refuse to
	go backward.
	Until efforts to repeal and sabotage this historic
	legislation cease, workers with preexisting conditions will be
	at risk of losing access to the care they need to live healthy
	and fulfilling lives.
	I now recognize the distinguished ranking member for the
	purpose of an opening statement.
	[The statement of Chairman Scott follows:]

	Prepared Statement of Hon. Robert C. ``Bobby'' Scott, Chairman,
	Committee on Education and Labor

	Today, we are here to examine the threats to affordable health care
	for workers with pre-existing conditions. I want to welcome and thank
	our distinguished witnesses for agreeing to be here and testify today
	on an issue that effects roughly 133 million Americans across this
	country.
	On March 23, 2010, President Barack Obama signed the Patient
	Protection and Affordable Care Act into law. Over the past 9 years,
	this historic legislation has improved the lives of countless Americans
	by making insurance more affordable and more accessible, while also
	strengthening the quality of health coverage and enacting lifesaving
	consumer protections.
	Prior to the ACA, Federal law allowed insurers to deny people
	coverage for certain pre-existing conditions, including recently
	treated substance use disorder, pregnancy, and cancer. Prior to the
	ACA, insurers in the individual market could exclude these individuals
	from coverage, charge higher premiums, or put annual or lifetime caps
	of health care coverage.
	According to a 2007 Commonwealth Fund survey, 36 percent of adults
	who attempted to purchase coverage in the individual market reported
	being turned down or charged a higher price because of their medical
	history. The ACA guaranteed access to affordable care for the roughly
	133 million Americans with pre-existing conditions at the standard
	rate.
	By any objective measure, the Affordable Care Act has been a
	success. The uninsured rate, which was 16.7 percent in 2009, fell to
	just 8.8 percent in 2017.
	The ACA's success is even more remarkable in the context of the
	persistent attempts to repeal and sabotage the law. Since it was
	passed, House Republicans have voted more than 70 times to repeal all
	or parts of the ACA. Those efforts were punctuated by the American
	Health Care Act, a bill passed by House Republicans in 2017, which
	gutted protections for patients with pre-existing conditions. According
	to the CBO, the repeal bill would have resulted in 23 million fewer
	Americans with health coverage and would have raised premiums by 20
	percent in the first year while providing less comprehensive benefits.
	The Trump Administration has taken an equally aggressive approach
	to undermining the law. For example, the Administration has expanded
	the use of junk health plans that rollback consumer protections, raise
	costs for all consumers, and have a troubling record of fraud and
	abuse.
	On June 19th, 2018, the Department of Labor finalized a rule to
	expand association health plans. Under the rule, associations can sell
	coverage to small businesses and self-employed individuals without
	meeting certain ACA standards that would otherwise apply, such as: 1)
	the requirement to cover essential health benefits; 2) the prohibition
	against charging higher premiums based on factors such as gender or
	occupation; and 3) the age rating limit, which prevents insurers from
	charging unaffordable premiums to older people.
	Extensive research has shown that association health plans create
	winners and losers. A report published by the Government Accountability
	Office in 2000, found that they are likely to increase costs to some
	workers and make it harder for older, sicker workers to get affordable
	care. The prevalence of fraud in these plans is equally concerning. A
	2004 Congressional Budget Office identified 144 ``unauthorized or
	bogus'' plans from 2000 to 2002, covering at least 15,000 employers and
	more than 200,000 policyholders, leaving $252 million in unpaid medical
	claims.
	On August 3rd, 2018, the Departments of Health and Human Services,
	Labor, and the Treasury jointly moved to expand the use of short-term
	health plans. The Departments issued a final rule to extend the
	allowable duration of short-term health plans from 3 months to up to 12
	months, with plans renewable for up to 36 months. Under the rule,
	short-term plans do not have include Federal consumer protections,
	including protections for patients with pre-existing conditions.
	Because of the risk of confusion and the overall lack of consumer
	safeguards, not one single group representing patients, physicians,
	nurses or hospitals voiced support for the rule expanding the use of
	short-term plans.
	The Administration's final and most dangerous attack on the ACA is
	its unusual decision to side with a group of Republican Attorneys
	General in a lawsuit against the Federal Government seeking to strike
	down the law in court. Specifically, the Trump Administration is
	arguing that the ACA's consumer protections should be invalidated.
	If it ultimately prevails, as it did in a District Court in Texas,
	the result would be catastrophic. All Americans, whether insured
	through an ACA marketplace or through their employer, would lose the
	consumer protections we all take for granted, including:
	Elimination of Lifetime and Annual Caps: The prohibition on
	lifetime and annual coverage limits, which protects workers from
	incurring unreasonable out-of-pocket expenses. Before the ACA, more
	than 90 percent of nongroup plans had annual or lifetime caps on
	coverage, and a majority of employer-provided plans imposed lifetime
	limits.
	Cost-Sharing Protections: The requirement that plans limit out-of-
	pocket costs to an affordable percentage of a worker's income.
	Elimination of Preexisting Health Condition Exclusions: The
	requirement that all health plans cover patients' pre-existing
	conditions.
	Preventive Services without Cost-sharing: The protection that
	allows workers and families to access vital preventive care without
	paying out-of-pocket.
	While I appreciate that my Republican colleagues are now voicing
	support for many of these protections, their words have not translated
	into actions. On January 9, House Democrats voted on a resolution to
	empower the House counsel to intervene in the Texas case to defend the
	ACA and protect people with pre-existing conditions. Only three House
	Republicans votes to support the resolution.
	There many different views both within the Democratic Party and
	across the political spectrum regarding the best path forward to
	further expand access to affordable care. But we must all commit both
	with our words and our actions to maintaining the lifesaving consumer
	protections enacted in the ACA and refusing to go backward.
	Until efforts to repeal and sabotage this historic legislation
	cease, workers with pre-existing conditions will be at risk of losing
	access to the care they need to live healthy and fulfilling lives.
	Thank you and I now yield to the Ranking Member, Dr. Foxx.
	______

	Mrs. Foxx. Thank you, Mr. Chairman. Americans with
	preexisting conditions need health insurance. This is a fact
	and a value that Congress and the President have affirmed
	countless times. It is also the law. Insurance companies are
	prohibited from denying or not renewing health coverage due to
	a preexisting condition. Insurance companies are banned from
	rescinding coverage based on a preexisting condition. Insurance
	companies are banned from excluding benefits based on a
	preexisting condition. Insurance companies are prevented from
	raising premiums on individuals with preexisting conditions who
	maintain continuous coverage.
	So it is perplexing why Committee Democrats are even
	holding this hearing. And by doing so, they are making it about
	threats. Instead, this hearing should focus on how the strong
	economy, with its extraordinary job growth, is increasing the
	number of workers with employer-sponsored health coverage.
	This committee's work on--employer-based health care
	options dates back to when the cost of health care began to
	rise several decades ago. The status quo was not sustainable,
	then and in 2010, the tide took a radical turn for the worse
	with the Affordable Care Act, which decimated options for
	employers earnestly seeking to provide competitive benefits
	packages to recruit and retain workers and sent individual
	premium costs on an even faster upward trajectory. Workers paid
	the price, employers paid the price.
	But, after 8 years of Republican leadership in the House of
	Representatives and the election of President Trump, the U.S.
	economy and job markets are thriving. With consistent wage
	growth and greater availability of highly competitive jobs,
	smart employers are continuing to ensure that they offer
	competitive benefits packages--including sponsored health care
	plans--to recruit and retain workers. And their efforts are
	working.
	According to the Kaiser Family Foundation, 152 million
	Americans--including many who have preexisting conditions--are
	insured through plans offered by their employer. That is the
	majority of the American work force and more than the
	individual market, Medicare, or Medicaid. Since 2013, 7 million
	more Americans have gained employer-sponsored health care
	coverage, with 2.6 million gaining coverage since President
	Trump took office. The plans employers offer are on average
	higher quality and provide better value than what can be found
	on the individual market.
	In 2017, the average premium for individual and family
	employer-sponsored coverage increased by a modest 3 and 5
	percent respectively. In contrast, the average exchange
	premium, Obamacare, went up by roughly 30 percent.
	So, if we are going to have this hearing at all, we welcome
	it as an opportunity to talk once more about the importance of
	making sure American workers have more options, more
	flexibility, and more freedom.
	Last Congress, the Republican-led House of Representatives
	passed the American Health Care Act. The legislation would
	restore stability to the health care marketplace and deliver
	lower costs to consumers. Ensuring protections for individuals
	with preexisting conditions was a central piece of the bill. It
	was Section 137 of the legislation stating: ``Nothing in this
	Act shall be construed as permitting health insurance insurers
	to limit access to health coverage for individuals with
	preexisting conditions.'' So, people may have an opinion, but
	they cannot argue with the facts. The facts are written in this
	legislation--Section 137.
	Republicans on this committee also led the passage of the
	Small Business Health Fairness Act. That legislation would
	empower small businesses to band together through association
	health plans, AHPs, to negotiate for lower health insurance
	costs on behalf of their employees. And last summer, the
	Department of Labor finalized a rule expanding access to AHPs.
	During the 115th Congress, House Republicans also passed
	the Competitive Health Insurance Reform Act and the Committee-
	led Self Insurance Protection Act. What all of these bills have
	in common is their goal to expand coverage, lower health care
	costs for all Americans, and again, give freedom to Americans.
	Committee Republicans welcome this opportunity once again
	to assure Americans with preexisting conditions that their
	coverage is protected.
	House Republicans will continue to champion legislative
	solutions to combat some of the most pressing problems facing
	our healthcare system, including skyrocketing costs, the high
	prices of certain drugs, the industry's lack of cost
	transparency, and the looming threat of a single payer system.
	These are the factors that pose the real threat to Americans
	having options to work for them.
	I yield back, Mr. Chairman.
	[The statement of Mrs. Foxx follows:]

	Prepared Statement of Hon. Virginia Foxx, Ranking Member, Committee on
	Education and Labor

	Americans with pre-existing conditions need health insurance. This
	is a fact, and a value that Congress and the President have affirmed
	countless times. It's also the law. Insurance companies are prohibited
	from denying or not renewing health coverage due to a pre-existing
	condition. Insurance companies are banned from rescinding coverage
	based on a pre-existing condition. Insurance companies are banned from
	excluding benefits based on a pre-existing condition. Insurance
	companies are prevented from raising premiums on individuals with pre-
	existing conditions who maintain continuous coverage.
	So it's perplexing why Committee Democrats are even holding this
	hearing, and by doing so they are trying to make it about threats.
	Instead, this hearing should focus on how the strong economy with its
	extraordinary job growth is increasing the number of workers with
	employer-sponsored health coverage.
	This committee's work on employer-based health care options dates
	back to when the costs of health care began to rise several decades
	ago. The status quo was not sustainable then, and in 2010 the tide took
	a radical turn for the worse with the Affordable Care Act, which
	decimated options for employers earnestly seeking to provide
	competitive benefits packages to recruit and retain workers and sent
	individual premium costs on an even faster upward trajectory.
	Workers paid the price. Employers paid the price.
	But, after 8 years of Republican leadership in the House of
	Representatives, and the election of President Trump, the U.S. economy
	and job markets are thriving. With consistent wage growth and greater
	availability of highly competitive jobs, smart employers are continuing
	to ensure that they offer competitive benefits packages including
	sponsored health care plans to recruit and retain workers.
	And their efforts are working. According to the Kaiser Family
	Foundation,
	152 million Americans--including many who have pre-existing
	conditions--are insured through plans offered by their employer. That's
	the majority of the American work force, and more than the individual
	market, Medicare, or Medicaid.
	Since 2013, 7 million more Americans have gained employer-sponsored
	health care coverage, with 2.6 million gaining coverage since President
	Trump took office. The plans employers offer are, on average, higher
	quality and provide better value than what can be found on the
	individual market.
	In 2017, the average premium for individual and family employer-
	sponsored coverage increased by a modest 3 and 5 percent, respectively.
	In contrast, the average Exchange premium Obamacare went up by roughly
	30 percent.
	So, if we are going to have this hearing at all, we welcome it as
	an opportunity to talk once more about the importance of making sure
	American workers have more options, more flexibility, and more freedom.
	Last Congress, the Republican-led House of Representatives passed
	the American Health Care Act. The legislation would restore stability
	to the health care marketplace and deliver lower costs to consumers.
	Ensuring protections for individuals with pre-existing conditions was a
	central piece of the bill with Section 137 of the legislation stating:
	``Nothing in this Act shall be construed as permitting health insurance
	issuers to limit access to health coverage for individuals with
	preexisting conditions.''
	So, people may have an opinion, but they cannot argue with the
	facts, and the facts are written in this legislation. Section 137.
	Republicans on this committee also led the passage of the Small
	Business
	Health Fairness Act. That legislation would empower small
	businesses to band together through association health plans (AHPs) to
	negotiate for lower health insurance costs on behalf of their
	employees, and last summer, the Department of Labor finalized a rule
	expanding access to AHPs.
	During the 115th Congress, House Republicans also passed the
	Competitive Health Insurance Reform Act and the committee-led Self-
	Insurance Protection Act. What all of these bills have in common is
	their goal to expand coverage, lower health care costs for all
	Americans, and again, give freedom to Americans.
	Committee Republicans welcome this opportunity once again to assure
	Americans with pre-existing conditions that their coverage is
	protected. House Republicans will continue to champion legislative
	solutions to combat some of the most pressing problems facing our
	health care system, including skyrocketing costs, the high prices of
	certain drugs, the industry's lack of cost transparency, and the
	looming threat of a single-payer system. These are the factors that
	pose the real threat to Americans having options that work for them.
	______

	Chairman Scott. Thank you. Without objection, all the
	members who wish to insert written statements to the record
	should do so by submitting them to the committee clerk
	electronically in Microsoft Word format by 5 p.m. February 19,
	2019.
	I will now introduce our witnesses.
	Our first witness will be Sabrina Corlette, a research
	professor at the Center on Health Insurance Reforms at
	Georgetown University's McCourt School of Public Policy where
	she directs research on private health insurance and market
	research. Prior to joining Georgetown faculty she was the
	director of health policy programs at the National Partnership
	for Women and Families where she focused on insurance market
	reform, benefit design, and the quality and affordability of
	healthcare. She is a member of the Washington, DC Bar
	Association.
	Chad Riedy is 37 years old, has cystic fibrosis. He lives
	in Alexandria, Virginia with his wife, Julie, and two sons. In
	addition to volunteering for the Cystic Fibrosis Foundation he
	has spent the last 13 year working in the real estate industry.
	Grace-Marie Turner is president of Galen Institute, a
	public policy research organization she founded in 1995 to
	promote free market ideas for health reform. She has served as
	a member of the Long-term Care Commission, the Medicaid
	Commission, the National Advisory Board for the Agency for
	Healthcare Research and Quality. Prior to founding the Galen
	Institute she served as executive director for the National
	Commission on Economic Growth and Tax Reform.
	Dr. Rahul Gupta is the senior vice president and chief
	medical and health officer for the March of Dimes. He is one of
	the world's leading health experts. In his role Dr. Gupta
	provides strategic oversight for the March of Dimes' medical
	and public health efforts to improve healthcare for moms and
	babies. Prior to joining the March of Dimes he served under two
	Governors as West Virginia's health commissioner, and as the
	chief health officer he led the State's opioid crisis response
	efforts and several public health initiatives.
	We appreciate all of the witnesses for being here today and
	look forward to your testimony. Let me remind the witnesses
	that we have read your written statements and they will appear
	in full in the hearing record. Pursuant to committee rule 7(d),
	the committee, and committee practice, each of you will be
	asked to limit your oral presentation to a 5-minute summary of
	your written Statement.
	Let me remind the witnesses that pursuant to Title 18 of
	the U.S. Code Section 1, it is illegal to knowingly and
	willfully falsify a Statement, representation, writing
	document, or material fact presented to Congress or otherwise
	conceal or cover up a material fact.
	Before you begin your testimony please remember to press
	the button on your microphone in front of you so that it will
	be turned on and the members can hear you. As you begin to
	speak the light in front of you will turn green, after 4
	minutes the light will turn yellow to signal you have 1 minute
	remaining. When the light turns red we ask you to summarize and
	end your testimony.
	We will then let the entire panel make their presentations
	before we move to member questions. When answering a question
	please remember once again to turn your microphone on.
	I will first recognize Ms. Corlette.

	TESTIMONY OF SABRINA CORLETTE, RESEARCH PROFESSOR, CENTER ON
	HEALTH INSURANCE REFORMS, GEORGETOWN UNIVERSITY HEALTH POLICY
	INSTITUTE

	Ms. Corlette. Thank you, Mr. Chairman. Ranking Member Foxx,
	members of this committee, it is really an honor to be here
	with you today and to discuss the need for affordable, adequate
	insurance coverage, particularly for those with preexisting
	conditions.
	In my testimony I will focus on some of the challenges
	faced by people with preexisting conditions before the ACA was
	enacted and how current threats to the ACA could have
	disproportionately harmful effects on these individuals and
	workers.
	Before the ACA was enacted roughly 48 million people lacked
	health insurance and an estimated 22,000 died prematurely each
	year due to being uninsured. 60 percent of the uninsured
	reported having problems with medical debt. The high number of
	uninsured was costing providers an estimated $1,000 per person
	in uncompensated care costs. The lack of affordable adequate
	coverage also led to a phenomenon called ``job lock'', where
	workers are reluctant to leave the guarantee of subsidized
	employer-based coverage for the uncertainty of the individual
	market. And for many people with health issues job-based
	coverage could also be spotty or include barriers to enrolling.
	Prior to the ACA, in most States, people seeking health
	insurance could be denied a policy or charged more because of
	their health status, age, or gender, or have the services
	needed to treat their condition excluded from their benefit
	package. Indeed, a 2011 GAO study found that insurance
	companies denied applicants a policy close to 20 percent of the
	time. Under the ACA these practices are prohibited.
	Prior to the ACA coverage also could come with significant
	gaps, such as for prescription drugs, mental health, and
	substance use services and maternity care. Under the ACA
	insurers must cover a basic set of essential benefits.
	Extremely high deductibles and annual or lifetime limits on
	benefits were also common before the ACA. The law protects
	people from both by capping the annual amount paid out-of-
	pocket each year and prohibiting insurers from placing
	arbitrary caps on coverage.
	Members of this committee are aware that the ACA is now
	under threat of being overturned due to pending litigation in
	Federal court. If the plaintiffs' argument prevails it would be
	tantamount to repealing the ACA without any public policy to
	replace it. And this is a scenario that Congress rejected in
	multiple votes in 2017. Congress rejected it because repealing
	the ACA without replacing it would result in 32 million
	Americans losing insurance, double premiums for people in the
	individual insurance market, leave an estimated three-quarters
	of the Nation's population in areas without any insurer, cause
	a significant financial harm for hospitals and other providers
	due to uncompensated care costs, cause the loss of an estimated
	2.6 million jobs around the country, and importantly for this
	committee, result in harm to people with job-based covered,
	including the loss of coverage for preventative service without
	cost-sharing, such as vaccines, well visits, and contraception,
	the return to preexisting condition exclusions, young adults no
	longer allowed to stay on their parents health plans, and
	insecurity due to crippling out-of-pocket costs for people with
	high cost conditions.
	This Administration has also instituted regulatory changes
	that have resulted in higher premiums for people in the
	individual market. These include the decision to cut off a key
	ACA subsidy, the dramatic reduction in outreach and consumer
	enrollment assistance, and the introduction of junk insurance
	policies that are permitted to discriminate against people with
	preexisting conditions. The zeroing out of the mandate penalty
	has also increased premiums.
	While the bulk of the negative effects of these policies
	are felt by people in the individual market, these negative
	effects spill over into the job-based market. The ACA is by no
	means perfect. Even its most ardent supporters argue that more
	could be done to expand Medicaid and improve affordability for
	middle class families. There are a range of policy options that
	this committee and others can explore to strengthen the law's
	foundation while also building on its remarkable achievements.
	Thank you for providing this forum and I look forward to
	the discussion.
	[The statement of Ms. Corlette follows:]
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	Chairman Scott. Thank you. Mr. Riedy?

	TESTIMONY OF CHAD RIEDY, RESIDENT, ALEXANDRIA, VIRGINIA

	Mr. Riedy. Good morning. Thank you, Chairman Scott, Ranking
	Member Foxx, and distinguished members of the committee for
	inviting me to testify today.
	I would also like to thank my wife, Julie, and my parents
	for being here today and for their support.
	My name is Chad Riedy and I have cystic fibrosis. I would
	like to share my story of what living with CF is like and what
	the protections in the ACA mean to me and millions of other
	Americans living with chronic health conditions. CF is a rare
	genetic disease that affects about 30,000 people in the U.S.
	and causes a thick, sticky mucus to buildup in the airways
	causing infections. There is no cure for CF.
	When I was diagnosed in 1984 at 3 years old, my parents
	were told that they should not expect me to live to age 12.
	Today I sit here at 37. I have been married for 12 years and a
	father of our 2 boys, Liam, who is 8, and Tate, who just turned
	7.
	Let me tell you what it is like to live with CF. Every day
	I take 30 pills to help me breathe, digest food, and reduce
	inflammation in my lungs. I also take inhaled medicines and use
	a vest that shakes loose mucus in my lungs. Four times a year I
	go through a lengthy evaluation process with a team of doctors
	at Johns Hopkins. I do this to keep my lungs well enough to
	keep me alive. But I will never have the lung capacity of any
	of you sitting here today.
	When I was 26 I got really sick for the first time. My wife
	and I had just returned from our honeymoon when I started to
	notice that I was having a hard time breathing performing
	normal, routine activities, like walking up stairs or talking
	on the phone. After a visit to my care team I was admitted
	immediately to the hospital, where I stayed for 7 days
	receiving intravenous antibiotics, chest physical therapy, and
	other procedures to stabilize my health. While my healthcare
	was covered under my employer-based insurance plan, when I
	returned home I received constant reminders about how close I
	was to hitting my lifetime and annual caps. Before the ACA
	banned these practices I would stay awake wondering would I
	exceed my limits or be denied coverage, then what, how would I
	pay for these things?
	The next time, in 2014, when I got very sick again, over 8
	months my lung function, which had been stable for 7 years,
	declined dramatically. I was so sick that not only was I
	missing work, I could not walk 10 feet across our living room
	floor without having to stop and catch my breath. I struggled
	to carry my kids, who at the time were four and one. Things
	progressed to the point where we started to have conversations
	about needing a lung transplant just to stay alive. Thankfully,
	because the ACA was in place, I could focus on making a strong
	recovery instead of the financial hardships from all these
	medical bills.
	In January 2018 I started on a drug that has changed my
	life called SYMDEKO. It treats the underlying cause of my CF,
	not just the symptoms. It has brought more stability to my lung
	function, but most importantly it has allowed me to be a better
	husband, father, and friend. I no longer worry when carrying
	laundry up a couple flights of steps from the basement. And
	when my boys are tired and want a piggyback ride or need extra
	love, daddy is there for them.
	My treatments and care help me breathe a little easier and
	stay healthy so that I can work to help provide for my family,
	but they are expensive. In 2018 the total cost of all my
	medicines was about $450,000. This does not include my care
	team, visits to them, or other procedures. While we spend a lot
	out of pocket, I am thankful that our insurance covers most of
	these.
	This is my story and there are so many more like it across
	the country. For people battling rare and chronic disease, the
	policies we are discussing today are a matter of life and
	death. If the Judge's ruling against the ACA stands and
	insurance companies are allowed to implement annual and
	lifetime caps I would reach them in a matter of years and be on
	the hook for unimaginable financial costs. In addition, the cap
	on out-of-pocket sharing is vital for someone like me.
	I am grateful that I have coverage that allows me to access
	a great team of doctors and cutting-edge medicines that help me
	fight this disease. Because of this I have hope, hope for a
	future where I grow old with my wife, see my kids grow up,
	graduate college, get married, and start families of their own.
	I am not asking for you to take care of me, I do that
	myself. I also understand that the ACA is not perfect, but the
	protections it contains are critical to me and millions of
	other Americans with preexisting conditions.
	I thank the committee for giving me the opportunity to
	share my story and I ask that you are to keep our hope alive as
	you consider legislation this Congress.
	Thank you.
	[The statement of Mr. Riedy follows:]
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	Chairman Scott. Thank you, Mr. Riedy. Ms. Turner?

	TESTIMONY OF GRACE-MARIE TURNER, PRESIDENT, GALEN INSTITUTE

	Ms. Turner. Thank you, Chairman Scott, Ranking Member Foxx,
	and members of the Committee for inviting me to testify today.
	At the Galen Institute we focus on ways to ensure
	affordable health coverage to all Americans, particularly
	protection for the most vulnerable. I am really pleased to be
	on the panel with Mr. Riedy, and thank you for so bravely
	sharing your story. I am thankful for the health care system
	that supports your care and for continued innovations so new
	treatments can be available.
	Today in my testimony I am going to discuss the centralrole
	that the employer health insurance market plays in our health
	sector, new opportunities to reduce costs and expand access to
	coverage, and bipartisan support for preexisting condition
	protections, and the need for further improvements.
	Nine out of ten workers are employed in the U.S. by
	companies that offer health insurance. These benefits are tax
	free, both to workers and companies, a generous benefit but one
	that leverages nearly $3 in private employer spending for every
	$1 in Federal tax revenue losses. Employers and employees want
	the best value for their health care dollar and often work very
	hard to balance cost and quality.
	Long before the ACA, employers offered preventative
	services because they know that addressing health issues before
	they become a crisis can lead to better outcomes and minimize
	costs. These employers also play a vital role in supporting our
	health sector. Physicians and hospitals are paid much less
	under Medicare and Medicaid than under employer plans, and
	because private insurance pays more, they provide the margins
	that allow many hospitals and providers to stay in business.
	Leading proposals to expand Medicare coverage to all Americans
	would extend these public disbursement rates universally,
	diminishing quality and access to care.
	The Trump administration is offering several options
	through its regulatory authority to help individuals and
	employees with more affordable coverage. The Chairman mentioned
	one of them, including association health plans. They allow
	small firms to group together to get some of the same benefits
	that large employers have. A Washington Post story just
	reported on a new study showing that AHP benefits are
	comparable to most workplace plans and plans are not
	discriminating on patients with preexisting conditions. They
	also have new flexibility under Section 1332 of the ACA to
	lower costs through risk mitigation programs. They separately
	subsidize patients with the highest cost, lowering premiums for
	others, and leading to increased enrollment. In Alaska,
	premiums for the lowest-cost bronze plan fell by 39 percent in
	2018 and Maryland is seeing an even larger drop this year.
	Putting the sickest people in the same pool with others
	means that their premiums are higher. Virginia Senator Bryce
	Reeves talked with one of his constituents recently who said he
	makes a good living, provides for his family, but he said his
	health insurance premiums are $4,000 a month. And he said that
	is more than my mortgage, and really pleading for help.
	Unfortunately, many healthy people are dropping out of the
	market because costs are so high.
	There is strong bipartisan support for preexisting
	condition protections. The ACA assures people cannot be turned
	down or have their policies canceled because of their health
	status, and these protections are still in place. Legislation
	passed by the House of Representatives maintained preexisting
	condition protection. But they do not work for everyone.
	Janet--did not use her last name--reported that she was
	diagnosed in 1999 with Hepatitis C. She lives in Colorado and
	applied for coverage in the State's high-risk pool. Her
	premiums in 2010 were $275 a month. Then her liver failed. She
	needed a transplant. The $600,000 bill was covered 100 percent
	with only $2,500 out-of-pocket. Colorado's high-risk pools
	closed when the ACA started in 2014. Her premiums rose to $450.
	By 2018 they were $1,100 a month. The deductible was $6,300.
	But her anti-rejection medications were not covered. She said
	almost everything I needed was denied, which threw me into a
	world of having to appeal to get the care I needed. She said
	those of us who are self-employed and are not eligible for tax
	credits wind up footing way too much of the bill. She said her
	costs are $19,000 a year before insurance pays and she has to
	pay extras for her medication. She keeps her insurance because
	if something else happened, and her liver failed and she needed
	another transplant, she said it would bankrupt my family.
	I hope to work with you to achieve the goals of better
	access to more affordable coverage and better protection with
	those with preexisting conditions.
	Thank you for the opportunity to testify today.
	[The statement of Ms. Turner follows:]
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	Chairman Scott. Thank you. Dr. Gupta, before you start I
	think I need to give full disclosure. I have been an active
	member of the--volunteer for the March of Dimes for several
	decades. So I appreciate your testimony.

	TESTIMONY OF RAHUL GUPTA, SENIOR VICE PRESIDENT AND CHIEF
	MEDICAL AND HEALTH OFFICER, MARCH OF DIMES

	Dr. Gupta. Thank you for being an active member, Mr.
	Chairman, and thank you, along with Ranking Member Foxx and
	members of the committee, for the opportunity to testify today.
	My name is Rahul Gupta, I am the senior vice president and
	chief medical and health officer at the March of Dimes. In
	addition to my role representing the March of Dimes I also
	bring perspective from my experience as a practicing physician
	and as a former State health commissioner and a local health
	officer.
	As a primary care physician, it was not uncommon for me to
	treat women who were struggling with high costs of employer-
	based health insurance or priced out of coverage altogether due
	to their preexisting conditions. These women were in the
	impossible condition of having to make choices between getting
	the care they needed and affording their families' basic
	necessities, such as food and prescription medications.
	Preexisting conditions are common among Americans. Six in every
	ten American adults in the U.S. has a chronic disease, and four
	in ten have two or more.
	Chronic conditions, such as high blood pressure, diabetes,
	heart disease, and obesity can have tragic consequences for
	women during pregnancy. Each day in the United States more than
	two women die of pregnancy-related causes, and more than 50,000
	have severe pregnancy complications. More American women are
	dying of pregnancy-related complications than any other
	developed country in the world, and it is not getting any
	better.
	As pregnancy or childbirth are also widely considered
	preexisting conditions the prevalence of at least one
	preexisting condition in this population is almost universal.
	If conditions like preterm birth, birth defects, or neonatal
	abstinence syndrome, are considered tens of millions of
	children could be subject to insurance discrimination
	throughout their lives. The Affordable Care Act contains a
	range of provisions to help ensure comprehensive, meaningful,
	and affordable coverage for women, children, and their
	families. Amongst its most important popular provisions is the
	requirement that health plans cover all individuals regardless
	of preexisting conditions. The law ensures that all American
	can obtain coverage without worrying that they will be subject
	to discrimination, whether outright denial of coverage, or
	carve-outs of the benefits they need the most.
	It is difficult for me to overstate the importance of ACA's
	requirements that all plans cover the 10 essential health
	benefits, including maternity care.
	The ACA has also addressed a range of issues related to
	affordability of coverage. Cost has historically been and
	remains one of the greatest barriers to care. If people are
	unable to afford coverage, healthcare becomes all but
	inaccessible. Under the ACA, policies sold on the individual
	and small group markets are prohibited from charging women high
	premiums. Health plans can no longer impose annual or lifetime
	caps. In the case of maternal and childbirth and child health,
	these caps could be financially devastating.
	A woman, for example, with a high-risk pregnancy and
	delivery could easily exceed an annual cap, leaving her unable
	to obtain needed care for the rest of the year. Worse, a baby
	born extremely preterm, who needs months of care in the
	neonatal ICU, could exhaust a lifetime cap before even coming
	home.
	This triad of preexisting condition protections, essential
	health benefits, and affordability provisions represent a
	three-legged stool that supports access to comprehensive
	quality and affordable coverage for all Americans. All three of
	these legs must be maintained to protect and promote our
	Nation's health, especially the health of women, children, and
	families.
	March of Dimes is deeply troubled by Texas v. U.S. This
	lawsuit appears to have been undertaken as a legal exercise
	divorced from any real appreciation of its ramification for
	millions of Americans and their health and wellbeing. With the
	recent decision of the Federal court judge to declare ACA
	unconstitutional in its entirety, the plaintiffs appear to be
	in a classic situation of the dog that caught the car. They
	were caught off guard by their own victory and now are unsure
	how to explain that they have argued for an action that will
	cost millions of Americans their health coverage and
	potentially even their lives.
	In addition, we are deeply concerned about efforts by the
	Administration to promote access to short-term, limited
	duration insurance plans. These plans are not required to cover
	essential health benefits, including maternity care, mental
	health, and substance use treatment, and could again exclude or
	charge patients more based on their preexisting conditions.
	Whatever changes may be undertaken to our Nation's health laws
	and systems, they must be made with the express goal of
	improving access to coverage and care that is accessible,
	comprehensive, and affordable.
	In essence, this concept is no different than when I am
	seeing a patient in my office. I endeavor to provide her with
	the highest quality care in a compassionate manner, keeping in
	mind that she should not have to sacrifice her next trip to the
	grocery store in exchange. I sincerely hope that we can provide
	the same guarantee to all Americans.
	Thank you for holding this meeting, and I look forward to
	any questions.
	[The statement of Dr. Gupta follows:]
	[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]


	Chairman Scott. Thank you, thank you. And now we will have
	our members ask questions. First, I am going to defer on my
	side, and the gentleman from Connecticut, Mr. Courtney.
	Mr. Courtney. Thank you, Mr. Chairman. And, again, I want
	to applaud the fact that we are holding this hearing in this
	committee. Back in 2009 and 2010, when the Affordable Care Act
	was crafted with three different committees, it was our
	committee which led the way in terms of preexisting conditions
	and all the patient protections, because we have jurisdiction
	over ERISA. So, again, we actually were the place where the law
	was written that was, in my opinion, you know, one of the great
	steps forward of our Nation in terms of social and civil
	rights.
	You know, again, Ms. Corlette talked about what the
	landscape looked like back in 2009 and 2010. I brought along a
	flyer that was being sold to a lot of businesses, which again,
	brings back the bad old days. Again, it is a health plan where
	it is touted as great news for people who buy their own health
	insurance, a flexible health plan, affordable. However, if you
	flip to the back, it had sort of in the smaller print the fact
	that they may not be able to cover people who have ever had
	treatment for the following, AIDS, alcohol or drug dependence,
	cancer, COPD, connective tissue disorder, Crohn's disease,
	diabetes, emphysema, heart attack or stroke, hepatitis,
	inpatient emotional or mental illness, organ or tissue
	transplant, or colitis. So if you are like an episode of
	survivor and you are not in that category, however, you are
	still not out of the woods yet because it also says that other
	individuals who are obese, underweight, have undergone
	diagnostic tests for a whole variety of different illnesses, as
	well as expectant parents or children less than 2 months old
	are also not going not be able to take advantage of that
	policy. And, last, it says this list is not all inclusive.
	Other conditions may apply.
	So, I mean that is what health insurance looked like until
	President Obama signed the Affordable Care Act in March 2010,
	which once and for all abolished this whole type of medical
	underwriting practice. And, again, it was also architecture
	that was built around it to make that meaningful, such as
	essential health benefits, the lifetime caps, which Mr. Riedy
	so powerfully testified to, adjusted community rating so that
	older people can't be charged more than three times a younger
	individual.
	So, again, regarding the Texas case, as Dr. Gupta said, I
	mean there is absolutely no question that the Justice
	Department, which participated with the plaintiffs and did not
	defend the Department of Health and Human Services, if that
	ruling were to stand, again, that would just take a wrecking
	ball to the whole architecture, again, that was built. Is that
	correct, Ms. Corlette?
	Ms. Corlette. That is correct. For the plaintiff States, if
	their position prevails the entire law would be invalidated.
	Mr. Courtney. And in terms of some of the other changes
	that they have made through the regulatory process, the
	association health plans, which, again, on surface sounds
	great, that small businesses can team together in different
	sectors and go out and buy collectively. By the way, that was
	totally legal prior to the Trump Administration's ruling and
	there were about 600 association health plans across the
	country. What the ruling really did was it basically allowed
	those plans to avoid, again, a lot of these patient
	protections, such as essential health benefits, which were
	painstakingly designed with the Institute of Medicine in terms
	of what is healthcare and what should health insurance be, and
	lifetime caps, et cetera.
	So, again, I just wonder if you could sort of focus on that
	point, that the Administration, again, is in fact undermining
	preexisting conditions and preexisting condition protections
	with those types of regulatory actions.
	Ms. Corlette. That is absolutely correct. Groups of
	employers have always been able to join an association and
	offer benefits if they choose to do so. What the Administration
	is encouraging is arrangements that essentially are allowed to
	cherry pick the healthiest and youngest employer groups out of
	the regulated market and thereby gain a pricing advantage.
	Mr. Courtney. And the short-term plans, Dr. Gupta, you
	mentioned, again, it is the same story, that it is really a
	device to avoid again the protections that were built into the
	Affordable Care Act.
	Dr. Gupta. That is very true. And along with that, the
	other part of this is the medical loss ratio that was built
	into the ACA and that is not subject to in the short-term
	plans. So they can have as much as 50 percent medical loss
	ratio and actually profit disproportionately out of--
	Mr. Courtney. And the short-terms plans are really not that
	short. Again, when the prior Administration allowed for a very
	short, short-term plan, these now almost are basically going to
	be sold for an entire year. Isn't that correct?
	Dr. Gupta. Correct. They could be sold for about 364 days
	and then renewable afterwards.
	Mr. Courtney. So, I mean it is basically a whole new
	product. And, again, we would see the bad old days in terms of,
	you know, this type of laundry list of fine print where people
	are going to have a rude awakening when they thought they had
	insurance and in fact it was totally useless and meaningless.
	I yield back.
	Chairman Scott. Dr. Foxx.
	Mrs. Foxx. Thank you, Mr. Chairman. Ms. Turner, people
	living with preexisting conditions, such as cancer, diabetes,
	or other illnesses face an incredibly difficult battle each and
	every day. And, in particular, I commend Mr. Riedy for his
	strength and courage to share his story with us today. People
	should not worry about having their coverage denied because of
	a medical condition when they should be focused on getting well
	and managing their quality of life. That is why congressional
	Republicans have voted time and time again to protect
	preexisting condition protections.
	Ms. Turner, are these protections under current law
	sufficient to protect access to coverage for the most
	vulnerable healthcare consumers, and do you agree that these
	protections should be maintained?
	Ms. Turner. The protections absolutely should be
	maintained. But I do believe that we do have to address the
	issue of cost because many people who need coverage are not
	able to afford it and then are completely, completely exposed.
	So I believe that the preexisting conditions that are in law
	today and that the House of Representatives supported in the
	American Health Care Act were important, will continue to be
	important. I see the strong support, both in Congress and with
	the American people, to maintain those protections.
	Mrs. Foxx. Thank you, Ms. Turner. Because of policies
	enacted by the previous House Republican majority and
	regulatory actions taken the by Trump administration our
	economy is thriving. As I mentioned, the economy added 304,000
	jobs last month, almost double what economists were expecting.
	As a result, the number of individuals with employer sponsored
	coverage has grown by nearly 7 million since 2013, with 2.6
	million gaining coverage since President Trump took office. How
	does strong economic growth contribute to more workers gaining
	health insurance from their employers?
	Ms. Turner. Virtually all employers want to offer health
	insurance to their employees, but many smaller businesses, in
	particular, just can't afford it, both because of the
	regulatory burdens as well as the cost. The Trump
	administration is giving them some new options, both with
	association health plans and with health reimbursement
	arrangements. For those that have employer coverage, it is such
	a valued benefit and employers and employees work together to
	balance cost and quality and comprehensiveness of benefits. And
	as a result, employer-sponsored health insurance is certainly
	the most popular benefit offered by employers. And I am pleased
	to say that is not only continuing but being enhanced by the
	strong economy.
	Mrs. Foxx. Thank you. Ms. Turner, when I travel around my
	district in North Carolina, I hear stories from so many people
	who struggle with the high and sometimes unpredictable costs
	that they face when taking care of themselves and their
	families. Out-of-control drug prices, surprise medical bills
	are two topics that President Trump has recently identified as
	places for reform and areas where I believe we can find
	bipartisan agreement.
	In addition to these issues, what other areas do you think
	that Republicans and Democrats can move forward and work on
	together to find a solution that benefits patients, workers,
	and families?
	Ms. Turner. I do work with a number of people in the policy
	community and it is surprising to see how much agreement there
	is on really trying to help people. I think we need to
	strengthen the system for the most vulnerable. I was on a panel
	yesterday--on Monday at the Academy of Health with several
	people from center-left and we talked about the importance of
	thinking of the whole person, of comprehensiveness of care, of
	allowing people to not only have coverage for health care, but
	housing support and food support and transportation support.
	Thinking of the whole person I think is really crucial and
	devolving more power and authority to the States and localities
	that have the understanding of their markets and resources I
	think is really crucial. But I also think addressing the cost
	of health coverage is so important.
	Between 2017 and 2018 we lost 2 million people in the
	individual health insurance market. They dropped out because of
	cost. So we have got to address the cost for people who want
	health insurance, who currently are healthy, but know they need
	protection. And we need to make sure that we are strengthening
	the system for the most vulnerable.
	Mrs. Foxx. Thank you, Ms. Turner. I yield back, Mr.
	Chairman.
	Chairman Scott. Thank you. The gentlelady from Oregon, Ms.
	Bonamici.
	Ms. Bonamici. Thank you, Mr. Chairman, and thank you to all
	of our witnesses.
	Last week there was a hearing in the Ways and Means
	Committee here in the House about preexisting conditions and
	one of the witnesses was the insurance commissioner from my
	home State of Oregon, Andrew Stolfi. And he talked about how in
	Oregon since the ACA we now have more than 3.7 million
	Oregonians, which is about 94 percent of our population, with
	health insurance coverage. And since the ACA that has been a
	significant improvement, significantly reducing the number of
	people without insurance. And before the ACA insurers had
	offered limited coverage or excluded so many people who
	applied. In fact, before the ACA the denial rate was about 30
	percent, 30 percent of people who applied were denied. And in
	Commissioner Stolfi's words, he said the ACA has helped change
	all of this, pregnant mothers know they can get the care they
	need and their babies need, children with developmental
	disabilities can get all of the essential physician-recommended
	physical, occupational, and behavioral therapy they need to
	grow to their fullest potential.
	So, the ACA is now protecting millions of people in Oregon
	who have preexisting medical conditions. Lisa from Beaverton is
	26 years old, she received a diagnosis when she was 23, stage 4
	lymphoma. I am happy to report that her cancer is now in
	remission and she is pursuing a master's degree, but she is
	pretty worried, frankly, when she hears all the conversations
	about repealing the ACA, this Texas lawsuit. She said ``I have
	hopefully a lot of life ahead of me and it frustrates me that
	my history of cancer could limit my access to healthcare.''
	Mr. Riedy, thank you so much for sharing your story. I have
	an advocate in the district I represent, Ella, a young woman
	with CF, and she comes to the Capitol when she can to advocate
	for more research and funding. And her family shares your
	concern about lifetime caps.
	How is the last couple of years--how have you personally
	felt when you hear all these conversations about repealing the
	Affordable Care Act? And when you hear about this lawsuit that
	might repeal the Act?
	Mr. Riedy. Thank you. It is scary to think, especially like
	I testified earlier, with the cost of my care currently, having
	caps or potentially being able to be denied coverage is a scary
	thought. Knowing that there is access to drugs that are
	changing my life and that there is more medicine coming down
	the pike that will ultimately, I fully believe, one day cure
	cystic fibrosis. But that will come at a cost. And it is hard
	to think or sort of comprehend that those treatments may be
	there and because of a lifetime cap or because of being denied
	access, that I will not be able to get those medicines, or your
	constituent's daughter would not be able to get those medicines
	that could potentially save or prolong her life.
	Ms. Bonamici. Thank you so much. And you made an excellent
	point, that access does not mean affordability. And if there is
	not the prohibition against discrimination for people with
	preexisting conditions, if the companies are saying well, we
	offer insurance to people with preexisting conditions, it just
	costs a fortune, it is not meaningful access.
	I have another question to Dr. Corlette. I have another
	constituent, Diane, who is a small business owner and for a
	long time she--she has a son with autism and a small business--
	for a long time she could not afford insurance before the ACA.
	She almost lost her home and business during the financial
	collapse. She went several years without coverage and she was
	uninsurable because she had preexisting conditions.
	So, she was not able to manage her arthritis, made it
	difficult for her to work. So, under the ACA she was able to
	get coverage, she could see a doctor, she eventually had hip
	replacement surgery, she is now able to work, has rebuilt her
	business. So, a really positive story largely because of that
	access to marketplace coverage.
	So, Professor Corlette, if the ACA protections we have
	discussed are undermined, what might that mean for Diane and
	other small business owners who do look to provide coverage for
	themselves, their families, and their employees?
	Ms. Corlette. Sure. So, if the ACA is invalidated in a
	Texas court it will wipe away some of the protections that your
	constituent has benefited from. So, for example, in the group
	market, if she is buying as a small business owner she could--
	her employees could face what are called preexisting condition
	exclusions where the insurance company excludes from your
	benefit package those services that would actually treat your
	condition, for which you actually need services, for up to a
	year. The insurance company would not be required to cover
	essential health benefits, which is a list of benefits that the
	Institute of Medicine and others have said should be in a basic
	benefit package, it could impose lifetime annual limits, there
	may not be a cap on the annual amount that she or her employees
	would pay out-of-pocket. So, there are a number of critical
	protections that people in job-based coverage would lose.
	Ms. Bonamici. Thank you very much and I see my time has
	expired. I yield back. Thank you, Mr. Chairman.
	Chairman Scott. Thank you. Dr. Roe.
	Dr. Roe. Thank you, Mr. Chairman. And, Mr. Riedy, I want to
	start with you.
	First of all, the easiest vote I have made here in the U.S.
	Congress was for the 21st Century Cures Act. To Dr. Collins,
	Francis Collins, the director of the NIH, it is very easy for
	me to vote to increase his budget to $39 billion. When I was a
	medical student, the first pediatric rotation I had in Memphis
	was St. Jude's Children's Hospital. Eighty percent of those
	children died in 1969 when I rotated there, today 80 percent of
	them live. If you have a rare condition, it is 100 percent for
	you. So I think there is a cure out there in the way and I
	think your future is very optimistic. And thank you for being
	here today.
	Look, we could all agree that we want to increase coverage
	and access and lower costs. That is exactly what we wanted to
	do with the ACA. Everyone can agree to that. And we agreed that
	we wanted to discuss preexisting conditions. And I want to go
	over very quickly, so everybody understands, that if you have
	health-based insurance, which I provide in my office for my
	employees, everyone--you cannot discriminate based on a
	preexisting condition. No. 2, if you have Medicaid or Medicare,
	you cannot discriminate versus on a preexisting condition. It
	is only in the small group and individual market where this
	occurred. And people feared if they lost their job and they
	ended up in the small group or individual market that they
	couldn't do that.
	I have a bill that I am dropping today, a very simple bill.
	It has one paragraph, it is three pages long, that essentially
	provides ERISA coverage to the small group and individual
	market. It treats them--me--as an individual--and I have been
	on the individual market--exactly like a large corporation. And
	that solves the problem and everyone in here--no matter what
	the Court does--if the Court rules whatever they rule. If they
	rule and it takes apart this, we have covered everybody and
	treated each individual exactly the same as a big company. This
	should be simple to do, it is one paragraph.
	And let me also say, Dr. Gupta, to you, let me share some
	experiences in Tennessee. We were promised the costs were going
	to go down. Our costs went up 175 percent and we lowered the
	number of plans out there that we could have. In my district,
	where I live, three-fourths as many people paid the penalty as
	actually get a subsidy. And what is happening in the real world
	is with these out-of-pockets and co-pays, if the hospital were
	our practice for 30 years, over 60 percent of the uncollectible
	debt are people with the insurance, not without insurance, but
	with insurance. And what happens is a patient will come to my
	office and if they had a condition, one of the 10 essential
	health benefits, they got their screening procedure done, that
	was fine, that was ``free''. If I found anything wrong with
	them and I had to send them down to the hospital for a test,
	they then have to meet their out-of-pocket and co-pay, which
	can be $3-4-5,000--and my family is $10,000. And so what
	happens, the hospitals, the providers, end up eating that. That
	is what his happening in the real world. Or people don't get
	the second test that they need, and that is what we have to
	look at.
	I also want to say to you all that I have a preexisting
	condition. I was treated 17-18 months ago for proState cancer.
	So I am in that pool of preexisting conditions and I don't want
	to be excluded either, nor do I want my patients excluded. And
	that is why I think we should all support this bill right here.
	And, Miss Turner, if you would, I would like for you to
	comment a little bit about my suggestion, about just applying
	these ERISA rules to me or to any individual out there.
	Ms. Turner. As we said, employers so highly value their
	employer coverage, and one of the reasons is because someone is
	negotiating on their behalf for a quality health plan. And
	health plans in the workplace are basically community rated.
	You may have different plan options, but everybody is basically
	paying the same amount for premiums. And HIPAA, of course,
	protections say that if you have group coverage through an
	employer and you move from one employer to another, that next
	employer must cover you at the same rate. So you can't then be
	basically underwritten. So there are a lot of existing
	protections in law.
	And I am very intrigued with your very creative legislation
	to basically extend those protections. I think it is important
	to note that if the Supreme Court--and I don't know anyone who
	knows what the Supreme Court is going to do--were to strike
	down the law, Congress is absolutely determined to fix it and
	to maybe improve the ACA in the process.
	Dr. Roe. I agree. And one of the things that I think is out
	there in the group market, in the self insured market--and we
	did this when I was on the City Commission in my hometown--is
	you can have disease management--Dr. Gupta knows this very
	well. And I have seen those cases where I have a friend of mine
	who has a large company with 15,000 employees, had a 1 percent
	increase in their premium per year for the last 5 years. And we
	can do that in the small group and individual market if we work
	together.
	Mr. Chairman, thank you. I yield back.
	Chairman Scott. Thank you. Gentleman from California, Mr.
	Takano.
	Mr. Takano. Thank you, Mr. Chairman. Let me begin by saying
	that my home district in Riverside, California, we cut--the
	Affordable Care Act enabled us to cut our uninsured rate by
	more than half because of expanded Medicaid and because of
	Covered California, which is the name of our exchange. I have
	personally spoken to older people in my district who have not
	reached Medicare age, but at an age when if there were no ACA
	they would not get any cost-sharing subsidies and they could
	not have afforded the insurance. They were very grateful that
	they got the cost-sharing subsidies so that they could reduce
	their exposure to a major medical incident.
	So, the majority offers these really false solutions of
	association plans and short-terms plans. Ms. Corlette, could
	you--you know, I think these plans are really evasions around
	minimum benefits. Is that correct?
	Ms. Corlette. That is right. So short-term plans are exempt
	from all of the Affordable Care Act rules, so they don't have
	to enroll people who have health issues, they don't have to
	cover the essential health benefits, and quite commonly with
	these plans, if you do get diagnosed with something after you
	enroll, they will do what is called post-claims underwriting
	and drop you from the plan to avoid paying your medical bills.
	So, if you do have an unexpected medical event or diagnosis,
	you might find yourself uncovered.
	The concern is that they will siphon away healthy people
	from the Affordable Care Act marketplaces and result in higher
	premiums for those who are not perfectly healthy and have to
	buy one of these ACA plans.
	Mr. Takano. So, the same for association plans, which were
	available, but the way the Administration has structured them,
	a similar sort of result.
	Ms. Corlette. Association health plans are similar but not
	exactly the same. They do have to comply with some of the ACA
	rules, but not all. And so they can use essentially the rating
	advantage they have, because they can charge higher rates based
	on age and other factors to cherry pick healthier employer
	groups from the ACA market.
	Mr. Takano. And there goes, you know, any affordability
	gain by the ACA. So, these are really ways to undermine the ACA
	and to undermine by extension protections for people with
	preexisting conditions, is that right?
	Ms. Corlette. That is right. If you have a preexisting
	condition or you simply want comprehensive coverage, like
	maternity care or other things that you feel are important, you
	would be buying in the ACA market, and if healthy people are
	siphoned away the ACA market risk pool will be smaller and it
	will be sicker, and insurers will price higher as a result.
	Mr. Takano. So, I would say that attempts to undermine the
	pools, undermine enrollment periods--so if we look at slashing
	funding for outreach and enrollment activities, that means less
	people enroll and makes these insurance pools less viable. That
	is also hurting people with preexisting conditions.
	Ms. Corlette. That is right. There is no question that
	research shows that advertising, marketing, outreach,
	education, consumer assistance, those all work to get healthy
	people into the pool.
	Mr. Takano. And this Administration has, you know, really
	refused to spend the outreach to get people to sign up for
	insurance, which then creates the premium dollar pool to make
	insurance viable and actually keep the cost down.
	Ms. Corlette. That is right. This Administration has
	slashed outreach and marketing by about 80 percent. So it is
	hard to bring healthy people in if they are not aware that the
	coverage opportunity exists.
	Mr. Takano. It was hard for me to square this President
	wanting to protect people with preexisting conditions knowing
	that his Administration intentionally did that.
	So also shortening the enrollment period, making it less--
	giving people less time to enroll into these insurance plans
	also has the same result.
	Ms. Corlette. That is right. And a number of the State-
	based marketplaces that can choose their own open enrollment
	periods have extended them to give people more time to enroll,
	and that has been a successful strategy.
	Mr. Takano. Well, and the Administration has also engaged
	in undermining the stability of the markets through ending the
	cost-sharing reduction payments for lower-income consumers.
	Would prevent people from being able to buy insurance because
	they don't have these subsidies.
	Ms. Corlette. It is absolutely the case that the decision
	by this Administration to cut the cost-sharing reduction
	subsidy led to an increase in premiums in the individual market
	significantly. I think 20 percent.
	Mr. Takano. Well, this intentional undermining in at least
	the three ways that I have spoken about, I mean certainly
	reduces the viability of these healthcare exchanges and also
	really makes meaningless any statement that this President
	wants to protect people with preexisting conditions and their
	ability to get insurance.
	I yield back, Mr. Chairman.
	Chairman Scott. Thank you. Gentleman from Pennsylvania, Mr.
	Thompson.
	Mr. Thompson. Chairman, thank you for hosting this hearing.
	Incredibly important topic. As someone who practiced healthcare
	for 28 years as a therapist, rehabilitation services manager,
	licensed nursing home administrator, I mean this is an
	important topic and preexisting conditions is a serious issue,
	an incredibly important issue. I have been disappointed over
	the past couple of years where, you know, with preexisting
	conditions individuals living with preexisting conditions
	obviously need confidence in their lives that they are going to
	be able to purchase insurance that they need to cover that
	condition, for treatment, rehabilitation. But quite frankly,
	what I have been disappointed in is how--there are people with
	preexisting conditions--need that health care professionals who
	are compassionate and dedicated, they want to provide those
	service, they want to access--they want those patients to be
	able to access those services. Well, we have got a lot of
	politicians that have been weaponizing preexisting conditions
	for political purposes. And whenever we do that, you know, my
	experience--I have only been here--this is my 11th year. I was
	here in 2009-2010. It doesn't serve anyone well.
	And so also my background, I used to get very frustrated
	advocating for my patients, whether it was in a nursing home,
	comprehensive inpatient, rehab, acute care, you know, going to
	battle with insurance companies. The people with some of the
	more chronic conditions are the ones that are facing those
	lifetime benefits. So I certainly support those improvements.
	But that said, let us--you know, I really want to clarify
	here, Ms. Turner, you know, protections for individuals with
	preexisting conditions has been a consistent area of agreement
	for both Republicans and Democrats. You Stated that protections
	for people with preexisting conditions are currently the law of
	the land and under the American Health Care Act, passed by the
	House last Congress, would the current law's legal protections
	for individuals with preexisting conditions be retained?
	Ms. Turner. If the Supreme Court were to invalidate the ACA
	and find the individual mandate unconstitutional and non-
	severable, which I think is unlikely, but if it would, it would
	certainly give several years of transition time before it went
	into effect to give Congress ample time to figure out how to
	back up these protections. And as you said, the Congress at
	the--whoever has been in control of the Congress has been a
	strong support of protection for preexisting conditions. Even
	if people don't have them now, they think they could get them
	in the future and they know someone has chronic conditions. So
	those protections need to be in place, but they need to be in a
	place in a way that actually allows the market to continue to
	work and doesn't drive out the healthy people because the costs
	are so high.
	Mr. Thompson. I mean there are a lot of things that impact.
	I think people getting into the pool, so to speak, that was
	mentioned by my friend from California, but the folks that have
	gotten out of the pool, I think there is a significant number
	who have gotten out because of post ACA, the cost, the
	escalating cost. And people with preexisting conditions that
	have--that were pleased that they could get it, the insurance
	but their costs have escalated. So we can't be complacent with
	the law as it is now, whether--we have to take measures.
	One final question for you, Ms. Turner. We constantly hear
	about the challenges that small employers face when dealing
	with costs and compliance burdens in providing health insurance
	coverage to their employees. While some small businesses are
	able to offer health coverage, many simply can't afford to do
	so. And one option, among others, which was passed by this
	committee, is for the small employers to band together to
	provide economies of scale for purchasing health insurance
	through association health plans.
	Now, what are other alternatives that encourage and enable
	employers, both small and large, to preserve and expand quality
	health coverage for their employees?
	Ms. Turner. Well, I do think it is important to focus on
	association health plans because this recent study by a very
	well respected analyst, Kev Coleman, said that he did not see
	that the plans that these new association health plans, which
	are offered in 13 States, just in the 7-months since the rule
	was finalized, and offering more than two dozen plans, that
	they really do provide an option for employers.
	I have been in seminars with H.R. directors of Fortune 500
	companies and talked with innumerable small businesses. They
	want to negotiate benefits that their employees want and they
	listen to their employees. And they are as comprehensive of
	benefits as they can afford and offer that coverage. So I think
	that it is important to give respect to the people purchasing
	these policies, that they will find a way to make sure people
	have coverage that is as good as they can afford, rather than
	no coverage at all, which is where too many people are without
	these options.
	Mr. Thompson. Thank you, Ms. Turner. Thank you, Chairman.
	Chairman Scott. Thank you. The gentlelady from Washington,
	Ms. Jayapal.
	Ms. Jayapal. Thank you, Mr. Chairman. On October 31 of last
	year, conveniently just a few days before the midterm election,
	President Trump tweeted, and I quote, ``Republicans will
	protect people with preexisting conditions far better than
	Democrats.'' That was a pretty big flip-flop given that the
	President and Republicans in Congress, including many on this
	very committee, spent most of last Congress voting to try to
	kill the Affordable Care Act and its protections for
	individuals with preexisting conditions. In fact, I think I am
	right about this, the only Republican members of this committee
	who did not vote for the horrible Trump Care bill last Congress
	were the eight new members who had not yet been elected.
	Now, this Administration is backing a lawsuit that could
	strip coverage for more than 133 million Americans with
	preexisting conditions with absolutely no plan to replace that
	coverage. And if this ruling takes effect more than 17 million
	people would lose coverage in the first year alone.
	So, to my Republican colleagues, which one is it? Do the
	American people deserve coverage for preexisting conditions or
	don't they?
	Let me also point out that overturning preexisting
	conditions protections would disproportionately harm racial and
	ethnic minorities. And, Mr. Chairman, I seek unanimous consent
	to enter a written Statement from the Asian and Pacific
	Islander American Health Forum into the record.
	Chairman Scott. Without objection. And I want to remind our
	colleagues that pursuant to committee practice, materials must
	be submitted to the committee clerk within 14 days following
	the last day of the hearing, preferably in a Microsoft Word
	format. The materials submitted must address the subject matter
	of the hearing. And only a member of the committee or an
	invited witness may submit the materials for inclusion in the
	record.
	Documents are limited to 50 pages. Documents longer than 50
	pages will be incorporated into the record by way of an
	internet link, so that you must provide the committee clerk
	with that in the timeframe, but recognize that years from now
	that link may no longer work.
	And I will give you a couple of seconds at the end.
	Thank you.
	Ms. Jayapal. Thank you, Mr. Chairman. And noted for the
	future.
	So let me start with my first question for Ms. Corlette.
	Thank you for your testimony. In your professional opinion as a
	research professor at the Center on Health Insurance Reforms,
	let us go back a little bit, why did it take an act of Congress
	to require insurance companies to insure people with
	preexisting conditions?
	Ms. Corlette. Well, before the ACA insurance companies, in
	order to make money, the business strategy was to enroll as
	many healthy people as you could, bring in their premiums, and
	pay out as little as possible in claims. So, to do that they
	engaged in what was called medical underwriting, which required
	people when they applied for coverage to submit health forms.
	They had lists of up to 400 different conditions that would
	cause you to be excluded from coverage. But, essentially that
	was the business strategy.
	What the ACA tried to do was change the business strategy
	away from risk avoidance to risk management.
	Ms. Jayapal. Thank you. So, just to be frank, insurance
	companies wouldn't cover people with preexisting conditions
	because they are too expensive, correct?
	Ms. Corlette. Yes.
	Ms. Jayapal. OK. So, Ms. Corlette, you also said in your
	testimony that the Affordable Care Act was enacted in part to
	correct serious deficiencies in health insurance markets that
	left millions uninsured and millions more with inadequate
	coverage. The reality is that the profit-seeking motives of
	insurance companies and big pharma are at odds with providing
	comprehensive care for everyone in this country. Do you believe
	that government should play a role in insuring that corporate
	greed doesn't allow insurance companies to deny coverage to
	people with preexisting conditions?
	Ms. Corlette. I think absolutely government needs to play a
	role, both in terms of financing, and I think it is important--
	you know, this committee is as aware as anybody else that
	employer-sponsored coverage is the source of the biggest
	subsidy in the Federal tax code. So critical role in terms of
	financing, but also to set the rules of the road. So, to the
	extent that we have private market actors on the provider side
	or the payer side, that there are clear rules of the road to
	protect people who need help, which is individuals, consumers,
	small businesses.
	Ms. Jayapal. So, thank you. In 2017--this is again a
	question for you--Aetena's CEO was paid nearly $59 million,
	Cigna's CEO took home almost $44 million, UnitedHealthcare's
	CEO $27 million. So, our healthcare system is underwritten by
	greed and health insurance companies and big pharma are
	profiting off of sick Americans. Without the protections
	ensured by the ACA, do you believe that insurance companies
	would continue to guarantee coverage for people with
	preexisting conditions?
	Ms. Corlette. No, I think they would go back to the
	business practices they were engaged in before the ACA was
	passed.
	Ms. Jayapal. Thank you. The Urban Institute estimates that
	17 million people will lose coverage in the first year alone if
	the Republican lawsuit stripping the ACA goes through. We have
	waited long enough for corporate executives to do the right
	thing, in my opinion. They simply aren't going to do so without
	government intervention. And that is why we passed the ACA.
	And, Mr. Chairman, that is why we must go further.
	Ultimately, I believe we need to take the pure profit-seeking
	motives out of our healthcare system and ensure that the No. 1
	thing we do is protect every American's right to have
	healthcare. And so today we are united as Democrats in
	protecting the ACA, making it clear that we stand with millions
	of Americans who are at risk of losing coverage. But I am also
	determined to put forward a bold new vision for Medicare for
	all, something that the majority of all Americans support. As
	Members of Congress, we are ready to listen to them and put
	people over profits.
	Thank you, Mr. Chairman, I yield back.
	Chairman Scott. Thank you. Gentleman from Michigan, Mr.
	Walberg.
	Mr. Walberg. Thank you, Mr. Chairman. Protections for
	individuals with preexisting conditions has been a consistent
	area of agreement for both Republicans and Democrats. We have
	to keep reiterating that.
	I strongly believe that these protections need to remain in
	place and I voted and co-sponsored legislation to safeguard
	them and give peace of mind to patients, and that is a matter
	of record.
	I am disheartened with my friends on the other side of the
	aisle's continued misinformation on our record on this issue.
	There was no Trumpcare, nothing got to his desk. There was the
	Affordable Health Care Act that dealt with all of the issues of
	concern that the ACA brought up because it didn't work for many
	people who did have a health care plan that they paid for, but
	when they went to use it, so many of them, so many of them did
	not have health care. So I hope that changes at some point in
	time, the rhetoric that continues on.
	This committee has jurisdiction over employer-sponsored
	health insurance. I know there are some that believe we need to
	move beyond the employer-sponsored coverage, however, the
	employer sponsored system currently provides health insurance
	for over 181 million Americans. So instead of forcing Americans
	off their plans that they like, or in the cases of union
	employees, forcing them to give up health plans that they
	worked hard for and made salary sacrifices to negotiate, we
	should explore ways to strengthen our employer sponsored
	system, reduce costs, so more businesses can offer these good
	benefits to their employees.
	I constantly hear from small employers in Michigan who are
	dealing with the cost and compliance burdens of providing
	health insurance coverage to their employees. While some small
	businesses are able to offer health coverage, many simply
	cannot afford to do so. One option among others, which was
	passed by this committee, is for small employers to band
	together to provide economies of scale for purchasing health
	insurance through an association health plan.
	Ms. Turner, thank you for being here. As you know, in
	August the Department of Labor issued a final rule to expand
	access to AHPs. In your opinion, when finalized, will DOL's
	rule help or hinder efforts to increase coverage for small
	employers and their employees?
	Ms. Turner. It absolutely will provide them an important
	new option to negotiate benefits on behalf of their employees.
	Talking with another H.R. director who has a work force of
	primarily medium and lower income workers, he said what happens
	is that as healthcare costs go up it eats up their wage
	increases. So employees see their wages as flat, but part of
	their compensation because too much of their compensation
	package is going to health benefits.
	Some employers are very creative, helping to provide
	coordinated care for people that they have identified that have
	the greatest healthcare needs. So I think employers play an
	important role and I think association health plans also play
	an important role, as well as the new health reimbursement
	arrangement rule, which would allow employers who cannot afford
	and do not have the resources to actually provide coverage to
	give their employees a stipend to be able to purchase health
	insurance on their own. We recommended they be able to combine
	salaries from two spouses, for example. One spouse may be
	offered health insurance at work, the other one can get a
	stipend to help make that a family plan rather than just an
	individual plan.
	Mr. Walberg. The beauty of more flexibility, creativity,
	and options that go on.
	Ms. Turner. Yes. And also to recognize the competition out
	there.
	Mr. Walberg. Right.
	Ms. Turner. Plans are competing, companies are competing,
	everybody is trying to do the best job to get the best value.
	Mr. Walberg. You mentioned in your testimony a study by Kev
	Coleman, a former analyst at the insurance information website
	HealthPocket. In his study, what type of plans did Mr. Coleman
	find that AHPs were offering? And let me ask this as well, are
	essential benefits covered in the plans that he discussed?
	Ms. Turner. The study by Kev Coleman showed that these AHP
	plans are offering benefits comparable to the largest employers
	that have negotiated these benefits for years and that they are
	not discriminating against patients with preexisting
	conditions. Many of these employers may have someone on their
	staff, maybe even a family member, that has a preexisting
	condition.
	Mr. Walberg. Or themselves.
	Ms. Turner. Yes. And so they want those benefits and they
	are really pressing the market to figure out how do you do that
	in a price that they can afford to purchase that coverage.
	Mr. Walberg. Thank you. I yield back.
	Chairman Scott. Thank you. Mr. Morelle from New York.
	Mr. Morelle. Yes, thank you, Mr. Chairman, for holding this
	very important hearing, and thank you to the panelists for
	being here and for answering the questions, particularly Mr.
	Riedy. Thank you for your courage in being here and sharing
	your story with us.
	Back in 1993 I co-sponsored and helped pass a law in New
	York that provided community rating for all New Yorkers that
	were in small business, the individual marketplace, as well as
	ending the practice of--well, beginning the practice of having
	protections for preexisting conditions. Something I am very
	proud of. So I took it as an article of faith that everywhere
	was like that, and then I became chair of the insurance
	committee about 15 years ago and during the time of the
	implementation of the ACA. I learned a great deal about what
	happens in the rest of the country. So this is very, very
	helpful in terms of understanding all of this.
	The first comment I would just make around coverage is we
	use the word coverage as though it means the same thing to
	everyone. The truth is, I remember as insurance chair, when
	people would come to me and say I had out-of-network benefits
	and it said out of network services were covered, yet it only
	covered 25 percent of my bill and I have this huge balance that
	I have to pay. You learn quickly that coverage doesn't mean
	coverage, that it means different things to different people.
	And cost avoidance is a big part of trying to provide coverage.
	But I wanted to just talk a little bit about the definition
	if I might. My daughter, Lauren, was diagnosed with triple
	negative breast cancer just a few years ago and she passed away
	about 17 months ago. I had never heard of triple negative
	breast cancer, but it is part of the diagnosis. And when you
	begin to look at treatment, you look at genetic panels and what
	you can learn from the genome. And it turned out that in
	Lauren's case while it wasn't passed on genetically, she did
	have a mutation in one of her genes.
	And so perhaps Ms. Corlette might be able to answer this,
	is there a concern that genetic predispositions will be defined
	more broadly as preexisting conditions in the way that some
	insurers view this or some people view it?
	Ms. Corlette. Well, there is a Federal law that was enacted
	before the ACA, the acronym, is GINA, the Genetic Information
	Nondiscrimination Act, that does prohibit insurance companies
	from discriminating against people based purely on genetic
	information.
	Mr. Morelle. And does that include then predispositions
	based on other things that would affect chronic conditions?
	Ms. Corlette. With respect to the preexisting conditions
	that we are talking about today, most insurance companies
	require you actually be diagnosed with a specific condition
	before it would be underwritten. Although I will say for short-
	term plans, you know, they will look at your medical history
	and even if you were not given a formal diagnosis they might
	say that you had the condition, you know, the cancer cell was
	in your body before you enrolled and might disenroll you
	because of that.
	Mr. Morelle. Yes, because it is certainly hard to tell when
	it manifests itself and--
	Ms. Corlette. Exactly.
	Mr. Morelle [continuing]. when it actually becomes disease
	state. Also to my colleague, Mr. Courtney, mentioned as he
	showed the pamphlet, in the description had obesity, which that
	would be a preexisting condition presumably?
	Ms. Corlette. Yes. Yes.
	Mr. Morelle. And that would be the case even if you had not
	exhibited or manifested any disease because of that condition,
	is that correct?
	Ms. Corlette. Correct.
	Mr. Morelle. And obviously that is not genetic in nature,
	but that is effectively underwriting which could lead
	ultimately to preexisting conditions?
	Ms. Corlette. Right.
	Mr. Morelle. And I did want to just mention coverage too
	because when you have community rating, and we don't even do an
	adjustment in New York for community rating, it is all the
	same. So that you have as you get older--as I am finding you
	have more medical conditions as you get older. Young, healthy
	people, obviously we want in the pools, and adverse selection
	often leads people to avoid coverage until they have a reason
	for it. But the larger the pool and the more that you
	essentially flatten the experience of the larger pool is really
	what insurance is all about. The avoidance of that with some of
	the plans that have either high deductibles or that in a sense
	sequesters the better risks is actually what causes the case of
	either uninsured or high premiums. Is that not right?
	Ms. Corlette. That is exactly right. You said it better
	than I ever could.
	Mr. Morelle. And that is my real concern here, Mr.
	Chairman, members, is that as we talk about coverage, as I
	said, it is not all the same, and you could be left with
	significant balance billing for procedures where you thought
	you had coverage, and this notion of sort of shifting risk to
	other groups of less well people is essentially what I
	understand the Administration policy to be.
	Would you care to comment on that?
	Ms. Corlette. Yes. I mean with respect to association
	health plans, short-term plans, it is really about shifting the
	risk from young, healthy people to older and sicker people. So,
	it is sort of rearranging the deck chairs without addressing
	some of the underlying issues about cost. Which is they are
	real. We have a cost problem in this country. But just creating
	new winners and losers is I don't believe the answer.
	Mr. Morelle. Very good. Thank you. I yield back my time.
	Chairman Scott. Thank you. The gentleman from Alabama, Mr.
	Byrne.
	Mr. Byrne. Thank you, Mr. Chairman. I appreciate you
	holding this hearing.
	Ms. Turner, I am sort of just the facts type person, and I
	didn't get here until I was elected in 2013, so I am having to
	go back and sort of make sure I understand how we got where we
	are.
	When Congress passed Medicaid and Medicare, embedded in
	those programs was protection for people with preexisting
	conditions. I think that is correct. And when they created some
	other public programs, like TRICARE, they did the same thing.
	And then I think I was told that when HIPAA was passed in 1996,
	bipartisan bill, that we provided similar protection to people
	that are in-group plans, employer-provided plans. Have I got
	that right?
	Ms. Turner. Absolutely.
	Mr. Byrne. So I asked my staff to go back and look at the
	most recent numbers we could get, which was 2017. Forty-nine
	percent of the people in America are under an employer provided
	plan. When you add up all the people on the public plans, like
	Medicare and Medicaid, it is another 36 percent. So if I am
	doing my math right, since at least 1996, 85 percent of the
	people in America have had protections on preexisting
	conditions as a result of bipartisan acts of the U.S. Congress.
	Have I got that right?
	Ms. Turner. Yes.
	Mr. Byrne. OK. So that is another 15 percent and every one
	of those people in the 15 percent is important. I do not think
	any of us can gain say that, but sometimes we start talking
	about this, we forget that 85 percent of the people in America
	have got the protections that they need. So when we look at
	what happened in the Affordable Care Act--and I was not here
	when it was passed, so I was not a part of that debate--I have
	actually talked to people in my district who were in that 15
	percent. In fact, the very moment I was running for Congress is
	when those notices went out to people, who were told by the
	President of the United States that if they liked their health
	care plan they could keep it, they actually came up to me at a
	high school football game where I am passing out pamphlets, and
	showed me the notice they got from their insurance company that
	said we are canceling your health care plan. But here is our
	new one for you, and the cost was a multiple of what they were
	used to paying. And these people, while they were working
	people, they could not afford it. And ACA did not provide those
	type people with the sort of help they need financially to do
	it. So I have met those people across my district who now are
	uninsured because they can't pay their premiums.
	So let me just ask you, are there individuals, including
	individuals with preexisting conditions, that the ACA might
	have actually materially hurt?
	Ms. Turner. There are people who say that the coverage that
	they had before, even in the individual market, was better than
	the coverage they have now because it is more affordable. Some
	of them are facing deductibles of $10,000. And they say that I
	might as well not be insured because I can't meet that
	deductible.
	Another friend who had a liver transplant needs significant
	anti rejection medications and he says that a health savings
	account actually is beneficial to him because he knows what his
	out-of-pockets costs are going to be, he can pay that on a tax
	free basis, and his catastrophic coverage actually was much
	better because it allowed him to wee any doctor without so many
	restrictions.
	So, yes, there are people who preferred the coverage they
	had before, but I absolutely agree with you that preserving the
	preexisting condition protections is vital. And also not
	frightening people to think that they might lose it. I had a
	friend write to me saying that she was worried if the court
	case were to be successful that she would lose her preexisting
	condition protection and Medicare. And there is no reason for
	her to be so frightened.
	Mr. Byrne. No, there have been scare tactics out there like
	that. It is unfortunate because even on Medicare you have got
	older people and they have got lots of other things that they
	are thinking about, and we don't need to be scaring them, we
	need to be helping them.
	I have talked to many Members of Congress since I have been
	here. I have not met a single person in either party that
	doesn't want to protect people that have preexisting
	conditions. The question is how do you do it? What is the
	smartest way to do it? What is the most cost-effective way to
	do it? But when you get up and tell the people of the United
	States, if you like your healthcare plan, you can keep it, and
	then they get a notice that says no, I can't keep it, and the
	substitute is something I can't afford, you have materially
	hurt people in the United States. And everybody in this
	Congress, Democrat or Republican, we should all want to work
	together to make sure we help those people, because those are
	the good, hardworking people in America who depend on us to
	look after them.
	I appreciate your testimony. And I yield back the balance
	of my time.
	Chairman Scott. Thank you. The gentleman from California,
	Mr. Harder.
	Mr. Harder. Thank you, Mr. Chairman, and thank you to all
	of our witnesses for being here on such an important issue.
	Protecting folks with preexisting conditions is the entire
	reason I ran for this office. On my district in the California
	Central Valley this is my highest priority. Over 100,000 people
	in our district have health insurance only thanks to the
	Affordable Care Act. And those 100,000 folks were at risk of
	losing their coverage if the Affordable Care Act was repealed,
	and it was only after that vote a year and a half ago, almost 2
	years ago now, that I decided to get on in and see what I could
	do to fix that. And I think the reality is, is in a district
	like ours, where nearly 50 percent of our individuals have a
	condition that qualifies as a preexisting condition, this
	affects every single human being, every person in my community
	has a loved one who would be affected if the Affordable Care
	Act was threatened. Every single person, including me. In my
	case it is my little brother David. He was born 10 weeks
	premature, less than 2 pounds when he was first born, spent the
	first 2 years of his life in and out of a hospital, came out
	with a healthcare bill 104 pages long. And because of that he
	would be without insurance until he is 65 and on Medicare if we
	did not have protections for folks with preexisting conditions.
	And, Mr. Riedy, I really was so touched to hear your story.
	I think your voice gives power to millions of folks. I think we
	need to be humanizing these statistics. And so when folks think
	about what life is really like with a preexisting condition,
	they are thinking about people like my little brother, they are
	thinking about people like you, and all of us, because the
	reality is each one of us has a loved one who would be affected
	by these changes.
	And in your testimony you mentioned you had a cost of
	medical treatment $450,000 in 2018. Is that correct?
	Mr. Riedy. That is correct. That was just for the cost of
	medicines.
	Mr. Harder. One year, one year. And I think that, you know,
	in a district like ours, where we have a high rate of
	unemployment, we have a lot of folks that have real financial
	stress, there is a lot of folks that could be impacted by that.
	I am very interested, based on your own experiences, Mr.
	Riedy, how do the annual lifetime caps affect patients with
	costly medical conditions?
	Mr. Riedy. So with the passing of the ACA and the ban on
	lifetime caps, it has--and annual caps, it has allowed me
	personally, and others with preexisting conditions, to have a
	better frame of mind to be able to focus on our health versus
	if I go and see this doctor, or I get sick and I have to go
	into the hospital or I have to have some costly procedure, what
	is that going to do, how close is that going to get me toward
	that cap, and then potentially if I get to that cap, what
	happens then. So not only are you dealing with having to fight
	to stay alive or have to focus on treatment regimens that take
	3 to 4 hours a day in my case, you are also then focusing on
	the mental aspect of this also and trying to focus on if I get
	to this point am I going to have to make decisions basically
	that affect my care and my family's wellbeing versus
	essentially dying or not being able to access that care which
	then will shorten my life and others.
	Mr. Harder. What do you would believe would happen to
	people like yourself and the people you advocate for if the
	Affordable Care Act was undermined by the court in the Texas
	case?
	Mr. Riedy. You know, I worry if the court case is upheld, I
	worry that insurers will institute lifetime and annual caps
	again, that they will reinstitute the ability potentially for
	me to be denied coverage simply because I was born with a
	genetic disease and have a preexisting condition, and that I
	will lose the comfort knowing that no matter where I work or
	what happens to me that I can continue to be there for my
	family and focus on what needs to happen versus--to take care
	of myself versus what the cost of that medicine is that my
	doctor prescribed, or not even being able to go and see
	especially--the highly specialized care that I need to take
	care of my lungs and by body.
	Mr. Harder. Thank you for your powerful testimony and for
	putting a face on what this really looks like. I think there
	are so many of us affected, nearly 50 percent of my district,
	and of many others. And we talk about millions of Americans, we
	talk about the 100,000 people in our community that would be
	without insurance if the Affordable Care Act were repealed and
	if it were undermined by some of these efforts of litigation,
	but I think the most important thing that we need to be
	considering is really understanding the day to day lives of
	folks who are living through these challenges today and
	understanding how those lives would be so different if we had
	not passed the Affordable Care Act.
	Thank you so much for your powerful testimony today.
	Mr. Chairman, I yield back my time.
	Chairman Scott. Thank you. The gentleman from Georgia, Mr.
	Allen.
	Mr. Allen. Thank you, Mr. Chairman, and thank you for
	having this hearing today. It is very enlightening. Obviously,
	you know, I have some preexisting conditions, I have family
	members that have preexisting conditions, so we are all very,
	very interested in how we go about making healthcare available
	to all Americans.
	The question and the big debate is how do we pay for it.
	Obviously we have the resources in this country to provide--
	and, Mr. Riedy, thank you for your testimony--to provide
	excellent medical care and hopefully a cure. We are all praying
	for cures for Alzheimer's, for all types of issues that we are
	dealing with in this country. And we are spending a lot of
	money to try to find cures for those things. But in the
	meantime, what is the best way to provide health care?
	Now, the question is, does the government do it more
	efficiently than the private sector? And I think, Ms. Turner,
	is there any information, like for every dollar of taxes that
	we pay, how much of that dollar gets back to take care of a
	patient under the Affordable Care Act.
	Ms. Turner. I have not seen--well, there is a medical loss
	ratio, so we know that based upon the company's size that
	either 20 or 15 percent of the money can only go to
	administration, the rest has to go to medical care.
	Mr. Allen. Right.
	Ms. Turner. But I do think that it is important to look at
	the approach that the American Health Care Act that the House
	passed in 2017 took. It actually dedicated specific resources
	to help people that have high health care costs--$123 billion.
	A similar amount in a Senate bill that didn't make it through,
	but that would have separately subsidized and provided extra
	money for the people that have chronic healthcare conditions.
	The ACA put them in the same market with everybody else and
	that raised prices to the point that you are driving the
	healthy people out. So there is a lot of evidence that if you
	separately subsidize those with the highest cost and the
	highest risks, you can lower premiums for other, get more
	people covered, and then focus on providing the coordinated
	care that people with multiple health conditions actually need.
	Mr. Allen. Exactly. And, you know, right now I think that
	Health and Human Services has a budget of about $1.2 trillion,
	the largest single piece of the Federal budget, and, you know,
	out of that $1.2 trillion I am interested--of course my
	background is the business world--and I am interested in
	exactly how much of that $1.2 trillion is taking care of Mr.
	Riedy. And I think we need to look at that and then we need to
	look at what would it cost if we returned health care back to
	the health professionals and we were able to, through programs
	deal directly in our health providers, deal directly with our
	health providers rather than got through HHS and these other
	agencies that have these huge budgets.
	And, frankly, as I understand it, our health care in this
	country is much more expensive than compared to other
	industrialized countries in the world. Is that correct?
	Ms. Turner. That is correct. We are also the research
	center for the planet. The great majority of new prescription
	drugs, like the one that Mr. Riedy says is so valuable, are
	developed in the United States. We pay a disproportionate share
	both for the research and for the drugs, and also new medical
	technologies and other innovations.
	Mr. Allen. Right. So we are subsidizing health care across
	the world? Would that be correct?
	Ms. Turner. Well--
	Mr. Allen. How can we afford--we are $21 trillion in debt
	and, of course, you know, I do not know who is going to be
	paying my health care bills, but it is probably going to be one
	of my grandchildren or great-grandchildren, but we have got to
	solve this problem. We have the ability to take care--you know,
	I tell folks back home, we have got plenty of money to take
	care of folks, particularly those with preexisting conditions,
	I just think it is all in Washington, and we need to get it out
	in our States and our communities and make healthcare
	affordable.
	And with that I yield back.
	Chairman Scott. Thank you. Dr. Schrier.
	Dr. Schrier. Thank you, Mr. Chairman, and thank you to our
	witnesses today.
	I just want to say that I can't think of a more important
	topic to bring up today as our first hearing because one thing
	that I have heard about from all of my constituents is
	healthcare, and that is their No. 1 issue. And I sit here today
	not just as a Member of Congress, but also as a pediatrician, a
	doctor who is taking care of patients for the last two decades,
	and as a person with Type I diabetes. And so I really share a
	kinship with people in my district and in this country with
	preexisting conditions.
	So, I can report to you first hand that my patients are
	worried. They are worried that either they or their loved ones
	will not be covered if they have a preexisting condition or
	that they will be priced out of the market, as we have been
	hearing a lot about, and they are worried even in these popular
	employer-based health plans that their prices are also going up
	and their deductibles are skyrocketing.
	And so, you know, I came here to bring down costs and
	protect my patients and make sure that no family goes bankrupt
	because of medical expenses. And so, I hear about these
	solutions, like these short-term health plans. And you can
	imagine, as a pediatrician, that preventative care, essential
	health benefits, and mental health care, well woman care, these
	are all critical, and that is why they are essential health
	benefits.
	And I just want to clarify, Dr. Gupta, you have not had to
	communicate anything for a while, so I thought I would give you
	a chance. Can you just be--very clearly, are those services
	covered under these short-term health plans?
	Dr. Gupta. Thank you for that questions. Certainly they do
	not have to be covered. I mean the idea of motherhood being a
	sort of preexisting condition comes back after a decade again.
	The idea well woman, well child preventative care, knowing that
	we are going through an opioid epidemic today that we are
	having a lot of adverse childhood experiences and a whole
	generation is going to have to deal with as children and grow
	up. And that will be the future of this country. None of those
	things will be covered. Neither will be things like
	vaccinations. Those will not be covered. Mental health
	screenings, domestic violence screening will not be covered
	potentially. Of course mammograms, pap smears, none of those
	things have to be covered.
	Dr. Schrier. Thank you. You are speaking my language. And
	then just also to clarify, do patients know that these are not
	covered when they buy these short-term less expensive health
	plans that are proposed to be a solution to skyrocketing
	medical costs?
	Dr. Gupta. That will certainly be in fine print, as was
	mentioned today. And I am sure that most of us are not going to
	realize until you get sick and then that will be the time that
	most patients will realize that they were not covered for those
	services.
	Dr. Schrier. And to read that fine print you would need
	glasses like these.
	OK, my next question is that I have seen in my own
	practice, you know, the classic story, a girl with a terrible
	rash whose mom brought her in and it had been weeks that they
	had been trying to deal with this at home with all the powders
	and creams and everything they possibly could. And when she
	finally came to me it was a disaster, she needed antibiotics
	and steroid creams. But she delayed care because of the cost of
	care. She knew that because of her deductible it would cost her
	a lot to come in and that she may as well try everything in the
	kitchen cabinet at home.
	And so when I think about these short-term plans and that
	preventative care would not be covered--and I know how
	important those well child checks are--I just would like your
	opinion as to how many families will show up for that
	critically important primary care and preventative care if
	those are not provided for free.
	Dr. Gupta. We know from studies that compared to the
	insured population, uninsured individuals tend to delay their
	care. That leads to lack of those preventative services,
	ultimately poor outcomes, and more expensive outcomes, not just
	from health but also for financial reasons. And what we saw
	after ACA was the amount of uninsured childbearing women went
	down from about 20 percent to 13 percent. So additional 5.5
	million women got the care for things like maternity care. So
	those things are happening now that we will again walk back
	several steps and we will end up the emergency rooms with
	uncompensated care, at doctors' offices, while mostly in
	primary care, where we already have shortages of tremendous
	amount across the field. And those offices will once again be
	seeing a lot of patients who do not have insurance and, like
	you have, I often provide care for those without regard to the
	level of insurance they have.
	Dr. Schrier. Thank you, Dr. Gupta. And I yield back my
	time.
	Chairman Scott. Thank you. The Gentleman from Kentucky, Mr.
	Comer.
	Mr. Comer. Thank you, Mr. Chairman. And I would like to
	talk about healthcare in Kentucky. Obamacare, or the Affordable
	Care Act, however you want to pronounce it, in Kentucky was a
	great deal for people who got free health care via Medicaid.
	But it was a terrible deal for working Kentuckians who actually
	have to pay for their health care premiums. In Kentucky, 30
	percent of the State is on Medicaid. That is pretty much free
	health care. But the rest of Kentuckians in the State who are
	working, struggling to pay health care premiums, they do not
	have a very favorable opinion of the Affordable Care Act.
	Ms. Turner, I would like to ask you a question addressing
	the rising cost of health care, including premiums,
	deductibles, and out-of-pocket expenses. This is a huge concern
	for most Americans and it should be a concern for the
	democrats. What options do you think policymakers should
	consider when discussing how to lower the cost of health
	insurance and provide a variety of affordable options,
	especially for employers and workers?
	Ms. Turner. I described in my testimony a plan that I have
	helped to develop with a number of my policy colleagues, called
	the health care choices plan. And it basically recognizes the
	States have a lot more knowledge about their individual markets
	and the needs of their citizens, and it is very difficult for
	Washington to finely tune legislation enough to let them do
	what they need to do. So we have recommended formula grants to
	the States to let them figure out how do they make sure that
	existing populations are supported. But they have the
	flexibility to be able to get coverage not only for the
	continued coverage for them, but to make sure that new people
	can come into the market and afford coverage, and quality
	coverage.
	Mr. Comer. Mm-hmm. If there is one thing that I think all
	of us would agree on in both parties is that everyone should be
	protected with preexisting conditions in health care. No one
	should be denied coverage based on their medical history. Given
	that, and given current law, Ms. Turner, are any reforms needed
	to ensure that individuals with preexisting conditions have
	access to health coverage?
	Ms. Turner. One of the things that several States have done
	is request waivers to use some of the ACA money to more heavily
	subsidize those with high risks to make sure they can have
	access to care and coverage. I talked about Janet in my
	testimony who is now under ACA coverage in Colorado, but it is
	inferior coverage to the high-risk pool coverage she had
	before. States can fine-tune that, high-risk pools, invisible
	high-risk pools, reinsurance, to make sure those with the
	highest healthcare costs are covered. Devote money to them, you
	cannot only lower premiums for other but increase access for
	the healthy people we need to come into the market.
	Mr. Comer. In Kentucky, prior to passage of the Affordable
	Care Act, we had a high-risk pool, called Kentucky Access, and
	it was successful. But it was eliminated with the passage of
	the Affordable Care Act.
	Just to followup on that question, would you say there are
	other factors that affect consumer access to health care?
	Ms. Turner. Well, that is one of the reasons I believe
	these short-term limited duration plans are so important,
	because somebody may be, you know, in a bridge between--they
	have just graduated from college, they had coverage then, they
	don't have a job yet, they are older than 26. Somebody who is
	near Medicare eligibility needs bridge coverage, somebody who
	is starting a new business needs to--there are people who need
	these temporary plans and that is another option.
	Indiana had a great plan called the Health Indiana Plan, a
	State-based plan. An account to make sure that people could get
	the preventative care they need, but they also had major
	medical coverage. There are a lot of other options, but I think
	that the State creativity, working with healthcare providers,
	is really valuable.
	Mr. Comer. Thank you very much. Mr. Chairman, I yield back.
	Chairman Scott. Thank you. The Gentlelady from Illinois,
	Ms. Underwood.
	Ms. Underwood. So, we have just heard from our colleagues,
	Ms. Foxx and Mr. Comer, who mentioned how they support
	protections for individuals with preexisting conditions.
	However, congressional Republicans and the Trump Administration
	have had relentless--attacked protections passed by the
	Affordable Care Act. And so many of my colleagues here voted
	more than 70 times to repeal parts of the ACA. Moreover, last
	August the Administration finalized a rule that expands short-
	term limited duration insurance, commonly known as junk plans.
	Junk plans do not have to comply with key Federal laws that
	protect patients and they can pose a serious risk to patients
	with preexisting conditions.
	Earlier today, along with Representative DeSaulnier, my
	Democratic colleagues and I introduced my first legislation in
	Congress to overturn the Trump Administration's rule expanding
	junk plans. Insurers should never have the option to
	discriminate against patients with preexisting conditions.
	So, Dr. Gupta, can you tell us more about why they are
	called junk plans and what kinds of consumer protections can
	junk plans exclude?
	Dr. Gupta. Well, thank you. I think part of the--what is
	important is not just the preexisting conditions protections,
	but also the affordability as well as the accessibility in
	terms of essential health benefits. So, none of this is covered
	or required to be covered in these short-term plans, or also as
	you termed them, junk plans. There are States that have taken a
	proactive lead, like California, Oregon, New York, New Jersey,
	who have actually worked to prohibit those plans in the way
	that they are today. And, obviously, other States will have to
	do more. Because what that does basically is sells people out
	there who may not be suspecting a bill of goods that they have
	no idea about. So, unless they read the fine print, when in so
	many ways stepping back to about a decade ago, and people when
	they find that they need the help that they need, they are not
	going to be able to get it because the preventative care, as
	well as a number of those essential health benefits, including
	maternity care, will not be covered.
	For example, prior to the ACA only 11 States required
	maternity care in individual plans, and only 13 percent of the
	insurers' individual plans covered maternity care.
	Ms. Underwood. That is why patients' groups, including the
	March of Dimes, the American Cancer Society, the American Heart
	Association are opposing the junk plan rule.
	Mr. Chairman, at this time I would like to ask unanimous
	consent to enter a letter from those patient groups opposing
	the rule into the record.
	Chairman Scott. Without objection.
	Ms. Underwood. Thank you. Dr. Gupta, what effects can junk
	plans have on patient access to care, particularly patients
	with preexisting conditions?
	Dr. Gupta. Ultimately it will cost their lives or their
	bank account, or both. The challenge with that is when somebody
	needs the help, early help to be able to detect cancer, like
	breast cancer, colon cancer, or be immunized for important
	conditions that could be communicable--we are seeing outbreaks
	of measles, for example--those could get worse. And people we
	diagnose much later in their stage and then they will not be
	able to be covered by those because of the preexisting
	conditions clause missing, and therefore they will be--again,
	will lose life and it will cost us a lot more. It is just the
	most--the least effective way of administering healthcare.
	Ms. Underwood. In fact, an analysis by the Los Angeles
	Times found that not a single group, not a single group
	representing patients, physicians, nurses, or hospitals
	supports the junk plan rule. And 90 percent of the comments
	from the public on this rule were either critical or opposed
	the rule outright.
	So, Ms. Corlette, are you concerned that public opinion on
	junk plans was disregarded when the rule was written? What
	needs to be done to ensure the needs of patients with
	preexisting conditions are truly represented in this debate?
	Ms. Corlette. Well, certainly with respect to the comments
	on the short-term plan rule, it would suggest that the
	Administration's mind was made up about what they wanted to do
	before the rule was finalized and the public comments did not
	make much of a difference there.
	I do think there is a real concern that a lot of people who
	are healthy before they sign up for these plans, have an
	unexpected medical event, and are left on the hook for
	thousands, tens of thousands of dollars in unpaid medical
	bills.
	Of course, for those who have preexisting conditions, they
	couldn't buy these plans even if they wanted to. They would
	have to buy in the ACA market, but the ACA market will be more
	expensive. CBO has said it will be about 3 percent surcharge on
	premiums as a result of these plans.
	Ms. Underwood. Thank you, Mr. Chairman, and thank you to
	all the witnesses for being here.
	I yield back.
	Chairman Scott. OK, thank you. The gentleman from Texas,
	Mr. Wright.
	Mr. Wright. Thank you, Mr. Chairman.
	Chairman Scott. Thank you.
	Mr. Wright. I want to thank all of you all for being here
	today. Mr. Riedy, God bless you and your family. I think it
	speaks to your character and your determination that you are
	even here today participating. So thank you.
	Ms. Turner, I think you would agree that, you know, we
	should never have laws on the books that are unconstitutional,
	and when the Supreme Court made its decision on the ACA, Chief
	Justice Roberts, of course, his opinion was that it was
	Constitutional by virtue of being a tax. I thought that was a
	very slender thread, but that is the opinion. If you take that
	thread away, then it follows that the law is unconstitutional.
	And as a Texas Congressman I am terribly proud of my State
	attorney general for leading the effort in this lawsuit.
	Because, again, if the reason it was determined that it was
	unconstitutional was that it is a tax and you take that away,
	doesn't it follow that it is no longer Constitutional?
	What is your opinion, Ms. Turner?
	Ms. Turner. Well, this is going to go through the Courts to
	determine whether or not the fact that the Congress did in fact
	zero out the tax penalty for individual insurance does
	invalidate the law, but I think the important thing is that we
	have seen since then all of the efforts by you and others in
	Congress to repeal and replace the law. So I think we have seen
	that there are definitely places that improvement is needed and
	to try to find a way to replace the coverage that people are
	relying on, but to allow markets to work better so that healthy
	people are not being driven out.
	Mr. Wright. Yes, ma'am. And the key word there is replace.
	I think the assumption that if ACA had not passed or if it had
	been ruled unconstitutional, that nothing would have happened,
	that there would have been no improvements in healthcare, is a
	completely false narrative, just as if it were to go away
	tomorrow we are not going to revert back to the status quo of
	2009 because there was always, even in 2009--I don't know if
	you were part of crafting or helping either side on that, I was
	here then. I was the chief of staff for the ranking Republican
	on Energy and Commerce Committee. I sat in some of those
	meetings, saw the markup. There was always Republican
	alternatives that included coverage for preexisting conditions,
	even going back to 2009.
	So this narrative that we keep hearing that Republicans are
	somehow opposed to that or don't want it, is patently and
	demonstrably false, and it needs to stop because it is not
	true.
	My last question is this, it has to do with the idea that
	is being advanced by the other side, and we heard it earlier
	today, about Medicare for all. Well, Medicare-for-all is
	Medicare for none. Would you agree with that? Can you speak to
	it?
	Ms. Turner. It certainly would not be the Medicare that
	seniors know now.
	Mr. Wright. If we go to socialized medicine, where it is
	all run by the government, then doesn't Medicare cease to
	exist?
	Ms. Turner. As I mentioned in my testimony, my colleague,
	Doug Badger, has done some research looking at these cross
	subsidies from the employer-based system with 170-some billion
	people participating. They pay a higher rate to physicians and
	hospitals that allow Medicare and Medicaid to save taxpayer
	money and to pay a lower rate. But if those reimbursement rates
	went across the board, 40 percent of physicians and hospitals
	would find that they couldn't even keep their doors open.
	So we need the employer-based system.
	Mr. Wright. Absolutely.
	Ms. Turner. And the private sector, not only for its
	innovation but for the money that it provides to support
	existing public programs.
	Mr. Wright. Right. Thank you very much. Thank you, Mr.
	Chairman.
	Chairman Scott. Thank you. The gentlelady from Georgia, Ms.
	McBath.
	Ms. McBath. Thank you, Mr. Chairman. And I do want to thank
	you for holding this hearing today. And I would like to thank
	the witnesses who are here to discuss the importance of
	protecting access to healthcare for all Americans.
	This is an issue that is deeply personal to me. I myself,
	like millions of Americans, live with a preexisting condition.
	As a two-time breast cancer survivor, I understand what it is
	like to have your life turned upside down by this very
	diagnosis. I was first diagnosed with stage 1 breast cancer in
	2010. And after completing treatment my cancer returned again
	in 2012. My cancer was detected because of a routine mammogram.
	I will never forget the way that I felt when I first heard my
	doctor say the words stage 1 breast cancer.
	For each of the two cancer diagnoses that I have received I
	underwent surgery through a procedure called a lumpectomy to
	remove the remaining cancer. And I received radiation treatment
	and drugs thereafter. I did it all while raising my family and
	working full-time. And I can tell you I was terrified. Despite
	being lucky and having good health insurance through my job, I
	was still worried about my financial security. I was concerned
	about making it to radiation treatments, sometimes every single
	day for weeks, and then back to work and then back home to
	raise my son, Jordan. It was exhausting, both physically and
	emotionally. But I had to do it, just like millions of
	Americans out there who share a similar story to mine.
	I truly do not know what I would have done or what would
	have happened if I had lost that health insurance coverage. And
	I am happy to say today that I am cancer-free. But, Mr.
	Chairman, not everyone is as lucky as I am. And I am worried
	for Americans and for those in my State of Georgia who might
	not detect their cancer or chronic health condition early on,
	when it is most easily treatable.
	The Centers for Disease Control and Prevention states that
	preventing diseases is critical to helping Americans live
	longer, healthier lives and keeping healthcare costs down. It
	is so important that Americans have access to the preventive
	services that are an integral part of the Affordable Care Act.
	These include screenings for certain cancers, screenings for
	Type 2 diabetes, and other critical health services. And I am
	worried about their future and their financial security.
	We here in congress, we have a responsibility to protect
	people. That is what we must do.
	Ms. Corlette, could you talk a little bit more about how
	the ACA protects patients and has created greater access to
	preventive services, like breast cancer screenings or high
	blood pressure screenings? Particularly how the ACA cost-
	sharing provisions impacts and also ensures Americans have
	access to these types of services?
	Ms. Corlette. Absolutely. Thank you for the question. So,
	the Affordable Care Act requires insurers both in the
	individual market and in the employer market to cover a set of
	evidence-based preventive services without any cost-sharing for
	the enrollee. And that includes many of the services that you
	mentioned in your Statement, but also vaccines, contraception,
	tobacco cessation counseling, a range of services that not only
	prevent disease but help keep people healthy over the long-
	term. Those services can also help diagnose issues that people
	have and help get them early treatment in order to get a better
	outcome at the end of the day.
	So, if the ACA were overturned or this decision in the
	district court in Texas is upheld, insurance companies would no
	longer have to provide that protection and people would face
	cost-sharing. And we know, and Dr. Gupta mentioned, that if
	people do face co-insurance or cost-sharing for those services,
	they tend not to get them or they delay them.
	Ms. McBath. Thank you. And my followup question is how
	could the Texas litigation impact American's access and
	affordability of these lifesaving services?
	Ms. Corlette. If the Texas decision is upheld millions of
	people will lose their insurance, about 17 million in the first
	year and up to 32 million by 2026. It is well documented that
	people without insurance delay, forego care. Before the ACA
	about 22,000 people died each year simply for not having
	insurance.
	For people with job-based coverage, they lose access to
	critical protections, like the lifetime and annual limits that
	Mr. Riedy discussed, the protection against excessive out-of-
	pocket costs--ACA has a cap on that every year--as well as the
	preventive services and essential health benefits that you
	mentioned.
	Ms. McBath. Thank you. Thank you.
	Chairman Scott. The gentleman from South Dakota, Mr.
	Johnson.
	Mr. Johnson. Thank you, Mr. Chairman. Mr. Riedy, you spoke
	so eloquently about your family. Are any members of your family
	with you here today?
	Mr. Riedy. Yes, my father and mother and my wife are
	sitting behind me.
	Mr. Johnson. I kind of suspected that was the case. And, of
	course, you were facing us during your testimony, and so I just
	want to take a minute to tell you, because you couldn't know,
	their faces were filled with an incredible pride during your
	testimony. And, of course, you should feel good because you did
	a good job. You should also feel very good because they clearly
	are very proud of you.
	Mr. Riedy. Thank you.
	Mr. Johnson. Almost every member of the Committee that has
	spoken has done a nice job raising their voice in support of
	protections for people with preexisting conditions. Of course,
	I want to raise my voice to echo theirs. Critically important
	and I am glad we are having this conversation.
	I also like how the panelists all in different ways have
	called forth this important connection between employer-based
	health coverage and some of these preexisting condition issues.
	I was a little concerned, Ms. Turner, in your testimony you
	talked about how 65 percent of employers offered health
	insurance in 2001, you mentioned that number had come down in
	recent years. I assume affordability is a key driver. Are there
	others that are maybe not as intuitive to me?
	Ms. Turner. It is primarily affordability, and also because
	there are fewer carriers now offering coverage in the
	individual and small group markets. But one point that I think
	is so important about when employers do offer coverage, they
	have an incentive. They were offering coverage for preventive
	care before the ACA because they know it works. It is so much
	better to detect breast cancer at stage one than at stage four.
	So helping their employees stay healthy, making sure that they
	have access to preventive care, and being able to access the
	diagnostics that they need early on for their coverage. So I
	think that employer coverage brings particular value to our
	health sector without the mandates. They know this is important
	because it works.
	Mr. Johnson. So I just want to make sure that I can square
	the math here. The number of employers how are offering this
	type of benefit has gone down. A number of people have talked
	about the how the number of people receiving that type of
	benefit has gone up. Is that just macRoeconomic trends, large
	employers getting larger, and smaller businesses being the ones
	more likely to drop this type of benefit?
	Ms. Turner. I could look further into the research, but
	based upon everything I have read since the ACA, the cost of
	compliance in providing health coverage to employees is
	significant. So it is not only the cost of the coverage, but
	also compliance. And if a company is hitting near that 50
	employee threshold where the employer mandate triggers, they
	often will sometimes put workers on part-time, they will scale
	back their staff, to avoid having to trigger that employer
	mandate.
	So I think in some ways the employer mandate has actually
	worked against smaller employers offering coverage. And without
	it and with more flexibility I think we would see more
	participation.
	Mr. Johnson. This is an area of concern, and I suspect it
	is an area of concern for everybody on the Committee,
	regardless of party or region, because so many people, from Mr.
	Riedy to others, have talked about how well I had an employer-
	based coverage, or I had job-based coverage. It is clearly a
	really important leg of this stool about how we make sure
	Americans are covered, how they can get the healthcare service
	they need.
	Are there things that we can do to strengthen employer-
	based coverage? Because the trends you are talking about we
	should not feel good about in this country right now.
	Ms. Turner. What employers want most is flexibility to meet
	the needs of their employees without having to charge so much
	that health insurance eats up their employees' pay increases.
	So they are looking for affordability, they want more
	competitors, they want more options rather than having to meet
	such specific benefit requirements to really allow them to--
	there may be other benefits that their employees value more
	than the essential health benefits list. So giving them more
	flexibility to meet their employee needs and keep costs down
	would increase participation.
	Mr. Johnson. Thank you very much. Well, Mr. Chairman, I
	just think this is a critical area for further study by the
	Committee. And, of course, I appreciate the time and I yield
	back.
	Chairman Scott. Thank you. Gentlelady from Connecticut, Ms.
	Hayes.
	Ms. Hayes. Thank you, Mr. Chairman, and thank you to all of
	the people who have come to share your testimony today. I
	really appreciate it on this very critical issue.
	Before I begin my questioning, I cannot underscore what my
	colleague, Ms. Underwood, said before she left, that while we
	hear everyone talk about protecting preexisting conditions our
	Republican colleagues voted more than 70 times to either roll
	back or repeal the Affordable Care Act, which really undergirds
	those protections.
	My questions this afternoon are for Dr. Gupta. In your
	testimony you talked about how the Affordable Care Act has
	improved the lives of millions of Americans, particularly women
	and children. And this was strengthened by those 10 essential
	health benefits that we all know about. Of those benefits, we
	have mental health and substance abuse treatment. Do you think
	that those are important benefits to protect?
	Dr. Gupta. Thank you for the question. Absolutely. I think
	one of the things we have yet to appreciate is the increase in
	tens of millions of people across this country who are
	suffering now from substance use disorder that may not have
	been the case even a decade ago. And a lot of the--when we look
	at the data, access issues, fear of being fired from their
	employer are some of the reasons that people do not seek care.
	So, it is a big stigma issue as well. For women, things like
	breastfeeding supplies, very simple things like a breast pump
	and not having to cost share on those things, are another one
	of those things that we should be working to protect, in
	addition to the maternity care benefits.
	Ms. Hayes. Thank you. Because I know we are talking a lot
	about preexisting conditions and our conversations are centered
	around genetic conditions or health-related diseases. So I am
	happy to hear that you recognize that addiction is also
	something that really further exasperates those conditions. It
	is undeniable that we are in a crisis with opioid addiction. In
	my own home State of Connecticut we have had significant
	increases. Over the past 6 years our numbers have tripled. In
	2017 my State marked a grim milestone of over 1,000 opioid-
	related deaths. And in June of last year we were on track to
	surpass that. In the district that I represent three of the top
	ten towns are the highest opioid deaths.
	This is no stranger to me. I grew up in a family that
	struggled with addiction. In my own hometown 45 people died
	last year as a result of opioid-related deaths.
	Does the current opioid crisis make the need for mental
	health and substance use disorder coverage more important?
	Dr. Gupta. Absolutely. And, again, when we talk about
	employer-based coverage, here is the real problem on the
	ground. When I am seeing patients at a charity clinic who have
	substance use disorders they are unable to have gainful
	employment because of their addiction issues, which need to be
	treated in the first place. And that allows them to actually
	gain and have meaningful employment to begin with. So, I think
	it is very important for us to make sure that we have systems
	in place that allow the treatment and access to treatment for,
	you know, one of the biggest crises to face our generation
	today.
	Ms. Hayes. I appreciate you viewing this as a crisis and
	talking about treatment and coverage and healthcare, as opposed
	to a criminal action, as we heard last week from our friends
	over at Purdue Pharma, who talked about people who were
	addicted to opioids as, ``reckless criminals''.
	During your time at the Department of Health and Human
	Services in Virginia you led several important initiatives to
	address the opioid crisis in your State. Could you tell us what
	impact the Affordable Care Act had on access to treatment for
	substance abuse disorder and families, not just the individual,
	but I am the daughter of an addict, so how families were
	impacted by the protections provided by the Affordable Care
	Act.
	Dr. Gupta. Absolutely. In a State like West Virginia, which
	is not any different from a number of States that are having to
	deal with this crisis firsthand on the ground, we found that
	having access to treatment, being able to expand those
	treatments and make that available--a part of which was
	Medicaid expansion. West Virginia was one of the first States
	that--we worked very hard to ensure Medicaid expansion. Allowed
	a number of people to enter the treatment spectrum and we found
	that the access to mental health treatment, access to the
	medications, being able to be able to transport it and being
	paid for being able to transport for treatment, are some of
	those factors that help us remove the stigma of addiction and
	help us move forward in that. And it is very important that we
	provide--reduce all the barriers to treatment when it comes to
	a stigmatizing disease, such as addiction.
	Ms. Hayes. Thank you for your time. Mr. Chair, I yield
	back.
	Chairman Scott. Thank you. The gentleman from Pennsylvania,
	Mr. Meuser.
	Mr. Meuser. Thank you, Mr. Chairman, thank you Dr. Foxx,
	thank you to all testifying today.
	Ms. Turner, I am Dan Meuser, Pennsylvania's 9th
	congressional district. And I appreciate you taking the time
	here, and all of you. I believe every American should have
	access to high-quality, affordable health care, regardless of
	health status, including preexisting conditions. Given current
	law, are there any reforms that you would feel, Ms. Turner,
	that are needed to ensure that individuals with preexisting
	conditions do in fact continue to have access to health care
	coverage?
	Ms. Turner. I don't think there is one particular answer,
	Congressman. I think they need a myriad of options. I think
	giving States the option to recreate their high-risk pools
	would be helpful to make sure people who have preexisting
	conditions have a place to go if their health insurance becomes
	so expensive. As Senator Bryce Reeves' constituent described,
	$4,000 a month premiums or deductibles that are $10,000. They
	need other options. And I think States also could do things
	like the Healthy Indiana Program, an account-based plan that
	allows people resources to access primary care, but knowing
	that they have major medical coverage as well.
	But I think the crucial issue is addressing cost and giving
	people more options, more flexibility, and giving companies the
	option to provide coverage that is more attractive, that
	healthy people want to get in the market, so they are not
	staying out of the market, putting more and more people who
	have high health costs in the market and driving up premiums
	for everyone.
	Mr. Meuser. That is encouraging to hear. Now that we have
	established that we are in agreement on preexisting conditions,
	I would like to ask you your thoughts on the Affordable Care
	Act's effect on association health plans. In Pennsylvania, for
	instance, the Pennsylvania Farm Bureau had 12,000 members in an
	association health plan and it worked very well, along with
	other organizations. The Trump administration has issued a
	final rule allowing for the use of AHPs, however, many
	Governors, democrat Governors it so happens to be, across the
	country, including in Pennsylvania, are blocking the formation
	of AHPs.
	Can you speak to the importance of the efforts to allow
	AHPs and maybe comment technically as to why these efforts
	would be blocked?
	Ms. Turner. So far association health plans are available
	in 13 States, about two-dozen plans in all. And some States are
	considering invalidating or blocking these plans, which they
	have full right to do, just as they are short-term limited
	duration plans. But what they are doing is foreclosing options
	for people who are otherwise likely to simply be uninsured. If
	they don't have an affordable option their family cannot only
	face bankruptcy, but not having access to that good high
	quality care that private insurance brings.
	So it is unfortunate if States take a view that because, I
	don't know, the Trump administration rules that therefore they
	should be opposed, because they are providing options for
	people who are desperate for coverage.
	Mr. Meuser. Yes. OK. That is unfortunate. Thank you.
	Medicare Advantage. I have people coming into my office and
	throughout my district talking about, speaking about how
	terrific Medicare Advantage programs are, how relatively
	affordable they are versus other Medicare plans. And, as a
	matter of fact, the Medicare Advantage plans have decreased,
	reduced in cost by 6 percent this past year when other plans on
	average are going up 12 percent. So would you say that this is
	a successful example of private sector innovation? And could
	you offer any other insight on the effectiveness of Medicare
	Advantage.
	Ms. Turner. They were created, as you know, in 2003 through
	the Medicare Modernization Act and went into effect in 2006.
	And there was no real significant promotion of Medicare
	Advantage plans. It was offered as an option for private
	coverage to seniors, so they didn't have to be in something of
	a Swiss cheese of a program with a fee-for-service Medicare.
	They have been hugely popular. I think almost half of seniors
	now have individually selected on their own, without any
	mandates, Medicare Advantage plans. And these plans compete
	fiercely for seniors. They have to cover a basic level--not
	basic but very generous level of benefits and many of the plans
	offer much more comprehensive coverage than people can get in
	traditional Medicare. And many of them also incorporate
	prescription drug coverage.
	I think that seniors see it is crucially important because
	it also provides an environment for coordinated care, rather
	than going from doctor to doctor and fee-for-service
	traditional medicine Medicare. Maybe getting the same
	prescription with different names from physicians and then
	winding up in the hospital with drug toxicity, they have
	somebody looking out for them and being able to really
	coordinate and help manage their care.
	Very, very beneficial. And, of course, these are private
	plans within Medicare.
	Mr. Meuser. OK. Do I have any more time, Mr. Chairman?
	Chairman Scott. Not really.
	Mr. Meuser. OK. Well, I yield the remainder of my time.
	Chairman Scott. Thank you. I appreciate it. The gentlelady
	from Florida, Secretary Shalala.
	Ms. Shalala. Thank you very much, Mr. Chairman. I don't
	want to add, a lot of my colleagues have asked the same
	questions I would have asked.
	I do want to point out that Medicare Advantage gets a lot
	more money than traditional Medicare and therefore it is
	expected to provide a lot more benefits. It also pays
	dramatically for the kind of marketing that the private plans
	want to do. So, we are paying with taxpayer money for Medicare
	Advantage significantly. And most analysis has shown that we
	are overpaying for Medicare Advantage given the benefits that
	are provided.
	I do have a couple of questions though. I want to ask Ms.
	Corlette, we focused here on preexisting conditions, but would
	coverage for preexisting conditions actually work very well if
	we didn't have the other consumer protections? I mean we could
	all agree on preexisting conditions, but if you don't take the
	caps off, preexisting conditions are limited. And Mr. Riedy
	would have a very difficult time with CF.
	Ms. Corlette. Yes, absolutely. And, in fact, New York is a
	great example of a State that had a number of preexisting
	condition protections before the ACA was passed, but they had a
	very expensive individual market because they didn't have the
	other provisions that the ACA included, such as the subsidies
	to support people up to 400 percent of the Federal poverty
	level to buy insurance, as well as the individual mandate
	penalty.
	So, it is important to note that the ACA included not just
	preexisting condition protections, but a number of provisions
	that were more holistically designed to try to make coverage
	accessible and affordable for people. All of those, of course,
	have been at least preliminarily ruled to be invalid by the
	Texas court.
	Ms. Shalala. Thank you very much. And, Dr. Gupta, yesterday
	the President said that he was going to invest some money in
	HIV drugs. And I want to ask you about that, because it is very
	important in my district. We have the highest incidence per
	capita, and therefore I am very supportive of any investment in
	HIV. But those investments don't work without a comprehensive
	plan around them. And could you talk a little about that?
	Dr. Gupta. Absolutely. Thank you for that question. So as
	opposed to the 1980's, where we had a challenge of diagnosing
	HIV, figuring out how to treat it, and make it a condition.
	People were dying on the streets because of that. Now, we have
	a challenge of finding those individuals who may not know that
	they have HIV. So, screening--that is why we have moved to what
	we call universal screening and you really have to opt out of
	it, otherwise most of us need to get screened. The idea behind
	that is most people that may have HIV do not know they have
	HIV. And if they can be caught early and put in treatment it
	becomes a chronic condition you can live with. You don't have
	to die because of the complications now.
	When you start to remove the other legs of that stool, in
	terms of essential health benefits, then obviously those people
	are going to not want to be screened for the HIV. The diagnosis
	will not occur and then they will not be treated. As a result
	they will continue to transmit the disease and we will result
	in having more cases than fewer cases and our conquest to
	eliminate HIV from the United States will not happen anytime
	soon.
	Ms. Shalala. Thank you very much. And, Ms. Turner, if I
	could ask a quick question about the flexibility you are
	talking about. Would it be OK with you if a State was willing
	to develop a plan that continued caps, had covered preexisting
	conditions but continued caps? Because, you know, private
	insurance is a mixed bag in this country. I have got half a
	million people in my own district that are covered by private
	insurance, but some of it is underinsurance because it has high
	deductibles. And how much flexibility would you give the States
	so that we would really recognize it as insurance and
	comprehensive insurance? Would you continue some of these
	consumer protections that we are talking about?
	Ms. Turner. I think that it is important to recognize that
	State officials have to answer to the same constituents when
	they are making changes, health policy changes that Federal
	officials do. And so that needs to be a conversation with their
	voters, and to make sure that they are answering the
	constituents' needs for affordable, quality coverage, but doing
	so in a way that may give them more flexibility.
	Some States in Medicaid, as you know, and I am sure under
	your Secretaryship some of the waivers were approved to give
	States like Oregon, for example, a lot of flexibility within
	its Medicaid program and what benefits were covered. So I think
	States can better fine-tune the mandates than a Washington
	mandate. The Affordable Care Act has been changed already
	either by administrative order or by acts of Congress 70 times.
	So, I think needing to give the States the flexibility to
	answer the needs of their constituents and know that their
	constituents actually can be better heard at the State level, I
	think is important.
	Ms. Shalala. I should point out that the Oregon simply took
	the same package. It actually didn't mix up the package of
	benefits very much. I am asking you specifically about caps and
	about preexisting conditions. Do you think that States ought to
	be able and the other consumer protections ought to be able to
	waive those consumer protections and would it actually be
	comprehensive insurance at the end of the day if they had
	flexibility on those consumer protections including preexisting
	conditions?
	Ms. Turner. We see with States that are saying they don't
	want short-term limited duration plans, California and offered
	in their States, Pennsylvania, restrictions on association
	health plans. If States feel that those consumer protections
	are important, I believe that they will keep them and if they
	feel that there needs to be some flexibility along with
	consumer awareness and transparency, then I think States should
	have the option of figuring out what works best for their
	constituents.
	Ms. Shalala. So you wouldn't favor ERISA protections for--
	and overrule States--using ERISA protections?
	Ms. Turner. I think that right now we basically have under
	HIPAA we have the protections that allow people to go from
	their employer plan--
	Ms. Shalala. Right.
	Ms. Turner [continuing]. to another employer plan and
	maintain that continuity of coverage and not be discriminated
	against. So those protections are already on the books and
	because of the community rating within employer plans, people
	are protected to make sure that their health status does not
	affect their premium costs.
	Ms. Shalala. I yield.
	Chairman Scott. Thank you. Gentleman from Wisconsin, Mr.
	Grothman.
	Mr. Grothman. OK, thank you. Moving now, Ms. Turner, and
	one more time, I think you've answered this, but it seems to me
	the Republicans, the Democrats are all favored, in favor of
	protecting coverage for preexisting conditions. Can you just
	one more time tell us, we have said it so many times but not as
	many times as the ads we have saying otherwise running against
	us in election. Under current law, are workers with preexisting
	conditions allowed to be charged more, denied coverage based on
	their condition?
	Ms. Turner. I'm sorry, repeat.
	Mr. Grothman. Under current law, are people allowed to be
	charged more, denied coverage based on their conditions?
	Ms. Turner. No, Congressman.
	Mr. Grothman. OK. So that is the current law right now.
	Good. Now I will give you some other general questions. I am
	from Wisconsin. In 2018 last year, Scott Walker worked with the
	Trump administration and CMS to approve a 1332 State innovation
	waiver, which caused our premiums to drop. Are you familiar
	with that situation?
	Ms. Turner. Yes, I am, sir.
	Mr. Grothman. Could you talk about what we did in
	Wisconsin?
	Ms. Turner. I mentioned actually in my testimony some of
	them, some of the impact that these plans have had and of
	course I can't find this chart when I'm looking for it. But
	they have been able to basically repurpose existing ACA money
	to help increase access to coverage or to improve access to
	coverage for people with chronic conditions, preexisting
	conditions, and therefore lower premiums in their general
	market.
	So a number of States have--Wisconsin is often taking the
	lead in health policy innovations and waivers and I think that
	this is an important one to move forward with.
	Mr. Grothman. And at least I am told that premiums dropped
	a little over 4 percent, is that your?
	Ms. Turner. Premiums dropped and enrollment increased as a
	direct consequence.
	Mr. Grothman. Good. And in the past, before this type of
	thing, we saw incredible increases in premiums and open
	enrollment falling. Is that--we saw that in Wisconsin. Is that
	your nationwide?
	Ms. Turner. Because the premiums were so much higher--
	Mr. Grothman. Right. As the premiums--a lot of people just
	throw in the towel.
	Ms. Turner. People just can't afford it and they also--we
	talk about a high deductible. The deductibles are so high and
	the ACA plans that if people are not eligible for cost-sharing
	reduction subsidies they basically say they might as well not
	be insured because they can't afford to pay the first $10,000
	every year out of pocket before coverage kicks in.
	Mr. Grothman. I am glad you mentioned association plans. My
	experience with health care in general, when you take a group,
	not a Statewide group because it is hard for the State to
	duplicate it, but when you take a business with a 1,000
	employees or something, a lot of those innovative businesses
	were doing a very good job. One of the things they did is
	employer-based clinics which saved tremendous amount of money
	for a variety of reasons. Is there any way that you can see
	that sort of thing can be duplicated through something like
	Obamacare or is this the type of innovation that is why we want
	the vast majority of Americans hopefully still insured through
	their employer?
	Ms. Turner. Well, the Affordable Care Act did allow some
	innovation incentives for people to do--not association health
	plans, I'm blanking on the name of the creative coordinated
	care plans within Medicare. And because the rules that were
	written around the Affordable Care Act were so strict, even
	plans like the Mayo Clinic and Cleveland Clinic and others that
	had been--Geisinger, that had been very successful in managed,
	coordinated care, couldn't make it work.
	So I do think that flexibility is really important and
	trusting employers--some employers have said for example that
	they feel it is worth flying their employee to another State
	and family members to get care at a center of excellence, of
	cardiac care, cancer care. So they really do try to innovate to
	get the best value and the best quality care.
	Mr. Grothman. It is another thing. I did mention employer-
	based clinics but these centers of value, flying people to
	other States because an employer has the ability to hire
	somebody and do a good job. Now I know there are a lot of
	people who always feel that setting up another big Federal
	bureaucracy is going to work after this seems to have failed
	like 120,000 times in a row, but what you are telling me is a
	way that the private insurance plans and for individual
	companies and hopefully to be duplicated by associated plans,
	they are able to find ways to reduce premiums and reduce costs
	that really as a practical matter are not being duplicated with
	a government bureaucracy.
	Ms. Turner. That is correct.
	Mr. Grothman. Thank you.
	Chairman Scott. Thank you. The gentleman from Michigan, Mr.
	Levin.
	Mr. Levin. Thank you, Mr. Chairman. I would like to dig in
	a little more deeply to the Texas v. United States case and I
	have a question to start for Ms. Corlette. In a departure from
	long standing precedent of defending Federal law against
	constitutional challenges, the Trump Administration's
	Department of Justice filed a brief last year requesting that
	the court strike down several provisions of the ACA in the
	Texas case. Among the provisions that the administration argues
	should be overturned include guaranteed issue, community
	rating, discrimination based on health status and preexisting
	conditions exclusions.
	Last week, President Trump told the New York Times that he
	is optimistic that the ongoing Texas lawsuit will terminate the
	Affordable Care Act. Would you say that the Justice
	Department's decision not to defend the ACA is consistent with
	Republican promises to protect patients with preexisting
	conditions?
	Ms. Corlette. Well, I would say that the Justice
	Department's provision--position if it prevails would strike
	down the protections that the ACA provides for people with
	preexisting conditions. So no, it's not consistent.
	Mr. Levin. And how does this, his statement reflect the
	Administration's approach to this issue?
	Ms. Corlette. I--
	Mr. Levin. Of preexisting conditions that we are here to
	talk about.
	Ms. Corlette. I have, yes. I have a little trouble divining
	exactly what the Administration's position is given that there
	do seem to be differences between what President Trump has said
	and what the Justice Department position is so I am not sure I
	can comment.
	Mr. Levin. And what they are actually doing. So you pointed
	out in your testimony that Republicans never have come up with
	a proposal to replace the ACA yet they continue with their
	efforts to unravel it, the most recent example being the Texas
	lawsuit.
	During the last Congress when we were debating the
	Republican bill to repeal the ACA, Republicans put proposed
	segmenting the population and dumping sick patients into high
	risk pools. The CBO had the following assessment of this
	proposal: ``Less healthy people would face extremely high
	premium. Over time it would become more difficult for less
	healthy people, including people with preexisting medical
	conditions in those States to purchase insurance because their
	premiums would continue to increase rapidly.''
	One of our witnesses, Ms. Turner, has put forth a similar
	proposal this morning or early this afternoon. Ms. Corlette,
	how do risk--high-risk pools stack up as an alternative to the
	coverage provided through the ACA?
	Ms. Corlette. Sure. Well, we have a history of high-risk
	pools. Before the ACA there were about 35 States that had high-
	risk pools and they varied. They were different, but I can tell
	you that for people who were in high-risk pools, the premiums
	could be as much as two times the standard rate. They often had
	preexisting condition exclusions so the condition that got you
	denied coverage in the individual market you didn't get covered
	in the high-risk pool for up to a year. You had annual and
	lifetime limits quite often, high deductibles and often many of
	these high-risk pools limited enrollment. Even still, they
	operated at a loss so they needed to be subsidized by the
	government.
	Mr. Levin. OK, thank you. I have a question for Mr. Riedy.
	In your testimony, you described the enormous cost of your
	medical treatments, totaling nearly $450,000 last year. Prior
	to the ACA plans in the both the individual and employer market
	were permitted to impose annual and lifetime limits on care and
	many of them did, including more than 90 percent of the plans
	in the individual market. You better than most people can speak
	to the real-world impact of these limits. Based on your
	personal experience, how do annual or lifetime limits on
	coverage impact patients with high-cost conditions?
	Mr. Riedy. Thank you for the question. Annual and lifetime
	caps for me personally if they were allowed to exist again
	would cause a severe financial burden on my family. Not just
	from the cost of having to pay for the care that I receive, but
	also from the impact that if I do reach that cap, what happens
	next? Do I have to pay for them out of pocket? And if I do then
	those costs can be unmanageable.
	As you mentioned my care last year just for the medicines
	was $450,0000. That is a lot of money to take and so the
	impacts of those caps, having them now provide peace of mind.
	They also know that I can continue to receive the highly
	specialized care and that I have access to that coverage that
	allows me to get that care.
	Mr. Levin. I can't thank you enough for coming and sharing
	your story with us and with the American people. And just in a
	note of solidarity, I like the gentlewoman from Georgia who
	spoke earlier, I am a two-time cancer survivor but also Mary
	and I have four kids. The two oldest both have Crohn's disease
	and have for 14 years and we would have gone bankrupt multiple
	times over just trying to pay for their medications if they
	weren't covered and because of, you know, caps. Lifetime, we
	would have blown by lifetime caps already so I really thank you
	for sharing your story. I yield back, Mr. Chairman.
	Chairman Scott. Thank you. The gentleman from Kansas, Mr.
	Watkins.
	Mr. Watkins. Thank you, Mr. Chairman. My question is for
	Ms. Turner. Ma'am, I represent Kansas and in Kansas, Kansans
	with preexisting conditions face a number of challenges and
	hardships. And I am glad that a lot of Democrats and
	Republicans agree that Americans with preexisting conditions
	should and have been for years been protected, for decades
	actually. And so in that of course even before the Affordable
	Care Act so unfortunately since its passage, the ACA continues
	to be problematic. Premiums continue to rise and the answer I
	believe is not to double down on ACA but and seek a one size
	fits all government-run health care regime.
	Therefore, Ms. Turner, since the passage of Obamacare, can
	you speak to the lack of actual affordability for the vast
	majority of Americans? Also the rate of continued premium
	increases because of the law?
	Ms. Turner. Premiums in the exchange markets have about
	doubled on average since the law went into--since the exchanges
	took effect in 2014. That is much higher than in the regular
	market and certainly before that. And a consequence of that is
	that it's driving more and more healthy people out of the
	market.
	The ACA as you know forces young people to pay a
	disproportionally high amount for their coverage because of the
	three-to-one age rating in the exchanges. And so we are
	losing--if young people are not eligible for their parent's
	coverage and trying to afford premiums on their own, they're
	paying a disproportionate amount for people who are older and
	sicker and therefore they're dropping out as well. So I think
	it is crucial if we really want to increase access to health
	coverage that we figure out a way to get cost down and to
	attract the healthy people into the market.
	Senator Reeve's constituent in Virginia, he doesn't want to
	drop out of health insurance market but he can't afford $4,000
	a month for premiums and having no choices of coverage. Some
	people need more choices. They need to be able to have more
	flexibility with benefits to protect their family and they need
	some of these bridge plans like association health plans and
	short-term limited duration plans.
	Mr. Watkins. Thank you. I also want to touch on our
	increasingly strong economy propelled by comprehensive tax cuts
	and regulatory reform. In fact, CNBC recently noted that
	January job reports just last week payroll surged by 304,000
	smashing estimates. Thanks to recent pro-growth Federal policy
	changes, more and more Americans are finally finding good
	paying jobs. Many of these jobs offer generous employer
	sponsored healthcare. So all the employers simply know that
	they can--that they have to be competitive to attract good HR.
	So, Ms. Turner, can a strong jobs market spurred by pro-growth
	policies lead to increased coverage rates nationally for
	employees--employers with preexisting coverage? What are some
	policies that can continue fueling work force participation?
	Ms. Turner. You are absolutely right that employees highly
	value the, their workplace coverage and the workplace--the H.R.
	departments, especially for big companies work tirelessly to
	try to negotiate the best benefits, the best drug formulary and
	the access to the highest quality hospitals for their employees
	to attract them so that they won't go to a competitor. And
	there are how many, 2 million jobs, two and a half million jobs
	that aren't filled now and employers can't even find the
	workers to fill them. So being able to offer attractive,
	affordable health coverage with the flexibility to meet the
	needs of their workers, and having providers that are competing
	for that business to get, to offer those lower costs, higher
	value plans, I think is really a crucial part of a thriving
	economy.
	Mr. Watkins. Thank you, Ms. Turner. I yield back, Mr.
	Chairman.
	Chairman Scott. Thank you. The gentleman from Maryland, Mr.
	Trone.
	Mr. Trone. I thank you, Mr. Chairman. Ms. Corlette, 30
	years ago I started my business with my wife and two little
	girls and I know firsthand starting a business can be scary
	without the fear you are going to be able to afford healthcare
	for yourself and your family. You mentioned prior to the ACA
	people were often tied to jobs they'd have otherwise left but
	simply because they needed to maintain healthcare, access to
	affordable health insurance. Could you elaborate on what the
	ACA's protections for patients with preexisting conditions has
	meant for entrepreneurship, startups, small business creation?
	Ms. Corlette. Sure. So, before the ACA, if you were leaving
	a job-based plan, you were required to maintain what was called
	COBRA coverage which was continuation coverage, but you had to
	pay the full premium. And for most people that was
	unaffordable. And so, people often had a lapse in coverage and
	then if you had a preexisting condition it was almost
	impossible to find an individual market plan to cover you and
	your family.
	With the ACA you can now if you have a business idea or
	want to go out on your own and start a consultancy or invent
	something, you can do so without having to worry that your
	preexisting condition would cause you to be denied or have a
	preexisting condition imposed on your--exclusion imposed on
	your policy.
	Mr. Trone. So, Dr. Gupta, the opioid epidemic as you spoke
	about and you are from West Virginia. My district borders
	western Maryland so we are right there together in the heart of
	the opioid epidemic on I-81. I lost my nephew, age 24, to a
	fentanyl overdose a couple years ago and so many folks in my
	district have been adversely affected by this tragedy.
	With the ACA, we closed a lot of gaps in coverage,
	especially in the area of behavioral health. And I think that
	is so important and it is all part and parcel of this disaster
	substance disorders. If the ACA was gone, what do you see as
	the human toll?
	Dr. Gupta. Thank you for that question. Certainly we
	understand, you know, States with border counties populations
	don't treat those as States, they are one community within
	those areas. So, it's very important for people to be able to
	move across and not have to worry about what is the State
	regulation in this State and the State regulation in that
	State? ACA allows that consistency to happen State to State.
	The mental health protections as well as the ability to get the
	help that need and people would have so many other challenges
	ongoing at the same time. ACA really allows that to happen and
	I think that is the most important piece as we are combatting
	this opioid crisis is to be able to not have any extra barriers
	in terms of coverage and accessibility to care. As the good
	treatments are existing and more come up, we have got to be
	able to have the access to provide tens of millions of people
	who are suffering and dying actually, tens of thousands per
	year to be able to save them and get them back to work.
	Mr. Trone. As we put together legislation on opioids to
	address that, what do you see as a couple key points that
	should be in that to address the mental health connectivity
	which was so crucial and part and parcel of this at all times?
	Dr. Gupta. I think it is very important for us to go back
	to see what we did with HIV. We realized HIV was much more of a
	social determinant aspect of this in the 80's and we put
	together, you know, the Ryan White Care Act for example, that
	not just took care of you as an individual, your medication,
	but you--looked at your house and your access and all those
	things.
	So I think it is very important when you look at this
	crisis, we are looking at housing, we are looking at access,
	daycare, all of those tools that surround somebody who is
	suffering from addiction to be able to be provided so that they
	can get into treatment and then they can have a successful,
	fair chance of recovery and back into employment.
	So, it is a lot more than just pills or just counseling.
	There is a societal response that we must have to this crisis
	in order to address it and I think that is the part that we can
	do more, not less.
	Mr. Trone. OK, thank you. I yield the balance of my time.
	Chairman Scott. Thank you. The gentleman from Indiana, Mr.
	Fulcher.
	Mr. Fulcher. Thank you, Mr. Chairman, and panelists.
	Chairman Scott. Excuse me, Idaho. Excuse me.
	Mr. Fulcher. Yes, it is a common mistake. Thank you.
	Panelists take heart. I think the end is near. It is coming
	close here OK and please forgive the lack of attendance by some
	of us on the front end. I, for one, am still struggling with
	the multiple committees as the same time. And so please know
	that wasn't rudeness.
	My question and I will probably address this to Ms. Turner
	because I know some of this has been covered and I am going to
	shorten things up because Mr. Watkins hit part of that. But in
	our State of Idaho, 2012 I think it was we--I believe we were
	the only State with Republican leadership in the House, the
	Senate, and the Governor's office that embraced the State-based
	exchange. And I was in the Senate leadership role at that time
	and in hindsight it just hasn't worked out well for us.
	Our insurance premiums across the board have averaged
	somewhere between a 15 and a 27 percent per year increase. And
	so as we speak right now, in our State, there is a lot of
	things on the table. It is--that have been--that are being
	discussed right now. Alternatives to try to figure out a better
	path and I would just like to get your counsel, your input, on
	some of those things and I will just list a few. But the
	expansion of HSAs, medical memberships, medishare, charity
	care. The expansion of insurance procurement across State lines
	which in our State we can't do, high-risk pool reform. Those
	types of things which are--they are more market-based and given
	our history and our struggle with the status quo that there is,
	your thoughts, your counsel on that type of an approach.
	Ms. Turner. States do talk about the difficulty of figuring
	out how to address the needs of their State but it's even more
	than the State. It's sometimes at a county level. You have
	rural counties who have very different problems then Cincinnati
	and Canton and Cleveland. They've really need to have the
	resources and the flexibility to meet the needs of those areas.
	And I want to really reinforce what Dr. Gupta was saying
	about the social determinants of health. We put so much money
	just into health care when people may actually need other kinds
	of supports to make their lives work better. And I believe that
	Ohio is one of the States that has--is implementing work
	requirements as well for Medicaid. And people who work with
	these communities say that is a valuable thing to make sure
	that people have someplace to go once they get through
	rehabilitation treatment, to have a job, something to give
	stability to their life. Help them with housing.
	If States had more flexibility and I believe the Trump
	Administration is working to do that. As we have said before,
	Congress had repeatedly voted for money to dedicate money to
	high-risk pools. Many States that were doing--the States that
	were doing high-risk pools in the past were doing it all with
	State money. With the ACA there is new money to put on the
	table to make those risk pools work better so that you can
	provide dedicated resources for them and more comprehensive
	care for chronic conditions.
	So care management for those high end patients, being able
	to have more flexibility, to provide the kinds of benefits
	structures that people actually want to purchase to protect
	themselves and their families I think are really crucial. And
	hopefully we can work with Ohio and other States in trying to
	think about what some of those waiver options might be to
	work--make it work better for your State.
	Mr. Fulcher. Thank you. Mr. Chairman, a quick followup and
	I will--thank you. Ms. Turner, in a few words because I am
	going to yield my time here in just a second. But that makes
	sense. But when it comes right down to it, should we be
	focusing on solutions that come out of this room and out of
	this building and out of the building next door or should be
	focusing on more market--enabling market-based solutions to try
	to improve our situation?
	Ms. Turner. We see in Medicare advantage for example that
	market-based solutions to provide more comprehensive care and I
	believe it is really based upon a formula very close to what
	traditional Medicare pays for Medicare advantage, can give
	incentives to begin to find the same kinds of cost efficiencies
	in the health sector that we see at other sectors of the
	economy.
	When you have so much of the time of health care providers
	and administrators focused on following Washington's rules
	rather than figuring out what is best for the patient, what is
	best for our State that it really takes away time and energy
	from solving the problem.
	Mr. Fulcher. Thank you, panelists, Ms. Turner. Mr.
	Chairman, I yield back.
	Chairman Scott. Thank you. Gentlelady from Michigan, Ms.
	Stevens.
	Mr. Stevens. I would like to take a minute to thank our
	panelists today. Ms. Corlette, your expertise and knowledge
	was--is so welcome and we thank you for taking the time.
	Mr. Riedy, thank you for your courage and your words of
	wisdom and sharing your personal story. It was a delight to be
	in this room with your family who was looking at you with very
	proud eyes. You are one of the reasons why the ACA was so
	critical and critical to every American taxpayer and American
	worker and I admire you from the bottom of my heart.
	And, Ms. Turner, I want to thank you for your eloquence and
	answering a lot of questions today. And, Dr. Gupta, thank you
	for being here.
	As we are here examining threats to workers with
	preexisting conditions, this topic could not be more critical
	as our Ranking Member Foxx indicated. We have a healthy economy
	and the health of our taxpayers and our workers is paramount.
	And Dr. Gupta, I would like to take my questions to you and
	your expertise which we are delighted to have in the room
	today. In your testimony, you discussed the issue of high-risk
	pregnancy and delivery and how women prior to the enactment of
	the ACA often found that, you know, they reached their policy's
	cap. They would reach their policy's cap on the amount of care
	provided. They would find themselves exposed financially,
	unsupported in the workplace, and generally pushed to a brink.
	And so, I would like to ask you, what is the cost of high-risk
	pregnancy and how likely are women to run up against these caps
	in the absence of the ACA protections.
	Dr. Gupta. Certainly, thank you for that question. March of
	Dimes certainly is doing a lot of work around this because we
	know that maternal mortality and morbidity amongst the 49
	developed countries in the world, we are number 49. We are
	actually three times mortality of the next country in line
	which is UK. So we are really in a bad shape right now. For--we
	have women dying every single day.
	The cost can be tremendous and when we look at the cost
	really it is not just human lives lost, but we are talking
	about one complicated pregnancy can cause that woman to lose
	potentially her absolutely full annual lifetime limits. So, she
	may not have coverage for the rest of the year and have to take
	care of not just the baby but the rest of the family.
	Same way we go back to the severe prematurity. One simple
	birth with severe prematurity can land a child, an infant for
	multiple months in a neonatal ICU. So, when the baby returns
	home for the first time when there should be a cause for
	celebration, it would then be a cause that the baby could meet
	his or hers lifetime limits on care and not be insurable until
	Medicare. And that's just a terrible thing to think about and
	those are the challenges we are dealing with where we need to
	be making progress to work in those maternity care deserts.
	We have a third of the counties in this country or 1,000
	counties, 5 million women, 150,000 babies that are being born
	what no obstetric care. And so that we are actually, you know,
	talking about walking backwards.
	Mr. Stevens. Well, and not only is this a cost to the
	mother and the family, it is a cost to the employer as we, you
	know, are talking about the workforce and our economy writ
	large. And, Dr. Gupta, as you know, the Affordable Care Act
	requires insurers to cover preventative health services without
	cost-sharing and these obviously include family planning, well
	women visits, screenings for domestic violence and other
	crucial health services.
	And I, just to back this out a minute, I would love for you
	to just reflect on how pregnant women and other new members--
	mothers, excuse me, utilize these services and what impact
	would overturning these provisions maybe through the Texas
	litigation have on these women?
	Dr. Gupta. So first of all, just the idea of preconception
	care to be healthy in order to get pregnant is very important.
	That would not happen. Then within prenatal care the notion of
	having things like vitamin--folic acid and vitamins, which we
	think is very basic, we recommend that all across the globe,
	yet we can have women that can have, deliver and cause real
	harm to the babies developing because of neural tube defects
	and other things that are not being provided. Throughout the
	prenatal care we know the amount of visits that happen with the
	doctor's office and this following a standard of care leads to
	better delivery, better care of not just the mother but also
	the baby as a result, getting the family dyad back together,
	the mom and baby. None of that would be possible if we were to
	remove that.
	And obviously one of the things that used to happen was the
	only time you could get into Medicaid was if you were--if you
	got pregnant and then it would be removed the coverage right
	after. Now we have 60 days, up to 60 days coverage post-partum.
	When we are dealing with challenges of post-partum depression,
	suicide, post-partum hemorrhage, hypertension, eclampsia, heart
	conditions, it's very critical for us to build on that coverage
	post-partum up to a year because of the increasing maternal
	mortality that is happening.
	This is still the most dangerous place for a woman to have
	birth in the developed world. And we need to be working again
	not at removing that but actually developing more steps but at
	this time, removal of ACA provisions will cost women and their
	children not only just their jobs but potentially their lives.
	Mr. Stevens. Yes. Well, Dr. Gupta, while you don't share my
	gender, I appreciate you sharing the stories of women and
	mothers and making that at the forefront of our minds today.
	Thank you.
	Chairman Scott. Thank you. The gentlelady from Nevada, Ms.
	Lee.
	Mr. Lee. Thank you. I wanted to first thank all of the
	panelists today for your testimony and answering the questions.
	And, Mr. Riedy, I wanted to speak directly to you. First of
	all, CF has had a place in my family. My husband lost a cousin
	about 30 years ago before groundbreaking technologies and
	treatments were available. And more importantly, my sister,
	Mary Lester, is a respiratory therapist at Keck Medical Center
	at USC and dealing with adult cystic fibrosis. So, through her
	years, through my years and I have experienced alongside her
	many of the struggles that patients like you go through. So,
	thank you very much for being here and your testimony.
	I wanted to ask, in your testimony you pointed out that
	you're fortunate to have comprehensive health coverage through
	your wife's employer. If your wife were to change jobs, choose
	to start a small business or possibly take time off for
	education, you might end up in a situation where you would have
	to change this coverage. And I wanted to know from you how do
	the Affordable Care Acts protections for patients with
	preexisting conditions provide peace of mind that you would
	never be without coverage?
	Mr. Riedy. Thank you for that question. Knowing that my
	wife or I could switch employers and still be adequately
	covered, it gives us peace of mind that allows us to be
	flexible and explore new opportunities potentially that before
	the ACA may not have existed. And without the ACA, you know,
	there is always that fear that leaving a job if I went to
	another one that I could still be denied insurance because of
	my preexisting condition or if my wife changed jobs, you know,
	would they deny me coverage because of my preexisting
	condition.
	Mr. Lee. And thank you. And to followup on that, what
	impact would an adverse decision in Texas case have on your
	wife's ability to change jobs?
	Mr. Riedy. Well, if the ACA was--if the ruling stands, my
	wife would have less of the opportunity to explore new
	opportunities. She is a teacher so she is at a great place
	right now but if she had to--if she wanted to do something
	other than teach or switch employers there's still that fear
	that we may be or I may be denied coverage or access to it. So,
	it could lock her into where she is.
	Mr. Lee. Lock her in. All right, thank you. One other
	question. According to the Department of Health and Human
	Services, the number of Americans with preexisting conditions
	ranges from at least 23 percent, 61 million people to as many
	as 133 million people. And prior to the Affordable Care Act
	these Americans with preexisting conditions could be denied
	coverage or charged an exorbitant premium to get coverage,
	something that my parents had experience both having high blood
	pressure at one point in their lives.
	Some families have even declared bankruptcy from high
	medical bills due to having a preexisting condition. Today,
	however, insurance companies cannot discriminate against people
	based on their medical history.
	Mr. Riedy, without employer-sponsored health insurance or
	insurance through your family prior to the Affordable Care Act,
	do you believe you would have been able to attain affordable
	health insurance?
	Mr. Riedy. Before the ACA I would have likely been denied
	coverage because of my preexisting condition without the access
	to employer-sponsored health coverage. And the ACA provides me
	with the opportunity to be adequately covered on the individual
	market I'm currently in. Without them I don't know if that
	would be possible.
	Mr. Lee. Well, thank you so much for your testimony. I want
	to say I texted my sister to tell her I was going to be
	speaking with you today and she sent me this message back that
	said please make sure we help people with cystic fibrosis
	because these patient needs to have their medical needs met and
	it is extremely expensive illness. She said they didn't cause
	this disease, but they must fight it and so thank you for your
	courage for being here. I appreciate it.
	Chairman Scott. Thank you. The gentlelady from
	Massachusetts, Ms. Trahan.
	Ms. Trahan. Thank you. Thank you, Mr. Chairman, for having
	this hearing and thank you, everyone, for hanging in for a long
	hearing. Part of the challenge of being later in the program
	and new here is so many of the thoughtful inquiries have
	already been made but I do have a couple of questions. I am a
	mother of two young girls, 8 and 4 as well as three grown
	stepsons who have benefited from the ACA and being able to stay
	on my health plan as they enter the workforce.
	Before the ACA women were often charged more than men just
	because of their gender and some couldn't even get coverage on
	the individual market. For women of childbearing age, the
	discrimination was particularly blatant, and the vast majority
	of plans excluded maternity coverage of any kind. And I
	appreciate my colleague from Michigan and her inquiry around
	maternal care.
	Dr. Gupta, I am wondering if you could just explain to us
	what it was like for women to get health insurance coverage
	before ACA and how many plans covered maternity coverage in the
	individual market and what improvements have women and their
	families seen since ACA?
	Dr. Gupta. Certainly, thank you for that. We know that
	prior to the ACA, only 11 States mandated the coverage of
	maternity care. Only 13 percent of the individual health market
	actually covered maternity care. We know that at that time
	obviously the gender of being female was a preexisting
	condition in effect. We also know that 47 percent of people who
	tried, adults who try to get coverage with preexisting
	condition were either denied, charged more or were precluded
	from at least one condition. That's from the Commonwealth Fund
	Study. So, we know that this was a big problem.
	Since then, March of Dimes did a study in 2015 and found
	that between 2013 and 2015 the uninsured coverage for
	childbearing age women went down from about 20 million to 13
	million, I'm sorry 20 percent to 13 percent. That means that
	another 5 and a half million of childbearing age gained
	coverage. Not only that, the unmet needs actually went down by
	10 percent points of those women. So clearly that has been a
	big gain.
	I would say when we talk about preexisting conditions,
	health inequities are the first cause of preexisting
	conditions. And when I talk about maternal mortality, a black
	woman in this country is more likely to die--three to four
	times more than a white woman. So, we still have for healthcare
	institutions across and healthcare systems across the country,
	today, race is a preexisting condition and we need to continue
	to work on that and I think that is a critical piece that I
	must bring up as well.
	Ms. Trahan. Thank you. Thank you, Dr. Gupta. and, Ms.
	Corlette, to borrow a phrase that is going around a lot, the
	dignity of work is something that means a lot of me. And I am
	the daughter of a union ironworker. My mom worked multiple
	part-time jobs while raising my sisters and me. I am constantly
	thinking about how are we going to support work and labor as it
	transitions to the future and what the future of work actually
	looks like?
	We talk a lot about our economy and adding more jobs but
	those don't always translate into employer-sponsored plans. So,
	a recent Department of Labor survey found that 10 percent of
	the workforce are categorized as either independent contractors
	or self-employed. This represents a growing segment of the
	workforce, in fact more than half of all ACA marketplace
	enrollees are small business owners, self-employed individuals
	or small business employees.
	I am wondering if you have looked at any additional
	research on the impact of the Texas lawsuit or even just the 70
	plus ACA repeal attempts would have on the future of work? And
	also, if we have time, can you discuss the impact of removing
	preexisting condition protections for gig economy workers,
	independent contractors specifically?
	Ms. Corlette. Sure. Thank you. It's a great question. So,
	for folks who do have job-based coverage, there are a couple of
	things to be concerned about if the Texas court decision
	stands. One of course is that people could lose--with chronic
	or high-cost health needs could lose some of the protections
	that Mr. Riedy has spoken so eloquently about. The other issue
	of course is job lock, and this is a phenomenon that was well-
	documented before the ACA where folks sort of hung onto their
	jobs and their job-based coverage because of the uncertainty of
	the individual market. And they may have had a great business
	idea or been a terrific entrepreneur but did not pursue that
	because of their need to maintain job-based coverage.
	Ms. Trahan. Great. Thank you. Thank you, Mr. Chairman, I
	yield back.
	Chairman Scott. Thank you. The gentlelady from North
	Carolina, Dr. Adams.
	Ms. Adams. Thank you, Mr. Chairman and thank you all very
	much for your testimony and for sitting out with us, we
	appreciate that very much. Mr. Riedy, thank you so much for
	sharing your story.
	Mr. Chairman, I would like to enter into the record first
	from the--some organizations that have commented regarding the
	preexisting conditions and the GOP plan. First, the American
	Cancer Society Action Network who says that these protections
	are hollow if patients and survivors can't afford insurance.
	From the American HealthCare Association, the plan would do
	just the opposite and not serve the health needs of all
	Americans. And then they also say that the greatest achievement
	of the ACA is protecting those with preexisting conditions. The
	National Disabilities Rights Network says that GOP plan permits
	discrimination against people with disabilities in the
	insurance market for preexisting conditions and I would like to
	enter this into the record, Mr. Chairman.
	Thank you. Let me just say as I have listened to you, all
	of you I thought about Dr. Martin Luther King, Jr., who talked
	about healthcare and inequities and who said that ``of all the
	forms of inequality, injustice in healthcare is the most
	shocking and most inhumane'' and indeed it is. I do want to
	just mention the impact that ACA has had on communities of
	color, in particular the protections of those with preexisting
	conditions.
	I am a diabetic and that's an illness that was considered,
	is considered a preexisting condition. It is very prevalent in
	my family. I had a sister who suffered with sickle cell, from
	sickle cell anemia, a preexisting condition who passed away
	before she was 27. African-Americans are 80 percent more likely
	than Whites to have been diagnosed with diabetes. About 365
	African Americans suffer with sickle cell anemia. Latin--Latino
	Americans have the highest rates of cervical cancer and Asian
	women are at the highest risk of osteoporosis.
	Simply put, the Affordable Care Act has saved lives and has
	provided healthcare to millions who previously thought
	affordable treatment was just a dream. Folks like me, families
	that grew up who didn't have healthcare at all, no health
	insurance, having to go to the emergency room to get our care.
	Dr. Gupta just one or two questions. For those with
	preexisting conditions or minority communities, how many more
	people with chronic illnesses have been covered and have those
	who suffer from chronic ailments seen improvements in their
	conditions as a result?
	Dr. Gupta. I can tell you that there has been a great
	progress made in that and I will certainly get you the exact
	numbers but the great progress made in that and the ability to
	again, level the playing field in our pursuit to level the
	playing field to get people to be covered. And we, I say that
	because these conditions are a part and representative of your
	socioeconomic condition. They're representative oftentimes of
	the culture we come from and lots of other things. What we call
	social determinants of health, education level. So being able
	to provide the basic healthcare that has happened as part of
	the health ACA has allowed our communities of color actually to
	be--have one less thing to worry about. So that's one of the
	things.
	The other piece I will go back to, you know, as March of
	Dimes we are focused on the health of moms and babies and
	nowhere is it more evident, the disparities and health
	inequities when we look at moms and babies. As I mentioned,
	three times to four times more likely to die if you're a black
	woman. Same way prematurely. Twice as likely to die if you're a
	premature child who is African-American. So, these are the type
	of things that we are fighting for and I think it is very
	important to understand that this will take us many steps
	backwards and we need to be moving forwards.
	Ms. Adams. Great, thank you very much. Wanted to just, you
	know, note that since the President assumed office we have seen
	a constant attack against ACA. So much so that we are seeing a
	reversal in quite a bit of the progress that we have made and
	just wanted you to just briefly comment on how this reversal in
	progress has impacted people of color specifically.
	Dr. Gupta. I think what we are--once again will end up
	happening, we will have individuals who will be dependent again
	on emergency care and urgent care as a result of which
	screenings will not happen, preventive visits will not happen.
	As a result of which we will not have--be able to catch those
	diseases early. It will be delayed, it will be more expensive
	and it will cost more lives. As Ms. Corlette eloquently pointed
	out a couple of times that we have clear data for ACA that when
	people were uninsured there were about, over 20,000, 22,000
	people we know in this country were dying every year because of
	the lack of insurance per say. We will go back to that.
	Ms. Adams. Thank you very much. I yield back, Mr. Chairman.
	Chairman Scott. Thank you. Gentlelady from Minnesota, Ms.
	Omar.
	Ms. Omar. Thank you, Chair. Thank you all for being here.
	Thank you for having this really important, critical
	conversation but sometimes frustrating conversation. And I say
	frustrating because of two reasons. One, to see the disconnect
	between what some of my colleagues would say in committee about
	healthcare and what their votes say about where their
	priorities and their values are, seems very, very frustrating
	for me.
	And the second is for us to have conversations about policy
	that have real impact on humans but to not really think about
	the humans that we are talking about in this discussion. So I
	am one that sees healthcare as a human right and I want to take
	some time for us to humanize this particular conversation
	because, you know, there are--there are people who will talk
	about the costs, they will talk about, you know, what struggles
	corporations will have or companies will have or a small
	businesses or all of these kind of things. But oftentimes we
	don't talk about the kind of stresses and the traumas that
	people like yourself, Mr. Riedy, have lived with as you not
	only deal with getting the diagnosis and figuring out how you
	go on with life, with the condition that could be a hindrance
	to your day-to-day life or could, you know, maybe end your
	life.
	So, what I wanted to do was maybe have you walk us through
	what it must have been like to go through the process to
	receive those letters from insurance companies before the
	passage of the ACA.
	Mr. Riedy. Well, thank you for the question. And this was,
	back in 2007 and to know--have spent 7 days in the hospital and
	to know that--what the cost of that care is and then after that
	I also spent 14 days at home on IV antibiotics at home which
	required a home healthcare nurse who came every couple days to
	draw blood and just check on the dressing and the IV and
	everything.
	But to receive information that describes the cost of your
	care A, is a shock to see how much it actually costs. But then
	to see how that is then compiled toward a limit of what an
	insurance company or someone is willing to pay is worrisome and
	scary because you know that without that care or access to--
	without access to the coverage that will give you that care, it
	will be much harder for you to stand a chance. And not just for
	me but for others with CF or with other preexisting conditions
	that faced those same struggles.
	It takes a toll not only on us as people but also on our
	families and those that love us because it, it's not just me
	that would sit and think about it. It's my wife, right. And my
	kids are--at the time at 2007 they weren't alive yet. But now
	if that was to happen again, that puts an unnecessary burden on
	them as well.
	And having the knowledge that there are no caps and not
	having to receive those letters anymore allows us to focus on
	our family and to continue to seek the best coverage and care
	that allows - and medicines that are highly specialized to
	target what the issues are with my disease and to help prolong
	my life so that like I mentioned earlier I can see my children
	grow up and go to college and not fear that I may have to make
	a decision one day so that they can continue to grow and me not
	have to have that coverage.
	Ms. Omar. Thank you. I see an immorality in the way that we
	are creating policy without taking in the actual impact that it
	has on the people's lives. We take a constitutional oath to
	protect the safety and the wellbeing of the people that we
	serve. So, thank you so much for sharing your story and I will
	tell you that you have people here in Congress who will make
	sure to constantly center that. So, thank you. I yield back.
	Chairman Scott. Thank you. And I recognize myself now for
	questions and the vote has been called so these are going to be
	some quick questions. Appreciate some quick answers.
	Ms. Corlette, you mentioned the New York situation where
	they covered--they guaranteed issue notwithstanding the
	preexisting condition and when the Affordable Care Act came in,
	is it true that the cost for individual insurance dropped more
	than 50 percent?
	Ms. Corlette. Yes. It's true.
	Chairman Scott. The effect of the Texas case, is it true
	that if the case is upheld there will be no protection,
	national protection against--for preexisting conditions?
	Ms. Corlette. The ACA protections will be stuck down, yes.
	Chairman Scott. Now we have heard that if it is
	unconstitutional the court would provide some transition time.
	Is there any--you are a lawyer, is there any guarantee that
	there would be a transition time if they call it
	unconstitutional?
	Ms. Corlette. There is no such guarantee.
	Chairman Scott. Now the repeal and replace, are you
	familiar with the American HealthCare Act that passed the
	House?
	Ms. Corlette. I do remember it, yes.
	Chairman Scott. OK. Is it true that if that had passed 23
	million fewer people would have insurance, costs would go up
	about 20 percent the first year, and there would be fewer
	consumer protections?
	Ms. Corlette. I don't remember the exact numbers but that
	sounds like what I remember, yes.
	Chairman Scott. And we have heard a citation in the bill
	that protects people with preexisting conditions but what
	wasn't read was an ability for States to waive that protection,
	so if you are unlucky enough to be in the wrong State that you
	could have no protection against preexisting conditions. Is
	that right?
	Ms. Corlette. Right.
	Chairman Scott. 11 million people who have, who got
	coverage through Medicaid expansion would they lose their
	coverage?
	Ms. Corlette. Yes.
	Chairman Scott. And the 10 essential benefits including
	prescription drugs, mental health, maternal and newborn care,
	preventive care, would those evaporate if the bill, if the
	law--if the ruling is upheld?
	Ms. Corlette. Yes.
	Chairman Scott. And we have heard about essential benefits
	and Dr. Gupta has been very articulate on that. If maternal
	and--maternity care were optional, who would buy it?
	Ms. Corlette. Well, who would offer it is the first
	question? Insurance companies generally would not offer it. And
	if they did, it would typically be as what is called a rider
	and the cost would be exorbitant.
	Chairman Scott. Because the only people that would buy it
	would be those who expect to have a baby in the next year.
	Ms. Corlette. Right.
	Chairman Scott. And the cost would be not insurance but
	essentially prepaid maternity care.
	Ms. Corlette. That's exactly right.
	Chairman Scott. And that is why it would be unaffordable.
	Now on the association plans, as I understand it you can get a
	healthy group, young healthy men and who would pay less. The
	arithmetic therefore says everybody left behind would pay more.
	Is that right?
	Ms. Corlette. That's correct.
	Chairman Scott. Now the navigators which you mentioned are
	community-based organizations that help consumers sign up for
	coverage. Language recently published by the Centers of
	Medicaid and Medicare--Medicare and Medicaid--states that
	priority will be granted and funding organizations that promote
	``coverage options in addition to marketplace plans such as
	association health plans, short term limited duration
	insurance.'' Is that consistent with the original purpose of
	the navigators?
	Ms. Corlette. No. Navigators are supposed to help people
	enroll in marketplace coverage.
	Chairman Scott. The--you know what has happened to the rate
	of bankruptcy because of medical bills as a result of the
	Affordable Care Act?
	Ms. Corlette. I don't have that data at my fingertips, but
	it has gone down.
	Chairman Scott. And can you say another word about job lock
	and why the Affordable Care Act gives people, particularly
	entrepreneurs the opportunity to switch jobs?
	Ms. Corlette. Sure. So, for people who have a preexisting
	condition themselves or somebody in their family who has a
	health condition, economists documented this phenomenon called
	job lock which prior to the ACA led a lot of people to stay
	with job-based coverage even if that job was not optimally
	deploying their skills or talents.
	Since the ACA if you are an entrepreneur or you want to
	start your own business, you can do so without worrying about
	coverage for your preexisting condition and if you are at least
	initially not earning much income, you can qualify for
	subsidies or even Medicaid.
	Chairman Scott. Thank you. I would like to thank our
	witnesses for their testimony. I now recognize the
	distinguished ranking member for closing comments.
	Mrs. Foxx. Thank you, Mr. Chairman, and I want to thank our
	witnesses also for being here. I particularly appreciate the
	opportunity that this hearing has given for Republicans to set
	the record straight on our position on preexisting conditions.
	I believe most every member spoke to it but we know that
	every member believes in coverage for preexisting conditions
	both those of us who were here to vote for the replace bill and
	the other, and the numerous replacement bills that we have
	offered.
	There is so much to say to correct the record here that
	there is not enough time. Perhaps I will submit some things for
	the record but I want to point out that if the court rules the
	ACA illegal, it would not repeal ERISA. It would not repeal
	HIPAA. There are safeguards in both of those pieces of
	legislation for preexisting conditions. Some of our witnesses
	have been extremely careful in how they have answered those
	questions and I appreciate that because they have been very
	careful not to completely mislead people about that situation.
	Contrary to what has been said about the work of Republicans,
	we have made provisions in all our proposals and past
	legislation that protects people with preexisting conditions.
	And I think it is important we continue to say that.
	The Affordable Care Act was built on lies. If you like your
	insurance, you can keep your insurance. If you like your
	doctor, you can keep your doctor. All of those things were said
	and they--or costs will be lowered. Those were not true. The
	ACA ordered people into a one-size-fits-all plan which
	increased costs dramatically and we know that. What America--
	what Republicans have done is to offer Americans freedom and
	choice. And what we should have been talking about today was
	what the ACA has done to raise the costs of healthcare and make
	it less affordable and less accessible. And with that again I
	thank the witnesses and I yield back.
	Chairman Scott. Thank you. Again, I want to thank the
	witnesses and members for their participation. What we have
	heard I think is a very valuable. The hearing has allowed us to
	take stock of where we are, to examine the attacks on
	preexisting conditions through unnecessary litigation, harmful
	rules that have a negative impact on those with preexisting
	conditions and I think we should try to improve and protect the
	healthcare that we have now and not jeopardize it.
	It is obvious that even the employer-based coverage with
	the protection for preexisting condition, those with employer-
	based coverage if we don't have the individuals covered, we
	will have uncompensated cost-shifting so they will be paying
	more if these, all off these other protections are repealed. If
	there is no further business to come before the committee, the
	hearing is now adjourned.
	[Additional submissions by Ms. Adams follow:)
	[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]


	[Whereupon, at 1:49 p.m., the committee was adjourned.]

	[all]
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