Datasets:

gtfintechlab
/

CoCoHD_transcripts

	<html>
	<title> - THE FAILURES OF OBAMACARE: HARMFUL EFFECTS AND BROKEN PROMISES</title>
	<body><pre>
	[House Hearing, 115 Congress]
	[From the U.S. Government Publishing Office]





	THE FAILURES OF OBAMACARE: HARMFUL EFFECTS AND BROKEN PROMISES

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

	HEARING

	before the

	COMMITTEE ON THE BUDGET
	HOUSE OF REPRESENTATIVES

	ONE HUNDRED FIFTEENTH CONGRESS

	FIRST SESSION

	__________

	HEARING HELD IN WASHINGTON, DC, JANUARY 24, 2017

	__________

	Serial No. 115-1

	__________

	Printed for the use of the Committee on the Budget





	[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]






	Available on the Internet:
	www.gpo.gov/fdsys/browse/committee.action?chamber=house&committee=budget




	_________

	U.S. GOVERNMENT PUBLISHING OFFICE

	24-442 WASHINGTON : 2017
	____________________________________________________________________
	For sale by the Superintendent of Documents, U.S. Government Publishing Office,
	Internet:bookstore.gpo.gov. Phone:toll free (866)512-1800;DC area (202)512-1800
	Fax:(202) 512-2104 Mail:Stop IDCC,Washington,DC 20402-001







	COMMITTEE ON THE BUDGET

	DIANE BLACK, Tennessee, Interim Chairman
	TOM PRICE, M.D., Georgia JOHN A. YARMUTH, Kentucky,
	TODD ROKITA, Indiana Ranking Minority Member
	MARIO DIAZ-BALART, Florida BARBARA LEE, California
	TOM COLE, Oklahoma MICHELLE LUJAN GRISHAM, New Mexico
	TOM McCLINTOCK, California SETH MOULTON, Massachusetts
	DIANE BLACK, Tennessee HAKEEM S. JEFFRIES, New York
	ROB WOODALL, Georgia BRIAN HIGGINS, New York
	MARK SANFORD, South Carolina SUZAN K. DelBENE, Washington
	STEVE WOMACK, Arkansas DEBBIE WASSERMAN SCHULTZ, Florida
	DAVE BRAT, Virginia BRENDAN F. BOYLE, Pennsylvania
	GLENN GROTHMAN, Wisconsin RO KHANNA, California
	GARY PALMER, Alabama PRAMILA JAYAPAL, Washington
	BRUCE WESTERMAN, Arkansas SALUD O. CARBAJAL, California
	JIM RENACCI, Ohio
	BILL JOHNSON, Ohio
	JASON LEWIS, Minnesota
	JACK BERGMAN, Michigan
	JOHN J. FASO, New York
	LLOYD SMUCKER, Pennsylvania
	MATT GAETZ, Florida
	JODEY C. ARRINGTON, Texas
	A. DREW FERGUSON, Georgia

	Professional Staff

	Richard May, Staff Director
	Ellen Balis, Minority Staff Director


	C O N T E N T S

	----------
	Page
	Hearing held in Washington, D.C., January 24, 2017............... 1
	Hon. Diane Black, Interim Chairman, Committee on the Budget.. 1
	Prepared statement of.................................... 4
	Hon. John A. Yarmuth, Ranking Member, Committee on the Budget 6
	Prepared statement of.................................... 8
	Grace-Marie Turner, President, Galen Institute............... 10
	Prepared statement of.................................... 12
	Robert A. Book, Ph.D., Senior Director, Health Systems
	Innovation
	Network, LLC............................................... 24
	Prepared statement of.................................... 26
	Dr. Book's response to questions submitted for the record 148
	Linda J. Blumberg, Ph.D., Senior Fellow, The Urban Institute. 35
	Prepared statement of.................................... 37
	Letter submitted for the record.......................... 92
	Edmund F. Haislmaier, Senior Research Fellow, The Heritage
	Foundation................................................. 95
	Prepared statement of.................................... 97
	Mr. Haislmaier's response to questions submitted for the
	record................................................. 150
	Hon. Todd Rokita, Vice Chairman, Committee on the Budget,
	questions submitted for the record......................... 147


	THE FAILURES OF OBAMACARE: HARMFUL EFFECTS AND BROKEN PROMISES

	----------
	JANUARY 24, 2017


	TUESDAY, JANUARY 24, 2017

	House of Representatives,
	Committee on the Budget,
	Washington, DC.
	The committee met, pursuant to call, at 10:00 a.m., in Room
	1334, Longworth House Office Building, Hon. Diane Black
	[interim chair of the committee] presiding.
	Present: Representatives Black, Rokita, McClintock,
	Woodall, Sanford, Grothman, Palmer, Westerman, Johnson, Lewis,
	Bergman, Faso, Smucker, Gaetz, Arrington, Ferguson, Yarmuth,
	Lujan Grisham, Moulton, Higgins, DelBene, Wasserman Schultz,
	Boyle, Khanna, Jayapal, and Carbajal.
	Interim Chair Black. Welcome panelists. This hearing will
	focus on the failures of Obamacare, its harmful effects, and
	broken promises. We are having this hearing today to discuss
	the damage that Obamacare has done to patients, medicine,
	workers, and our economy. And after 6 years, no one can dispute
	that this law has been nothing but a series of broken promises.
	Patients have lost their doctors and their insurance plans,
	premiums and deductibles have skyrocketed, and small businesses
	have been forced to reduce their benefits and wages or put off
	hiring of new workers altogether.
	Obamacare was sold as a solution that would tackle one of
	the biggest problems in our healthcare system, the rising cost
	of insurance. In fact, President Obama promised this law would
	lower premiums by $2,500 a year for an average family. In
	reality, the complete opposite has been true. Average family
	premiums have risen by $4,300 and deductibles have risen by 60
	percent in the employer-sponsored market.
	For working folks across the country, more money out of
	their paychecks just to pay for health care makes life much
	harder. And what are Americans getting in exchange for these
	higher costs? Well, not much. Twenty million Americans have
	said that Obamacare just is not worth the cost or the trouble,
	choosing to pay a fine or to file an exemption instead. And for
	those who do have insurance, access to care has not improved.
	So, while our friends on the other side of the aisle may
	claim that Obamacare is increasing the number of people
	covered, the question we would ask is what kind of care are
	they receiving? For those pushed into a broken Medicaid system
	who are having to navigate the complicated Obamacare
	bureaucracy, they are not receiving the very best health care
	our Nation has to offer. And as a nurse for over 40 years I
	know that we can do better.
	Now I am sure the Democrats will cite the CBO study from
	last week that discusses what happens to coverage numbers if we
	repeal Obamacare. But what the CBO study ignores is any
	potential Republican ideas to reform the health care and expand
	access. And access to quality care is what so many people in my
	home State of Tennessee are lacking under this law.
	Let me give you an example. In our State, 28,000 people
	lost their coverage on a single day when Access Tennessee,
	which is a program that helps those that are in the risk pool,
	lapsed after the Obama administration decreed that it ran afoul
	of the Federal Government's top down requirements. Yes, in one
	day 28,000 people lost their insurance. This happened despite
	President Obama's claim that, ``If you like your plan you can
	keep it.''
	Now, premiums in our State are rising by an average of 63
	percent, and three-fourths of our counties only have one
	coverage option to choose from on the Obamacare Exchange. In
	five other States around the county, Alabama, Alaska, Oklahoma,
	South Carolina, and Wyoming patients only have one insurer in
	the marketplace to choose from. And if you only have one
	choice, then you are probably not going to find a plan that
	best fits the unique needs of you and your family.
	And for folks not living in the city or suburbs, Obamacare
	has been especially harmful. Since 2010, eight rural hospitals
	have been forced to close, further restricting choice and
	access. But the good news is that it does not have to be this
	way. We do not have to accept Obamacare failures and broken
	promises. And that is why our House and Senate have worked
	together in this new Congress to pass a budget that begins the
	process to repeal Obamacare and stop the damage that it is
	causing.
	And in the coming weeks, we will consider legislation that
	will roll back some of the worst aspects of this law, and begin
	laying a foundation for a patient-centered healthcare system.
	And we already have great ideas to build on. My Tennessee
	colleague whom I am very proud of, Congressman Phil Roe, a
	physician, has introduced the American Health Care Reform Act.
	And Congressman Tom Price has offered the Empowering Patients
	First Act.
	And last year, our House Republicans put forward a better
	way, 37 pages of reform proposals that we will act on this
	year. So, we have got a lot of hard work ahead of us and
	today's hearing will be another critical step forward. And that
	is why I am glad that today we will welcome some witnesses and
	get their ideas for improving health care for the American
	people.
	First, we have Grace-Marie Turner who is the President of
	the Galen Institute. Next, we have Dr. Robert Book, a Senior
	Director of the Health Systems Innovation Network. We also have
	Edmund Haislmaier, a Senior Research Fellow in Health Policy
	Studies at the Heritage Foundation. And finally, we have Dr.
	Linda Blumberg, a Senior Fellow at Urban Institute's Health
	Policy Center.
	Thank you all for taking time out of your busy schedules
	today to join us for discussion. Everyone on this committee
	looks forward to your knowledge and insight on what we can do
	to improve America's healthcare system. We are committed to
	rolling back the damage caused by Obamacare to achieving true
	healthcare reform by bringing the best minds together, which we
	believe we have done today. And always remembering to put
	patients ahead of Washington's bureaucracy we will succeed.
	Thank you, and with that I yield to the ranking member, Mr.
	Yarmuth.
	[The prepared statement of Interim Chair Black follows:]

	[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


	Mr. Yarmuth. Thank you, Chairman Black. I want to join the
	chairman in welcoming our witnesses this morning. My Democratic
	colleagues and I are confused why the majority did not hold
	this hearing before rushing through a budget to repeal the
	Affordable Care Act and defund Planned Parenthood. However, we
	will use it as an opportunity to set the record straight about
	a number of things.
	The American people have made it clear they do not support
	repealing the Affordable Care Act. They rightly fear losing
	access to quality and affordable care, and know the
	consequences would be disastrous.
	Over the weekend, millions of people across the Nation
	rallied against the dangerous policies of the new
	administration, including threats to our health care. I know
	every one of my Democratic colleagues has heard from people
	whose lives have been transformed or saved because of the ACA.
	And there are hundreds of thousands of constituents in every
	Congressional district across the country who have benefitted
	from the law.
	Let me tell you about one of them, Steve Riggert, a
	constituent who recently wrote to me. Steve's daughter, Anna,
	was diagnosed with chronic pancreatitis at the age of 12 and
	has been hospitalized more than two-dozen times over the past
	10 years for a variety of reasons. From the beginning, Steve
	knew that Anna's serious medical problems would make getting
	health insurance difficult once she transitioned out of her
	parents' policy.
	When the ACA was enacted, he was immensely relieved that
	she could always get coverage even though she had a pre-
	existing condition. But the Republican plan to repeal the ACA
	has now left Steve feeling, and these are his words,
	``helpless,'' ``petrified,'' and ``literally losing sleep.'' At
	age 64 and recently diagnosed with pancreatic cancer himself,
	he fears that he will not be able to help his daughter. To
	quote his letter, ``Repeal of all aspects of the Affordable
	Care Act would place everything I have worked for and those I
	care about in jeopardy.''
	Steve is one of many. There are a lot more. In fact, the
	Congressional Budget Office, as Chairman Black mentioned,
	estimates repealing the major coverage provisions will cause 32
	million people to lose health insurance. In the individual
	market, eventually, three-quarters of the U.S. population will
	have no access to an insurer, and premiums will double. But
	that is just the beginning.
	Under a full repeal of the law, insurance companies will
	once again be able to deny coverage based on pre-existing
	medical conditions, people with job-based insurance will face
	annual and lifetime limits on coverage and copays for
	preventive services, and seniors in Medicare will pay more for
	prescription drugs. Hospitals caution that repeal will increase
	uncompensated care costs, likely leading to service cuts,
	layoffs, or higher prices for everyone. Outside experts say
	repeal will result in 3 million lost jobs in 2019 alone.
	Republican governors are pleading with the Republican
	Congressional leadership not to go through with this repeal.
	Despite these warnings and despite the grave consequences, here
	we are.
	I expect my Republican colleagues today, as Chairman
	Black's already done, will wave around bills and claim they
	have a plan to replace the ACA. They do not. The reality is
	that in nearly 7 years, Republicans have yet to introduce a
	single bill that has the support of the majority of their
	conference, or comes close to matching the ACA's record of
	success.
	We will hear a lot of ideas today from my colleagues on the
	other side of the aisle. And I would wager that at the end of
	the day, these ideas will also fail to garner the majority of
	their conference, or come close to a plan that matches the
	ACA's record of success. They will also not comprise a plan
	that any American citizen could infer how it will change their
	lives or affect their lives. I will keep an open mind. I will
	ask questions and I look forward to hearing more from our
	witnesses. And I yield back the balance of my time.
	[The prepared statement of Mr. Yarmuth follows:]


	[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


	Interim Chair Black. Thank you, Mr. Yarmuth. Panelists, the
	committee has received your written statements and they will be
	made part of the formal record hearing. You will each have 5
	minutes to deliver your oral remarks. And Ms. Turner, you may
	begin when you are ready.

	STATEMENTS OF GRACE-MARIE TURNER, PRESIDENT, GALEN INSTITUTE;
	ROBERT A. BOOK, SENIOR DIRECTOR, HEALTH SYSTEMS INNOVATION
	NETWORK, LLC; LINDA J. BLUMBERG, SENIOR FELLOW, THE URBAN
	INSTITUTE, HEALTH POLICY CENTER; AND EDMUND F. HAISLMAIER,
	SENIOR RESEARCH FELLOW, HEALTH POLICY STUDIES, THE HERITAGE
	FOUNDATION

	STATEMENT OF GRACE-MARIE TURNER

	Ms. Turner. Thank you, Chairman Black, Ranking Member
	Yarmuth, and members of the committee for the opportunity to
	testify today on the impact of the Affordable Care Act. I plan
	to focus primarily on families, small businesses, and young
	people. While numbers of people have received health coverage
	through the Affordable Care Act, many more have felt personal
	harm.
	I know that you and many members of Congress, including the
	leadership, have provided assurances that those currently
	receiving coverage through the Affordable Care Act now, will
	have that coverage maintained as a safety net lifeboat while
	you build a bridge to new coverage that will protect people
	that are currently being harmed by the law, but also provide
	new patient-centered options for care and coverage.
	The cost of health care continue to be a primary concern. I
	rode with an Uber driver last week who said that he lives in
	Maryland and he has to work this second job to pay his $1,200 a
	month premium for himself, his wife, and his child. So, he says
	this is taking time away from my family, but I have to do it in
	order to provide them coverage. Many millions more are facing a
	similar fate and really are pleading for help.
	Young people have been particularly disadvantaged. The law
	requires that insurance companies charge them only 3 times less
	than older people. And this 3-to-1 age rating has meant that
	young people are required to pay 75 percent more for their
	coverage than someone just pre-Medicare age. The savings for
	somebody on Medicare or 64 years old, so just before Medicare,
	are only 13 percent.
	So what is happening is, young people are saying this just
	is not a good value. They are not purchasing from the coverage
	and they are not entering the pools that we need them in so
	that they can help balance out the risks. The ACA's employer
	mandate also is disadvantaging them and making it much harder
	to get that first real job, because it makes hiring them so
	much more costly.
	On families, NPR's Morning Edition had a self-employed
	consultant from Portland, Oregon saying he is just not going to
	buy health insurance in 2017 because his premium had shot up to
	$930 a month. A broker said, ``I have got clients saying the
	prices are nuts and I will not pay it. I will pay the penalty
	instead.'' The Congressional Budget Office had said, as you
	said, Madam Chairman, 21 million people would be enrolled in
	the exchanges as of this time and as of June 2016, but only
	about 10.5 million were. Many millions of people just do not
	see the value in this expensive coverage, particularly in the
	exchanges where premiums increased an average of 25 percent
	last year.
	In Kansas City, Warren Jones said that his coverage was
	$318 a month when he started under Obamacare in 2014. In 2017,
	his premium is going to be $716. So, it went up 46 percent. He
	said, ``My wages have not gone up close to that.'' In addition,
	many hundreds of thousands and millions of people lost the
	coverage they had now. But particularly egregious, I think, is
	those who were on the co-ops.
	The Congress provided $2.4 billion to provide the start-up
	funds for these cooperative health insurance plans. And all but
	five of them have failed, causing 800,000 people to suddenly
	lose their coverage because the plans were not able to, for a
	number of reasons, price their premiums properly. And then many
	millions of Americans have been impacted by the taxes; nearly
	two-dozen taxes, many of which go directly to the bottom line
	in increasing health insurance costs. Small businesses thought
	that they would be able to get relief, but the shop exchanges
	and small business tax credits that were supposed to help them
	were so complicated that they drew very little interest.
	And then, finally, on Medicaid. Brian Blase of the Mercatus
	Center said that in his research, 70 percent of Medicaid
	enrollees in the expansion were eligible for the program in
	pre-ACA rules. While many unintended consequences have resulted
	from the law, I think one of the saddest is how it has impacted
	vulnerable populations.
	Charles Blahous of Mercatus said that one of the results
	was to require the most sympathetic and vulnerable Medicaid
	populations, low income enrollees, pregnant women, children, et
	cetera to face more competition for health services from a
	marginally less vulnerable population--childless adults of
	somewhat higher income. A Louisiana Medicaid recipient told the
	New York Times, ``My Medicaid card is useless for me right now.
	It is a useless piece of plastic. I cannot find an orthopedic
	surgeon or a pain management doctor who will take Medicaid.''
	President Trump's Executive Order ordered the bureaucracy
	to try to provide people some initial relief but, of course,
	only Congress can really act to change the underlying law.
	Thank you, Madam Chairman. I look forward to working with you,
	members of your committee and hopefully both sides of the aisle
	in coming up with options to solve these problems.
	[The prepared statement of Ms. Turner follows:]

	[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



	Interim Chair Black. Thank you, Ms. Turner. Dr. Book, you
	are recognized for 5 minutes.

	STATEMENT OF ROBERT A. BOOK

	Dr. Book. Thank you, Chairman Black, Ranking Member
	Yarmuth, and members of the committee. Thank you for the
	opportunity to share my research on the failures of the
	Affordable Care Act to achieve its goals. As well as the
	harmful and presumably unintended affects it has caused some
	reforms that can be enacted to make health care truly
	affordable for all Americans who seek it.
	Proponents of the ACA, both inside Congress and outside,
	promised that it would bring about lower health insurance
	premiums, better access to health care, lower healthcare costs
	for patients, lower total national health expenditures in part
	due to savings on administrative costs and non-profit co-ops,
	and most of all fewer Americans foregoing health care because
	they cannot afford to pay for it. In fact, the opposite has
	happened.
	Health insurance premiums have increased at record rates,
	especially but not only, for those who have to pay for their
	own coverage instead of getting it at work. More health plans
	than ever have narrow networks of providers limiting access to
	care in the name of saving money. Co-payments and deductibles
	are at all-time highs. And according to Gallup more Americans
	than ever say they have avoided or delayed obtaining health
	care because they cannot afford the cost. Clearly, having
	health coverage does not mean that one can actually obtain
	health care.
	In addition to paying record high premiums, families
	earning as little as $41,000 per year may have to spend as much
	as $14,300 out of pocket before obtaining any coverage for
	treatment of diseases or injuries. And even that coverage may
	be restricted to a very small network of providers.
	Despite all these factors making it more difficult for
	patients to access health care, total national spending on
	health care has continued to increase every year, both in
	dollars and as a percent of GDP. Administrative costs of
	insurance have increased as well, as the cost of establishing
	and operating the government-run exchanges vastly exceeded the
	savings to insurers by marketing through those exchanges.
	Most of the co-ops have shut down taking their taxpayer
	financed start-up loans with them. One reason the ACA was
	passed was that we were paying too much for health care and not
	getting enough in return. Clearly, we are paying even more and
	getting even less than ever before. The problems that plagued
	the healthcare system before the ACA are still with us, and a
	new layer of problems has been added.
	Another reason the ACA was passed was to save lives.
	Proponents said that thousands of people were dying due to a
	lack of health coverage. If that were true mortality rates
	should have decreased when the full provisions of the ACA came
	into effect; however, this has not happened. The Centers for
	Disease Control and Prevention recently reported that U.S. life
	expectancy dropped in 2015 for the first time since 1993. While
	this decrease might not be the fault of the ACA, there is
	certainly no increase in life expectancy or decrease of
	mortality, for which the ACA might take credit.
	Medicare beneficiaries face a separate set of new
	obstacles. For example, the ACA mandated a Federal program
	whose express purpose is to pay doctors and hospitals bonuses
	for providing less health care to seniors and the disabled. The
	canard heralded health insurance companies for decades that
	they are denying care to patients just to save money has now
	become the official policy of the Federal Government towards
	its own beneficiaries. And worse, they are co-opting providers
	of cures by paying them bonuses to deny care and say no.
	In addition, the promise of health coverage for all, even
	just coverage not care, has still not been achieved. On
	September 9, 2009 then-President Obama told a joint session of
	Congress that, ``There are now more than 30 million American
	citizens who cannot get coverage.'' The latest figures from the
	census bureau indicate that as of 2015 there were still 29
	million uninsured. Due to a change in definitions, these
	numbers might not be directly comparable, but it is quite clear
	that the ACA's goal of achieving coverage for everyone is far
	from being achieved.
	Last week, CBO issued an alarmist report on a possible ACA
	repeal predicting, based on March 2016 data, that many people
	would lose coverage and premiums would increase if, as the
	report put it, portions of the ACA would be repealed. To get
	this result, the CBO assumed that all the ACA provisions that
	made coverage expensive and difficult to obtain, would remain
	in place, but that subsidies to pay for insurance in the
	individual mandate would be repealed. This is a straw person
	argument because it is not anyone's idea of how to reform
	health care. Furthermore, this report was based on data
	obtained before 2017 premiums and enrollment data were
	available. And, in fact, most of those premium increases they
	predicted have already occurred, even under the ACA.
	In order to make health care accessible and coverage
	affordable, it is necessary to eliminate those factors that
	artificially increase prices without improving care or
	benefitting patients. It is imperative to repeal provisions
	requiring people to purchase health plans that include costly
	coverage for services they do not want, will not need, or will
	not use. People should be permitted to purchase comprehensive
	coverage if they so choose, or basic coverage if they so
	choose. Furthermore, if subsidies are to be given, they should
	be structured in such a way to encourage health insurers to
	provide coverage for individual's pre-existing conditions by
	basing subsidies on health status rather than merely on income.
	Thank you very much and I look forward to your questions.
	[The prepared statement of Dr. Book follows:]


	[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



	Interim Chair Black. Thank you, Dr. Book. Dr. Blumberg, you
	are recognized for 5 minutes.

	STATEMENT OF LINDA BLUMBERG

	Dr. Blumberg. Chairman Black, Ranking Member Yarmuth, and
	members of the committee thank you for inviting me to testify
	today. The views that I express are mine alone and do not
	represent the views of the Urban Institute, its funders, or its
	sponsors.
	The ACA is an imperfect law, but it has generated
	substantial benefits since its full implementation in 2014.
	Including increasing insurance coverage by over 20 million
	people, improving access to care and affordability, prohibiting
	insurer discrimination against the sick, catalyzing insurance
	market price competition in many areas for the first time,
	lowering the growth in per capita healthcare spending, and
	doing all this with virtually no evidence of negative effects
	on employment.
	Our analysis and that of the CBO indicates that repeal of
	the ACA through the reconciliation process without a
	replacement plan would leave the U.S. Healthcare System worse
	off than would have been the case if the ACA was never passed.
	It would lead to an increase of 29.8 million uninsured in 2019,
	nearly doubling the uninsurance rate from 11 percent under the
	ACA to 21 percent.
	The non-group market would virtually collapse due to the
	loss of predominantly healthy enrollees when the individual
	mandate and financial assistance were eliminated, while the
	rules that prohibit insurer discrimination against those with
	health problems remained in place. Unsubsidized premiums would
	increase dramatically and three-fourths of the population would
	not have any insurer selling non-group coverage in their area.
	Over 10 years, there would be an increase of $1.1 trillion
	in uncompensated care that would be sought from healthcare
	providers due to the large increase in the uninsured. But there
	would be no obvious source to finance this additional care.
	Likely, it would result in much greater financial pressures on
	hospitals and other healthcare providers, and much more unmet
	medical need for households.
	This scenario is realistic since opponents of the ACA have
	not coalesced around a replacement policy. And doing so would
	require raising significant new revenues, making dramatic cuts
	in existing programs, or increasing the deficit while earning
	some Democratic votes, all of which are very politically
	challenging.
	Contrary to some public statements, non-group insurance
	markets under the ACA are not in a death spiral. Market
	experiences vary a lot across the country. About 40 percent of
	the population lives in areas where low cost silver premiums
	decreased or increased only modestly in 2017. But about 40
	percent of the population does live in areas with 2017 premium
	increases of 20 percent or more; in most cases though, these
	increases represent adjustments to underpricing by insurers in
	the early years of reform. In these cases, high growth rates do
	not mean high premiums.
	In other cases though, premiums are high because of the
	market power of providers and/or insurers or adverse selection
	into the non-group market. However, policy strategies many of
	which have had bipartisan support in other context could be
	used to address these situations. And I will come back to that
	shortly.
	This evidence and still increasing enrollment show that it
	is simply not true the marketplaces are in a death spiral.
	However, a death spiral would occur under a repeal via
	reconciliation or by maintaining the ACA, but neglecting the
	important administrative tasks that are required for the system
	to continue to operate effectively.
	The replacement proposals delineated by members of Congress
	thus far fall firmly in the philosophical camp of reducing the
	sharing of healthcare risk, separating expenses of people with
	significant healthcare needs from those who are healthy. These
	approaches may well reduce premiums for those who are currently
	very healthy, but they all would reduce access to adequate and
	affordable medical care for people with greater needs.
	The proposals would also do much less for those with lower
	incomes. These strategies include such policies as expansion of
	health savings accounts, replacement of income-related tax
	credits and expanded Medicaid eligibility with age-related tax
	credits, sales of insurance across State lines, continuous
	coverage requirements, and traditional high-risk pools.
	Faced with a very challenging political reality, policy
	makers should consider fixing the major problems they have with
	the ACA rather than repealing it. The following policies would
	address critics' concerns and also strengthen the law.
	Replace the individual mandate with a modified version of
	the late enrollment penalties currently used in Medicare parts
	B and D. Eliminate the employer mandate. Replace the Cadillac
	tax with a cap on the tax exclusion for employer insurance with
	some adjustments. Improve affordability by increasing premiums
	and cost sharing assistance and extend an 8.5 percent of income
	premium cap to those with incomes above 400 percent of the
	poverty level.
	Doing this, would allow you to loosen the 3-to-1 age rating
	bans. Stabilize the marketplaces by taking steps to increase
	enrollment, including more outreach in enrollment assistance,
	and allowing states to expand Medicaid up to 100 percent of
	poverty instead of 138 percent.
	Address the effects of insurer and provider market power on
	non-group premiums by capping provider payment rates for non-
	group insurers just like the Medicare Advantage Program does.
	And create a permanent reinsurance program to protect non-group
	insurers from very high cost cases just as Medicare Part D and
	Medicare Advantage have. This approach would avoid the turmoil
	of repeal and replace for households, healthcare providers,
	insurers, and State governments, and would protect access to
	affordable adequate care for all individuals regardless of
	health status or income.
	Thank you very much. And I look forward to your questions.
	[The prepared statement of Dr. Blumberg follows:]

	[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


	Interim Chair Black. Thank you, Dr. Blumberg. Mr.
	Haislmaier, you are recognized for 5 minutes.

	STATEMENT OF EDMUND HAISLMAIER

	Mr. Haislmaier. Thank you, Madam Chairman and Mr. Yarmuth,
	ranking member. I have submitted, of course, testimony which I
	will briefly summarize. I am a senior research fellow in Health
	Policy at the Heritage Foundation and the testimony is my own
	and is not, and should not, be construed as an official
	position of the Heritage Foundation or anyone else.
	I am testifying in response to the committee's request to
	present the analysis of health insurance enrollment data that I
	have been conducting; basically looking at the areas that have
	been most affected by the key provisions of the Affordable Care
	Act. That would be the expansion of Medicaid and the
	introduction of subsidized coverage through the exchanges for
	the individual market and the related rules governing the
	individual and employer market, particularly the small employer
	market.
	I should note, very briefly, that this is data that I am
	using that is drawn from regulatory filings that insurers make
	in the case of the private market with State regulators. In the
	case of Medicaid, this is data reported by the states to the
	Centers for Medicare and Medicaid Services, which publishes it.
	That data is done periodically though in the case of the
	private market, quarterly in the case of the Medicaid data
	monthly though the best and most comprehensive is on an annual
	basis.
	When you look at the experience that we have seen in the
	first 2 years, 2014 and 2015, we saw a growth in the individual
	market from a base of 11.8 million people at the end of 2013,
	that was pre-ACA. We saw a growth to 17.7 million people in
	that market. In the employer coverage market, we saw two things
	fully insured, that is plans where the employer buys the
	coverage as a group policy from an insurer. Fully insured
	employer coverage declined from 60 million to 53 million. At
	the same time, self-insured employer coverage, and those tend
	to be larger employers, grew by 4 million.
	The net of those three interactions on the private market
	was a net increase over 2 years of 2.3 million people with
	private market coverage. In comparison, over the period, you
	saw an increase from 60.9 million to 72.7 million in total
	Medicaid enrollment. So what that leaves us with is a net
	growth of enrollment in those 2 years of 14 million of which
	almost 84 percent was in Medicaid.
	Now, when we turn to 2016, we do not have full year data
	yet for either of these programs. But we do have some initial
	data for the first three quarters. And what we see is a growth
	of a further 842,000 people in the individual market, a further
	decline of 1.1 million in the fully insured employer group
	market, a further increase of 776,000 roughly in the employer
	self-insured market, and a further 2 million increase in
	Medicaid enrollment.
	Again, these are preliminary figures. But it looks like by
	the end of 2015 we, 2016 sorry, we can reasonably project that
	over the course of the 3-year period, health insurance
	enrollment will have expanded by about 16.5 million
	individuals. Of which 13.8 million would be attributable to
	public coverage, Medicaid and CHIP, and the other 2.7 million
	to private coverage.
	What does all of this mean? In general, what it means is
	that the experience of the ACA appears to have had three
	significant effects. It has increased the number of people
	covered by individual market insurance. But a lot of that has
	been offset by a decline in employer provided insurance. And it
	has principally produced enrollment increases through an
	expansion of public programs, particularly Medicaid, and
	particularly in those states that adopted the ACA expansion to
	able-bodied adults.
	I will be happy, Madam Chairman, to answer any questions
	the committee may have. Thank you.
	[The prepared statement of Mr. Haislmaier follows:]

	[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



	Interim Chair Black. Thank you, Mr. Haislmaier, excuse me.
	We will now begin our question and answer session. I will start
	by, first of all, again thanking all the witnesses for being
	here and asking some questions.
	Again, by saying as a nurse for over 40 years, what I am
	really concerned about and as folks in my district call me and
	tell me the stories that are just so disheartening to me about
	their access to quality care and affordability. It really just
	bothers me terribly to know that there are some folks, as I
	said in my opening statements, that liked what they had and
	were not able to keep it. In particular, the high-risk patients
	in our State who were on a plan that the State had set up
	themselves and people were happy about it. And in one day,
	28,000 people, with some pretty serious conditions, were out of
	care.
	But let me also go to some statistics. Let me first of all
	talk about the cost, the rising cost, because we hear this
	every day in our office; 25 percent average increase in
	premiums this year for millions of Americans that are trapped
	on the exchanges. There was a lady in Tennessee who runs a
	daycare center, and she was on the exchanges, and her
	deductible went from $2,000 to $9,000 this last year. There is
	no way someone running a daycare business can afford that.
	One trillion dollars in new taxes mostly falling on
	families and job creators have really hurt people in what they
	are able to do in their life besides just their health care. It
	really has hurt them.
	How about choice? Nearly one-third of the U.S. counties
	have only one insurer offering the exchange plans. In our State
	three-fourths of our State only has one option. That is not
	choice--that is a monopoly. We also see 4.7 million Americans
	kicked off of their healthcare plans by Obamacare.
	And finally, I think you mentioned it, Ms. Turner, is the
	fact of the failed Obamacare co-ops. We had a co-op in our
	State that went belly up and this is a cost to the taxpayers of
	$1.9 billion, billion dollars not million, forcing many of
	these patients to try to find new insurance. And if I could
	have the staff pull up slide number 5, this is particularly
	disturbing to me because, let's go back to the one with the
	hospitals, yeah there.
	Hospitals who have been forced to close under the
	Obamacare, these are rural hospitals; 50 percent of my district
	is rural. If you can look at Tennessee, you will see a number
	of Hs, hospitals who have closed in my district. Now, when that
	happens if someone has an emergency, such as a heart attack,
	they are about 40 minutes from the closest hospital because
	their small rural hospital has closed.
	This is devastating to communities not just for care that
	is provided, but also for recruiting businesses, because one of
	the things that new businesses will ask is, ``Where is your
	health care?'' They want to know that there is health care in
	that community. This has really been devastating and I think
	that we cannot discount these real stories that come to our
	office and just break my heart that that is what is occurring.
	So, let me ask you, Mr. Haislmaier, Obamacare really
	focused almost exclusively on coverage--we saw that as they
	were pushing people into the computer to sign up for that--
	while neglecting the cost and the access of care. It was just,
	``Let's get as many people signed up as we can so we can say
	that this program was successful.'' If health insurance does
	not cover the care you need, or if you cannot afford the
	deductibles that come with your plan, or you do not have
	access, then is not the number of people that are covered
	really meaningless?
	Mr. Haislmaier. Sorry, it is true that the authors of the
	legislation prioritized enrollment over cost control, which I
	think is one of the reasons the public was never sold on the
	bill, because most of the public wanted the reverse; they
	wanted cost control prioritized.
	In terms of the deductibles and the coverage, the argument
	had been made, indeed, by advocates of this law that insurance
	with high deductibles was of less value; some even called it
	junk insurance. The interesting thing is that that is what this
	law has produced. The reason for that is pretty
	straightforward. We saw that in other states that had adopted,
	in the 1990s, similar measures, and that is when the law limits
	what dials the insurers can turn, they reach for the only dials
	that are left. In this case, the only dials really left are to
	raise the deductibles as much as you can and/or to limit the
	networks, and that is what we have seen progressing in the last
	several years in plan design in the exchanges, yes.
	Interim Chair Black. Ms. Turner, you talked about some of
	young folks. I know that there are about 20 million Americans
	who have said that Obamacare just is not worth the cost; they
	have either paid the fine--which really is just almost funny to
	me where the whole idea of this is to make sure everybody has
	coverage, and what is more important is now you are paying
	fines for something you are not even going to get coverage on,
	and then there are another group of people that filed an
	exemption.
	So, we have got 20 million people out there who maybe would
	have had access to health care, potentially, insurance, but now
	the cost of it is so high that they neither have the access to
	the health care, nor do they have a dollar in their pocket
	because they are paying a fine. Could you talk a little bit
	about that?
	Ms. Turner. Well, as you say, Madam Chairman, it does
	really go against the purpose of the law and I know that many
	of the policy proposals that you and others have advocated
	would provide incentives for people to buy the coverage, and of
	course, the most important incentive is to make it more
	affordable.
	One of the reasons that the coverage is so expensive is not
	only because of the 3-to-1 age rating ban that is so
	disadvantageous as young people, but also because of the
	benefit requirements that are so much more generous than most
	people could afford. I think those are two specific things to
	look at in addition to the taxes that really go the underlying
	cost mechanism of the law. Getting the costs down would provide
	the incentive for people to purchase coverage.
	Interim Chair Black. I think it is interesting, when we
	talk about 20 million--and that number moves all over the
	place, but let's just use 20 million--that 20 million people
	have received insurance. We look at the other side; there are
	20 million people who have not received it but either are
	exempt or who have paid the penalty. I do not know that we need
	to hurt one group to help the other. I think that we probably
	can get to the place where we have a true patient-centered
	care, and that we are helping everyone. I know, Dr. Book, I am
	going to just leave you about two and one-half minutes. But as
	we prepare legislation in this area that truly is patient-
	centered reform, what is the biggest lesson from the Obamacare
	experience that we can learn? And then, if you have a second to
	tell us if there is anything that you think we ought to take
	from it that would also help us to make sure that we take out
	what is good.
	Mr. Book. Thank you. I think the biggest thing to learn is
	that when Washington tells people what they need to buy, that
	does not necessarily make those people better off. The main
	reform I would suggest, though, one thing that we all want, is
	not to exclude people, make it impossible for people with
	preexisting conditions to get coverage.
	I myself had multiple preexisting conditions when I left my
	previous employer and had to go and buy my own insurance, and
	this was before the ACA reforms took effect. I had no problem
	getting insurance. I did have to pay for it, more than the
	average person, but I had no problem getting it, and that was
	under a law that was passed at least a decade before.
	On the other hand, now that Obamacare is in effect, I am
	paying two and one-half times as much for my premium and my
	deductible has gone from $2,400 to $7,000; my out-of-pocket is
	$13,000; and I am one of those people that was supposed to be
	helped by the bill as a self-employed person who pays for his
	own insurance and has preexisting conditions. I think we need
	to adjust the way we do subsidies.
	Right now, we subsidize insurance companies for covering
	people who have low incomes. There is nothing necessarily wrong
	with that, but people with low incomes are not necessarily the
	same as people with health problems. Obviously, there is
	overlap, but they are not all that well correlated. I think we
	need to incentivize companies to cover people who actually have
	adverse health status. We do that in the Medicare Advantage
	program using something called risk adjustment.
	There is a risk adjustment provision in the ACA, but it is
	completely different; it just moves money around between
	insurance companies without any reference to the health status
	compared to the underlying eligible population. If we did a
	risk adjustment that was based on the eligible population, I
	think we could solve the preexisting condition problem without
	forcing insurers to charge more to everybody else. That would
	be my primary suggestion.
	Interim Chair Black. Thank you very much. I now recognize
	the ranking member from Kentucky, Mr. Yarmuth, for any
	questions.
	Mr. Yarmuth. Thank you, Madam Chairman. Thank you all for
	your testimony. It occurs to me that what we have basically
	just heard, in the aggregate, is our biggest complaint and
	observation about this debate in recent weeks and months, and
	that is, we spent a lot of time hearing about the problems with
	the ACA and very little hearing about the alternatives, if I am
	going to characterize all the testimony.
	Now, Dr. Blumberg gave a number of suggestions; by the way,
	I would say, Dr. Blumberg, every one of those could be
	implemented by this Congress acting. And eliminating the
	employer mandate, for instance, could be done by this Congress.
	There has been no suggestion from the Republican side of doing
	that, and that is kind of where we have been over the last 6 or
	7 years, is that while we have seen problems arise, Republicans
	have been unwilling to address problems.
	Instead, they have just said, ``Let's repeal it,'' and they
	have done that 65 times in the House. Anyway, Ms. Turner, in
	your testimony, I guess you could infer that you would
	recommend doing away with the employer mandate since you said
	that was a problem, but beyond that, you really do not offer
	any solutions.
	Dr. Book had seven pages of criticism of the ACA and
	identifying problems and then three paragraphs of solutions,
	one of which is two provisions to be repealed and then
	mentioning the question of the high-risk population which, I do
	not know, I would characterize it as just another form of a
	high-risk pool; you just change the mechanism for government
	financing of high-risk patients. And Mr. Haislmaier had no
	particular recommendations which probably makes sense since the
	Heritage Foundation was the originator of the idea of the
	Affordable Care Act, much of it. This is why we are so
	frustrated, because this Congress and this President have said,
	``We are going to repeal it; that is first priority'' and
	really there are no ideas for replacing it.
	Now, I have my opinion about that and I have said it many
	times: There are only, in my opinion, two alternatives to the
	Affordable Care Act. One is to go back to where we were, where
	insurance companies decided who lived and died, and single-
	payer, Medicare for everyone. The other solutions that have all
	been proposed are just tweaks of the Affordable Care Act and
	that is why we keep saying there is no plan. There are ideas.
	Health savings accounts; that is an idea. Selling insurance
	across State lines is an idea. It is also allowed under the
	Affordable Care Act, but this is not a plan.
	That is, again, a lot of my frustration, but I am also
	frustrated about the way we talk about this and debate it,
	because we all have anecdotes. I mentioned an anecdote in my
	opening statement; the chairman has mentioned anecdotes. In my
	State, which has probably done the best job of expanding
	Medicaid of any State in the country, we have reduced the
	uninsured population by 60 percent; 440,000 people signed up
	for Medicaid as part of the expansion, and yes, some of them
	probably would have qualified before, but not all of them, by
	any stretch. We do not have any complaints about access to
	providers.
	As a matter of fact, if you look at virtually every
	category of care--preventive health, screenings, dental visits,
	vision visits, just about every one you can mention, we have
	had a more than 100 percent increase in that activity in our
	State, so our State is getting a lot healthier.
	It is also kind of frustrating--here where we tend to get
	in the weeds a lot--we hear the statistic all the time ``one-
	third of the counties in the United States have one provider.''
	I would say one-third of the counties in the United States do
	not have enough people to support more than one provider. I
	mean, that has to be a factor in that statistic. But again, it
	sounds pretty doom-and-gloom. The Chairman mentioned 80 rural
	hospitals closing since 2010. We passed the Affordable Care Act
	in 2010; I would be interested in knowing how many of those
	hospitals have closed in the last 2 or 3 years because in my
	State of Kentucky, what we have heard is that rural hospitals
	have been saved by the ACA.
	As a matter of fact, we had a hospital in Morehead,
	Kentucky--not in my district--which was on the verge of
	bankruptcy. Because of the ACA and because the population that
	that hospital serviced was largely a very, very poor and
	unhealthy population, now they are getting compensated for the
	care they were not getting compensated for, and they have now
	built a big professional office building, the hospital is doing
	fine, and we hear that story time after time. So, again, we can
	all cite anecdotal situations that support our point of view,
	but we need to be balanced in that.
	I have a question, Dr. Blumberg. Several of the replacement
	plans that we have heard about--Dr. Price's and several
	others--seem to be at least focused on certain common elements,
	and one of them is a tax credit. In Dr. Price's plan, for
	instance, you can go out and buy insurance that provides tax
	credits that vary only by age, and it goes from $900 to $3,000
	per person. Do you have any idea what kind of coverage in
	today's market you could buy for $900 to $3,000 a person?
	Ms. Blumberg. Well, we have recently done some estimates.
	What the goal was, was to construct a package; we assumed five-
	to-one age rating, as many of those looking for replacements
	are leaning that direction with the age rating. We tried to
	construct a package that would allow an individual of any age--
	so, any adult from 18 to 64--to buy a particular package with
	the tax credit that was offered under the Price plan by the
	different age categories.
	The most generous plan that we were able to construct that
	brought in everybody of those ages with that amount of money
	was a plan that would require the individuals to spend the
	first $25,000 in health expenses, so a $25,000 deductible for a
	single; $50,000 for a family. We found that we had to take out
	coverage for drugs that were not generic, so only generic is
	covered. That excludes chemotherapy drugs; it excludes
	insulin--those are not generics--a number of other expensive
	drugs for chronic illnesses.
	We had to exclude coverage for outpatient mental health and
	substance use disorder treatment. We had to exclude physical
	therapy, occupational therapy, speech therapy, and
	rehabilitation care. Now, you could structure this somewhat
	differently, but you are bound and constrained by the math. So,
	you could provide some coverage up front and then far less at
	the back end. You could fill a little bit with which of the
	benefits that we included or excluded, but you are quite
	constrained by the amount of money.
	Mr. Yarmuth. So, let me get you to repeat that. We would be
	talking about $25,000 per insured in deductibles, $50,000 for a
	family, and elimination of a substantial amount of the coverage
	that a policy under the Affordable Care Act would provide?
	Ms. Blumberg. That is correct.
	Mr. Yarmuth. I appreciate that. One thing, while we are on
	the subject of costs, that I think we need to mention is that
	while costs have gone up--and by the way, the year before we
	passed the Affordable Care Act, I think insurance policies
	across the country, rates were going up 38 percent; I know they
	were in California, they were in Kentucky, they were in
	Connecticut; that was a strange number, but that 38 percent
	seemed to occur in a lot of places.
	After the Affordable Care Act has now been in effect for 5
	or 6 years, we have seen the lowest rate of growth in insurance
	costs and in Medicare expenditures and in Medicaid that we have
	seen in modern history. Medicare, I think, is down to about 2
	percent annual growth. Private insurance is around the 2
	percent level. So, while, yes, costs are still going up in the
	system, the improvement has been rather dramatic. Is that your
	assessment as well, Dr. Blumberg?
	Ms. Blumberg. Yes, what we know is that per capita spending
	in national health expenditures has grown much more slowly than
	had been anticipated prior to implementation of the Affordable
	Care Act. Certainly, some of that is attributable to the Act
	itself and some of it is from other economic and structural
	changes, but that certainly is the case.
	Mr. Yarmuth. And finally, I think it is interesting that
	several of you said the ACA focused largely on coverage, which
	was certainly one of our goals, but the changes that were made,
	again, with protections for people who already have insurance,
	the changes in annual and lifetime limits, the removal of those
	limits, allowing young people to stay on their parents'
	insurance policy until 26, these had nothing to do with people
	who did not have coverage. This was people who already had
	coverage, and also the improvements we made in Medicare,
	reducing the costs of prescription drugs in Medicare, getting
	free preventive care, annual wellness visits.
	There were a lot of improvements that have been made for
	patients who already had care one way or another.
	Unfortunately, we did not talk about them, and that is the main
	reason, I think, that the Affordable Care Act has not been as
	popular over the last few years as it otherwise would be. Thank
	you very much, Madam Chairman. I yield back.
	Interim Chair Black. I thank the ranking member. I do feel
	that I do need to make a statement here. When we talk about
	these scenarios that we talk about, anecdotal scenarios, these
	are real people; 28,000 people in my State, who were sick
	people that were in a risk pool that liked it, lost their
	insurance in one day because it did not meet all the criteria
	that Washington said it needed to meet. I want to tell you,
	before I came here last week I got a call from one of my
	constituents who has lupus. She had lost her insurance when
	that day occurred. She is now on the exchanges.
	She is unable to use the doctor that she has used for years
	to control her lupus. There is only one provider of the
	insurance company in her area. So, now she lost her doctor; she
	cannot take the same medication that she was taking previously
	that helped control her condition for years; and now her costs
	have gone up to the point where she said, ``I have got to pay
	it; I cannot do anything else or I am not going to be able to
	function.''
	These are very real faces that we are talking about. These
	are not stories that are made up. These are very real lives,
	and we have got to change that so that people can have their
	lives. With that, Mr. McClintock from California, you are
	recognized for 5 minutes.
	Mr. McClintock. Thank you, Madam Chairman. The thing about
	Obamacare is you really cannot spin one way or the other. To a
	greater or lesser extent, every family in America has had an
	up-close and personal experience with it. I think any
	politician that tries to convince them that their experience is
	different than what they know is going to look downright
	foolish.
	The polls tell us most Americans do not like it. This was a
	prominent issue in the last three congressional elections in
	which the Democrats lost a net of 67 U.S. House seats. This
	Congress has a mandate to deal with it to relieve families of
	its burdens, to fix the underlying issues that spawned it, and
	restore what was once the finest healthcare system in the
	world.
	There are basically two options that we have. One is to
	repeal it in its entirety and immediately replace it with the
	patient-centered free market reforms that the Chairman
	referenced earlier; restore to people the freedom to choose a
	plan that best meets their own family's needs from a vast
	market that is competing with each other to provide better
	services at lower prices and to, through the tax system, assure
	that every family has at least a basic plan within their
	financial reach. That is one option.
	There is another option that we seem to be pursuing, and
	this is what I want to drill down on in my questions, and that
	is to repeal parts of Obamacare with reconciliation and through
	administrative action, and then rely on follow-up legislation
	to finish the job. Reconciliation would bypass the 60-vote
	closure rule in the Senate; the follow-up legislation cannot,
	and that leads me to wonder, what is the market going to look
	like if Senate Democrats decide not to cooperate on the post-
	reconciliation fix? I would like to ask a series of yes/no
	questions of Dr. Blumberg and Mr. Haislmaier to see where the
	two sides agree and where they do not.
	Can reconciliation end the Obamacare subsidies and replace
	them with tax credits? Dr. Blumberg, yes or no?
	Ms. Blumberg. I know it can repeal the subsidies. I am not
	clear on the--replacing it.
	Mr. McClintock. Okay, Mr. Haislmaier.
	Mr. Haislmaier. I believe so.
	Mr. McClintock. Okay, so we generally agree on that. Can it
	zero out the taxes and the tax penalties that are used to
	enforce the individual mandate?
	Ms. Blumberg. That is my understanding, yes.
	Mr. McClintock. Mr. Haislmaier.
	Mr. Haislmaier. Mine as well.
	Mr. McClintock. Can it end the noncompliance penalties on
	businesses, return Medicaid to its pre-Obamacare condition?
	Ms. Blumberg. I believe that is the case, yes.
	Mr. McClintock. Mr. Haislmaier.
	Mr. Haislmaier. I believe so, yes.
	Mr. McClintock. Okay, now, HHS does have some latitude in
	redefining the mandates, does it not? Dr. Blumberg.
	Ms. Blumberg. There is some latitude, yes.
	Mr. McClintock. Right. Mr. Haislmaier.
	Mr. Haislmaier. HHS does have latitude, yes.
	Mr. McClintock. Okay. Is the HHS, though, still required to
	provide guidance consistent with benefits found in a typical
	policy? Dr. Blumberg.
	Ms. Blumberg. I am not sure I understand the question. Can
	you ask again?
	Mr. McClintock. Does not the underlying bill, or underlying
	law, require that the essential benefits match those found in a
	``typical'' policy?
	Ms. Blumberg. That is right. There is some State
	flexibility on that.
	Mr. McClintock. Okay. Mr. Haislmaier.
	Mr. Haislmaier. They have such categories of benefits and
	within that HHS would have to work.
	Mr. McClintock. Is HHS still bound by the Administrator
	Procedures Act that forbids actions that are arbitrary or
	capricious?
	Ms. Blumberg. I am not familiar with that, so I cannot
	answer.
	Mr. McClintock. Mr. Haislmaier.
	Mr. Haislmaier. Yes.
	Mr. McClintock. Can reconciliation repeal the underlying
	law? Dr. Blumberg.
	Ms. Blumberg. I do not think reconciliation can repeal all
	the components of the law, no.
	Mr. McClintock. Mr. Haislmaier.
	Mr. Haislmaier. That is my understanding of Senate
	procedure as well.
	Mr. McClintock. Okay. Will noncompliant policies then still
	be illegal? Whether it is being enforced or not, will they
	still be illegal?
	Ms. Blumberg. Noncompliant plans are not illegal today,
	sir. There are many of them being sold. That is one of the
	problems in the State of Arizona, and why their premiums have
	gone up so much, because there are lots of noncompliant plans
	being sold.
	Mr. McClintock. Mr. Haislmaier.
	Mr. Haislmaier. Yes, there are noncompliant plans that are
	legal and will remain so.
	Mr. McClintock. Okay, now, is this because state
	governments are still the principal enforcement mechanism for
	Obamacare?
	Ms. Blumberg. It is because the Affordable Care Act
	regulated a certain category of non-group insurance coverage,
	but not those that remained outside. So, plans that do not
	cover you for an entire year are noncompliant plans and are out
	there.
	Mr. McClintock. Mr. Haislmaier.
	Mr. Haislmaier. Yes, there are certain underlying types of
	coverage that are exempt from the ACA.
	Mr. McClintock. In a post-reconciliation world, do state
	governments still have to approve any new plans? Dr. Blumberg.
	Ms. Blumberg. Right. The Department of Insurance and the
	State regulates what is offered there.
	Mr. McClintock. Mr. Haislmaier.
	Mr. Haislmaier. That is a matter of state law, yes.
	Mr. McClintock. Okay, now, final question, and this you can
	elaborate on, but you have about 5 seconds each to do it, and
	that is, in this post-reconciliation market then, do we run the
	risk of adverse selection being accelerated and States refusing
	to approve noncompliant plans or insurance companies refusing
	to issue them?
	Ms. Blumberg. There is a definite risk that non-group
	markets in general, for comprehensive coverage and other types
	of coverage most people like to purchase in the non-group
	market, would utterly collapse.
	Mr. McClintock. Mr. Haislmaier.
	Mr. Haislmaier. There is a slight risk of making the
	current adverse selection in the market marginally worse. There
	are things that HHS administratively can do to marginally
	decrease the adverse selection that is already occurring, so,
	on balance, it may be about where we are right now.
	Interim Chair Black. The gentleman's time is expired. The
	gentleman from New York, Mr. Higgins, is recognized for 5
	minutes.
	Mr. Higgins. Thank you, Madam Chair. Now that the
	Affordable Care Act has been taken out of a political context,
	at least in terms of the calendar, it needs to be dealt with in
	a legislative context, and facts are very important in that
	regard.
	Medicare is where 55 million Americans get their health
	care. It costs $600 billion a year; it is 15 percent of the
	Federal budget. Before the enactment of Medicare in 1965, more
	than half of the senior citizens in this country did not have
	health insurance, the reason being is that for-profit insurance
	companies did not want to write a policy for people that were
	sick and therefore costly, so the American government had
	responded by establishing a Medicare program. We went from 56
	percent of American seniors without health care to, today, 97
	percent do have health care because of that program.
	But the cost of that program was not sustainable because
	between 1970 and 2010, Medicare per-person costs grew at an
	annual rate of 7.5 percent, about four times the rate of
	inflation. It was breaking businesses, it was breaking
	individuals, and the number of individuals that were filing for
	bankruptcy protection soared because of this. Today, because of
	the Affordable Care Act, annual per-person growth is at 1.4
	percent, fully 6 percent less than it was prior to the
	enactment of the Affordable Care Act, and Medicare costs are
	lower per person today by over $1,300 per person than they were
	in 2010.
	When we set out to do healthcare reform, there were two
	objectives. One was to increase the number of people that did
	not have insurance. Individual mandate; why? Because the
	insurance model only works in health care if you have healthy
	payers who are paying for the cost of those that need it later
	in life, analogous, some people say, to car insurance. Twenty
	million more people have health insurance today, so that is a
	success.
	The other objective was bending the cost curve, as
	economists would call it, basically trying to reduce the annual
	growth of health care so that it does not exceed the rate of
	inflation. Because if it does, eventually, businesses go broke
	and individuals go broke. That is just how it works. I think on
	those two counts the Affordable Care Act has been a very
	positive thing. Before we consider repealing it or obliterating
	it, we ought to have an alternative that is constructive and
	based on fact.
	The individual mandate; again, a hallmark of healthcare
	reform. The idea, again, is to ensure that you have healthy
	payers that are paying into the system to pay for the cost of
	those who are older and need health care. Mr. Haislmaier, how
	long have you been at Heritage?
	Mr. Haislmaier. That is a trick question, because I left
	and came back, but I have been associated with it for about 30
	years, of which I have been there about 15.
	Mr. Higgins. Thirty years? So, you were there in 1989?
	Mr. Haislmaier. Yes.
	Mr. Higgins. Did you contribute to a report that was
	sponsored by Heritage called ``A National Health System for
	America?''
	Mr. Haislmaier. Yes.
	Mr. Higgins. And you collaborated with Stewart Butler?
	Mr. Haislmaier. Yes.
	Mr. Higgins. In that report, Mr. Butler said that, ``Many
	States now require passengers in automobiles to wear seatbelts
	for their own protection; many others require anybody driving a
	car to have liability insurance. But neither the Federal
	Government nor state requires all households to protect
	themselves from the potentially catastrophic costs of serious
	illness. Under the Heritage plan there would be such a
	requirement.''
	That was the basis for the individual mandate. Do you still
	believe that the individual mandate should be a part of the
	healthcare system in America?
	Mr. Haislmaier. Well, it depends on how you define an
	individual mandate.
	Mr. Higgins. I think it is pretty clear here, sir.
	Mr. Haislmaier. Well, no, it is not, because you are
	assuming that it is a pay-or-play mandate. When we actually
	helped draft legislation, which we did in 1993 with the
	Nickles-Stearns bill, we said, look, if you did not have health
	insurance, you would lose your personal exemption on the tax
	code. Now, one might be able to characterize that as a mandate,
	but that is very different than the design in the ACA, which
	says, ``Buy a plan or we fine you.''
	Mr. Higgins. Claiming back my time, because my time is
	expired, I would just say for the record that it is pretty
	clear here the origins of the individual mandate, and the sound
	reasoning behind it. That was embraced as a major piece of the
	Affordable Care Act.
	Interim Chair Black. The gentleman's time has expired.
	Mr. Higgins. I yield back.
	Interim Chair Black. The gentleman from Georgia, Mr.
	Woodall, is recognized for 5 minutes.
	Mr. Woodall. Thank you, Madam Chair. I am pleased to be
	back on the Budget Committee with you this cycle, but I will
	tell you, if we reclaim time that has already expired, then we
	see what the problems are we are going to face.
	Interim Chair Black. That is right.
	Mr. Woodall. So, I am going to try to balance this budget
	going forward. I am glad you all are here. Dr. Blumberg, I
	particularly appreciate the solutions that you added to the end
	of your testimony because I do think there is so much that we
	can do together.
	Mr. Haislmaier, they asked you how long you had been
	associated; here I was a staffer on the Hill when it was led by
	the great bipartisan Newt Gingrich from the State of Georgia,
	and of course, in those good bipartisan times, we passed
	healthcare reform. We abolished preexisting conditions for
	every single healthcare plan that the Federal Government had
	jurisdiction over. Every single one.
	You may think that that got jammed through with
	reconciliation. I happen to have those conference report
	numbers here. There was a conference report with that bill at
	that time, abolishing preexisting conditions. The vote in the
	Senate was 98-0 and the vote in the House was 421-2, with one
	of those great opponents of healthcare reform, Pete Stark,
	voting no at that time. Of course, Pete voted no because it did
	not go far enough, not because it got that done. I contrast
	that with what is going on right here.
	You suggested, Dr. Blumberg, that if we repealed the ACA
	today that we would be worse off than if the ACA had never
	passed. I want to stipulate that I believe that to be true. I
	think we have wasted so much time fighting about this that we
	could have dedicated to real, fundamental reform. You know how
	much time we have spent arguing about repealing preexisting
	conditions in the Federal healthcare market since 1996? Zero.
	Zero, and people are benefiting from it. We are wasting time
	and money here, and a repeal would not get that back.
	I think we have also threatened some of the underlying
	economics of the plan. I want to point to Mr. Haislmaier's
	testimony; he says this--reading glasses have come about since
	we have been fighting about the Affordable Care Act, too--he
	says, ``In general, enrollment that indicates that
	implementation of the ACA appears to have had three effects on
	health insurance coverage: an increase in individual market
	enrollment, an offset and decline in the fully ensured employer
	group plan enrollment, and a significant increase in Medicaid
	enrollment.'' Does anyone dispute the--Dr. Blumberg?
	Ms. Blumberg. Yes, I dispute his findings of his study.
	Mr. Woodall. You believe that we have not seen an increase
	in Medicaid?
	Ms. Blumberg. No, I know we have had an increase in
	Medicaid.
	Mr. Woodall. Do you believe we have not seen a decrease in
	employer coverage?
	Ms. Blumberg. Absolutely not. We have not seen any
	measurable decrease in employer-sponsored insurance, and we see
	that in multiple nationally representative surveys, both of
	employers and of households. Employer-sponsored insurance has
	remained incredibly stable since the implementation of the Act.
	Mr. Woodall. But the truth is, if you are going to spend $1
	trillion on a program, it is really not surprising that we can
	tell stories of folks who have benefited, and I am glad. I say
	that sincerely; I am glad for folks who have found a benefit
	out of $1 trillion out of taxpayer money. What is shocking, is
	that we can spend $1 trillion and find folks who are worse off
	today than they would have been today before.
	The small groups that I experience in my district, those
	small family businesses that went out of their way to buy a
	more expensive plan because one secretary in that office had a
	special needs child and the entire office wanted to collaborate
	in order to get that child the plan that they needed, the care
	that they needed, and those days are behind us now. Those plans
	have gone away. That employer cannot afford to do that anymore
	because he has lost the choice in that marketplace.
	I think about the work that Ms. Turner has done. Yes, 75
	percent higher rates for young people for a corresponding 12
	percent decrease for 64-year-olds. And when those young people
	act based on their own economic self-interest--shocking that
	people still do that, but they do--then we see those elderly
	folks, those 64-and-under folks, disadvantaged in ways that
	they would not have been pre-the Affordable Care Act.
	It encourages me that I can read Ms. Turner's testimony and
	I can read Dr. Blumberg's testimony and I can see that we all
	agree that those three bands have failed. We all agree that
	that pricing structure has failed, and it can be on the short
	list of things that we begin to collaborate on. 421 to 2, 98 to
	0, Republicans in the House, Republicans in the Senate,
	Democrats in the Senate, and Bill Clinton in the White House
	got this done, and shame on us for having started down this
	road. I hope we can do better in fixing it. I yield back.
	Interim Chair Black. The gentleman's time has expired. The
	gentlelady from Washington, Ms. DelBene, is recognized for 5
	minutes.
	Ms. DelBene. Thank you, Chairman Black and thanks to all
	our witnesses for being here with us today. If you knew nothing
	else about the Affordable Care Act all you would need to do is
	read the title of today's hearing to understand that it's
	brazenly partisan. The majority wants to talk about the effects
	of the ACA, so let's talk about them.
	One effect is that people do not go bankrupt when they get
	sick anymore. That sounds like a pretty good outcome to me.
	More than 120 million Americans with pre-existing conditions
	are no longer denied coverage. Young adults can stay on their
	parents' plans until they are 26, and over 10 million seniors
	have received help with their prescription drug payments. And
	all insurance plans are required to cover preventative services
	at no cost.
	This is especially critical for women. Each year, this
	helps 55 million women save more than $1.4 billion on birth
	control. Many of my friends from across the aisle have said
	they want to keep the good parts and just get rid of the bad.
	So, what are we really doing here? For years, my colleagues
	and I have offered proposals to strengthen the ACA and were
	turned away each time. I have a bill to make it easier for
	small businesses to provide coverage for their workers, for
	instance, and yet folks do not want to talk about that. They
	just want to talk about repeal.
	So, now we know the effects of the ACA, which is the
	purpose of the hearing today. So, let's talk about the effects
	of repeal. You are going to hear a lot of numbers thrown around
	today, and it is easy to get lost in the statistics and forget
	that this is about people.
	What is important to remember is, repealing the ACA hurts
	real people across the country in profound ways. It means
	taking away health coverage for 30 million Americans, it means
	seniors will have to pay more for critical prescription drugs,
	and it means women will once again be denied coverage simply
	for being a woman.
	It also means a great deal to people like Sue Black. Sue is
	a public school teacher from my district who was diagnosed with
	stage four ovarian Cancer at the age of 47. Five years later,
	she received a short, but terrifying letter from her insurance
	company. In four sentences, it said she had exhausted three-
	quarters of her lifetime benefit limit. Thankfully, the
	Affordable Care Act banned lifetime caps on coverage. And she
	is not the only one.
	In the past few weeks, my office has been flooded with
	stories from constituents describing how the Affordable Care
	Act saved their life or the lives of their loved ones. And
	meanwhile, the Republican plan for health care in America is
	repeal the Affordable Care Act and then just trust us. I think
	our constituents deserve better than to have their health
	coverage taken away with no plan for what comes next.
	Ms. Blumberg, I wondered in your opinion, is there a
	segment of the population that would benefit from repealing the
	Affordable Care Act without a replacement plan in place?
	Ms. Blumberg. You know, folks who do not want to purchase
	health insurance coverage and are subject to a mandate penalty
	as a consequence of the Act--under that sort of repeal through
	reconciliation, they would have less penalty to pay. The
	problem is that there would be such a huge loss of insurance
	coverage for a much larger percentage of the population, the
	uncompensated care burdens would increase so much on healthcare
	providers and on state governments that I think that would be
	far outweighed. Otherwise, I cannot really come up with people
	who are going to be benefiting as a consequence.
	Ms. DelBene. And can you describe the effects on children
	if the Affordable Care Act were repealed?
	Ms. Blumberg. By our estimates, roughly 4 million children
	would lose health insurance coverage. Some of these children
	are covered with their families through the marketplaces with
	financial assistance. Others will lose their coverage, because
	what we know from a lot of experience with the Medicaid system
	and with the ACA is that when adults know that they can have
	assistance in getting coverage, they find out when they go to
	enroll that their children are eligible for CHIP as well. And
	so, if the parents know they cannot get coverage and they do
	not go seeking it, then their children will not end up getting
	insured as well.
	Ms. DelBene. Thank you. And we keep hearing from my
	colleagues on the other side of the aisle how the Affordable
	Care Act is going to collapse, but has not enrollment been
	growing, especially right now, and is not the real threat,
	right now, the promise of repeal?
	Ms. Blumberg. Absolutely. The repeal without replacement is
	a recipe for a death spiral. And right now, the Affordable Care
	Act, as I said, has some areas in which there have been high
	premiums and that we have some policy strategies that should be
	put in place to address them. But, by and large, it is being
	successful at increasing coverage, increasing access, and
	improving affordability.
	Ms. DelBene. Thank you. I yield back, Madam Chair.
	Interim Chair Black. The gentlelady's time is expired. The
	gentleman from Alabama, Mr. Palmer, is recognized for 5
	minutes.
	Ms. Palmer. Thank you, Madam Chairman. I just want to share
	some information that I have gotten from some of my
	constituents. A doctor sent me some information that he saw a
	patient last week whose deductible was $9,000. Essentially, her
	insurance is basically catastrophic insurance. She probably has
	two patients a month who cannot schedule surgery, or they
	schedule and then cancel the surgery.
	And basically, because people cannot afford the deductibles
	they are not getting the health care that they need. It is
	impacting the quality of life, impacting their health. Here is
	another family that has gone through three or four different
	plans. Their premiums went from about $1,400 for a family of
	four to $2,100. When they take the out of network, their
	deductible is $13,700. Madam Chairman, the Affordable Care Act
	is an oxymoron.
	There is still over 28 million people who do not have
	health insurance, and most of them, according to the Kaiser
	Foundation, say it is because they cannot afford it. So, you
	have basically put one group into the Affordable Care Act, most
	of them are Medicaid. You have displaced people who had
	employer-provided plans, I think there are about 8 million of
	those. You have caused companies to not expand. I have
	information here from companies where they would not hire that
	50th employee; as a matter of fact, one of these had 45
	employees, they have cut back to 32 because of the premiums
	that they have to pay to provide health insurance for their
	employees.
	And Madam Chairman, it has had a terrible impact on
	employment. I do not know if our friends across the aisle are
	aware of this, but there is over 94 million able-bodied
	Americans who are out of the workforce, the highest number, I
	think, ever for the country. Prior to 2008, there were 100,000
	more businesses starting up than were closing. These are mostly
	small businesses.
	According to a report from Gallup as of 2014, there are now
	70,000 more businesses closing than starting up. You have
	people who had full-time jobs with good wages and health
	benefits that have been cut back to part-time. They are now
	having to work two part-time jobs at lower wages with no health
	insurance.
	You know, the best thing that I can say about the
	Affordable Care Act is that we now know what does not work. And
	I am confident that we can move forward with plans to replace
	it. Ms. Turner, you have worked in this area for years. We
	know, I think goes all the way back to the 1990s, that you have
	been involved in health care reform, are you confident that we
	can repeal this and replace it with something that we do not
	put millions of people out of the insurance market, we allow
	people to actually choose their doctor, choose their health
	insurance. Do you think we can do that?
	Ms. Turner. Absolutely. I agree with you, Mr. Palmer, that
	we have learned a lot about what does not work with this law,
	and I think that is a good foundation to figure out what we can
	do. And I know that many members actually have real legislation
	on both sides of the aisle and, certainly, the House spent a
	great deal of time developing the better-way plan that the
	chairman talked about. There are good ideas out there. They
	involve putting patients at the center, returning power to the
	states, to add resources to the States, to better organize
	their health insurance markets to be more responsive. But, yes,
	I am highly confident. Everybody talks about repeal and
	replace, not just repeal.
	Mr. Palmer. Dr. Book, you brought up the fact that life
	expectancy declined this past year for the first time in over
	two decades. I think, what was it, 12 or 13 million people were
	put into Medicaid, that gets counted among the number of people
	who received health insurance. Are you aware of the studies
	that show that people who are on Medicaid have poor health
	treatment outcomes than if they had no insurance at all? Can
	you comment on that?
	Mr. Book. Yes, I am familiar with that. There are multiple
	studies showing that people on Medicaid have worse health
	outcomes than people who are uninsured. It is hard to argue
	that Medicaid actually makes people sicker, but it is possible
	that people who are uninsured are either able to pay their own
	bills, able to obtain charity care, or perhaps, are simply
	healthier to begin with. But, certainly Medicaid does not have
	a very good record in terms of restoring people to health,
	making people live longer. People with Medicaid use emergency
	rooms more than the uninsured and more than people with
	insurance, and they have worse health outcomes than any other
	group.
	Interim Chair Black. The gentleman's time is expired.
	Mr. Palmer. Thank you, Madam Chairman.
	Interim Chair Black. The gentleman from California, Mr.
	Khanna, is now recognized for 5 minutes.
	Mr. Khanna. Thank you, Madam Chair, and thank you, Ranking
	Member Yarmuth for your leadership. It is an honor to be on
	this committee. Ms. Turner, on April 8, 2016, you were quoted
	in the New York Times as describing President Trump's proposals
	as ``sketchy and inadequate.'' You went on to say and I quote,
	``He has to flesh out his proposals with much more detail if he
	hopes to persuade voters that he has a credible plan to replace
	Obamacare.'' Do you remember saying that?
	Ms. Turner. Yes, sir.
	Mr. Khanna. Do you still believe that?
	Ms. Turner. That was a very early preliminary list of seven
	points that he issued during the primary season.
	Mr. Khanna. Do you believe he has now articulated a
	comprehensive plan?
	Ms. Turner. He is working with members of Congress as, I
	think, is really a very appropriate and looking forward to----
	Mr. Khanna. Can you point to any specific changes that he
	has offered, now different from your statement in April?
	Ms. Turner. Yes, he gave a major speech in Pennsylvania on
	November 1st, and outlined a very different and visionary kind
	of approach to health reform that would return much more power
	to the states, deregulate the market, give people many more
	choices of coverage than before----
	Mr. Khanna. I thought he has been saying that since he
	announced. Was there any specific changes he has offered since
	your statement in April?
	Ms. Turner. He is working with members of Congress. He does
	not do, as I think, the Obama administration----
	Mr. Khanna. Okay. If I can move on, President Trump also
	had called for removing barriers to imported drugs from other
	countries, same as, by the way, Senator Sanders. Now, you are
	opposed to the President's policy on that, correct?
	Ms. Turner. I believe that there is a great risk to the
	American people of imported drugs that we do not know the
	origin----
	Mr. Khanna. So, you disagree with President Trump when it
	comes to imported drugs?
	Ms. Turner. Yes.
	Mr. Khanna. And you disagree with Bernie Sanders, and you
	are on the opposite end of what President Trump is proposing on
	that? Is that correct?
	Ms. Turner. I think that there are legitimate safety
	concerns that the Federal Government, including former FDA
	Commissioner Mark McClellan--cannot provide safe terms.
	Mr. Khanna. I picture that I am--I just want to be clear
	that you are on the--you disagree with President Trump when it
	comes to that?
	Ms. Turner. Yes.
	Mr. Khanna. And your op-eds consistently, as you disclosed
	to your credit, say that your organization is funded by the
	pharmaceutical industry--is that correct?
	Ms. Turner. No, that is not correct. We received some
	funding from the pharmaceutical industry, but we have brought
	broad funding from individuals inside and outside the health
	sector.
	Mr. Khanna. I respect that, but on all the op-eds it says
	you're partly funded from pharmaceutical industries. In your
	own McClatchy editorials.
	Ms. Turner. And so as--virtually every person in the think
	tank has some funding from pharmaceutical companies because
	they believe in innovation, as we do.
	Mr. Khanna. Can you disclose to this committee which
	pharmaceutical companies fund your organization and how much
	money you receive from them?
	Ms. Turner. Those--that list is really a proprietary
	information, it is basically how we--how we have special
	relationships with all of our donors inside and outside the
	health sector.
	Mr. Khanna. Ms. Turner, with due respect, when I have to
	disclose every financial interest, I have, my spouse has,
	because if I am going to articulate a viewpoint on something,
	the public has a right to know what financial interests I have.
	I would suggest, if you are giving testimony to the United
	States Congress, the public should have a right to know what
	financial interests your organization has.
	Ms. Turner. We disclosed those on an I-90 Form that we file
	with the Internal Revenue Service every year. The Congress has
	seen fit to allow the list of donors to remain private as
	proprietary information because it is basically our
	intellectual property. How do we get our funding?
	Mr. Khanna. So, you are unwilling to disclose which
	pharmaceutical companies are funding your organization or how
	much money you received from them?
	Ms. Turner. It would be unfair to them, because they are--
	we receive funding from many other organizations, a great
	majority outside the pharmaceutical industry.
	Mr. Khanna. So the pharmaceutical funding is less than the
	majority?
	Ms. Turner. Oh, absolutely.
	Interim Chair Black. Mr. Khanna, that really is not the
	purpose of this hearing. I think the witness has already
	answered that she is following the law, if you would like to
	ask another question. I think we ought to stay on the topic of
	what we came here to do.
	Mr. Khanna. Well, Madam Chair, I think that the issue with
	the President has said that he is for the importation of drugs
	and that is an important point in this debate on health care.
	The witness is offering an opinion that is in opposition to the
	President of the United States. And I am trying to understand
	why she believes what she believes and if there are financial
	interests that may be coloring her opinion.
	Interim Chair Black. Mr. Khanna, I think the witness has,
	again, answered that she is following the law. Now, if there is
	a part of this that you would like to change the law, you
	certainly have the authority to be able to offer a bill.
	Mr. Khanna. And I think my time has expired.
	Interim Chair Black. Thank you. The gentleman from South
	Carolina, Mr. Sanford is recognized for 5 minutes.
	Mr. Sanford. Yeah, and given the last interchange, I think
	we should all be careful about judging each other's intent. I
	could list a long list of left-leaning organizations that do
	not disclose their funding sources, there are groups on the
	right. I think we need to be careful about that. And in that
	regard, I would give credit to my Democratic colleagues for
	what they have tried to do with Obamacare. I think that if you
	look at the actual intent of Obamacare, it was good. The idea
	was to help people with preexisting conditions, to look at how
	you deal with this. I remember there was a great movie years
	ago, Helen Hunt was in it and I cannot remember the name of the
	movie to save the life of me, but there was a great tag-line.
	This is back at the time that insurance companies were
	declining people, and she said something to the fact of,
	``Well, my insurance company declined me.'' And the audience in
	the movie theater that I was in, I mean, they went nuts; I
	mean, the people literally started clapping spontaneously.
	So, I think that the intent of Obamacare was good, it was,
	``How do we get our arms around this problem?'' The question
	has been in implementation. I think that that is was a lot of
	us struggled with from the Republican side, and I suspect many
	independents and Democrats, as well. And with that said, I
	guess I would say a couple of different things, you know, I
	think fundamentally we all recognize the fact that the
	marketplace likes a product that somebody else pays for. That
	in the history of mankind, there is almost unlimited demand for
	a product, in fact, that somebody else is paying for.
	And it has, to a degree, part of that fatal flaw built into
	it. I think that we have to recognize--the math certainly shows
	it--that sick people cost more than healthy people. And, you
	know, the fundamental problem of health care in general is, it
	is almost an 80/20 phenomenon; that wherein 20 percent of the
	folks are costing about 80 percent of what we deal with in
	health care. That is from the right or from the left.
	And as we age, we cost more. I mean, my sons are immortal,
	or pretty closely so. And as you look at large pools of
	population, those trends hold true, notwithstanding horrible
	illnesses that happen to young people. And what we have come up
	with in construct with Obamacare, is we are going to stick the
	young people with the bill. In essence, it is fundamentally
	flawed. This 3-to-1 ratio is mathematically incorrect. And
	there is some math built into this equation that just does not
	work. And so, a number of us are saying, ``Okay, the intent was
	good, but practically speaking, where do we go from here given
	the fatal flaws that are built into it mathematically?''
	To my colleague, Mr. Palmer's, point, if you look at some
	of the outcomes, and I dealt with this for 8 years when I was
	governor as we were dealing with Medicaid, that, you know,
	there is just some fundamental flaws. We have a disease-
	treatment program, but we do not have much in the way of
	prevention.
	And so, I think we are all struggling with, ``Where do we
	go from here?'' Is there a different way of dealing with
	preexisting condition and high risk pools, and all the things
	that are talked about that perhaps you have seen at a different
	country, or something that really has worked well with an
	individual county or State? I just in a minute and 35 seconds
	that are left, I would be curious to hear any of your thoughts
	in terms of best practices that we can borrow as we all
	collectively struggle with this debate before us. Yes, ma'am.
	Ms. Turner. I would say that, you know, almost all
	industrialized countries have a single payer type system
	where--I agree with you. The fundamental problem with doing
	reform is this skewness of the distribution of health expenses.
	And so how do you share those expenses? And I think, you know,
	obviously, all the foreign single payer plans spread those
	costs broadly through the tax payer system.
	And, you know, here we are not in that place to be doing
	that, but I think, you know, we do not want to criticize the 3-
	to-1 age rating without recognizing that without a different
	mechanism, the people who are older adults who have more health
	problems would not be able to afford their coverage if we went
	to--I mean, I used to see 11-to-1 rating from some insurers in
	the old says. So, yeah.
	Mr. Sanford. See, I have 30 seconds.
	Ms. Turner. Okay.
	Mr. Sanford. I am going to reclaim it. It just seems to me
	on that very point that you raise--it is a legitimate point in
	terms of industrialized countries around the globe--that you
	have got three variables within health care though. You have
	got access, you have got costs, and you have got quality. And
	in as much as many of those countries have been able to spread
	access, it has been to the detriment of quality and cost. And
	so people do not go to Britain to do certain procedures. You
	are literally on a death list in Britain. And I think that
	those kind of societal questions are part of what we are
	struggling with. I am going to hand off to your colleague--go
	in the second you have got.
	Mr. Book. In 5 seconds, a lot of those single-payer
	countries have annual and lifetime limits on the services they
	can provide to a person and they have much higher death rates
	from serious disease like cancer, because they just do not
	treat them.
	Mr. Sanford. Thank you.
	Interim Chair Black. The gentlelady from Washington, Ms.
	Jayapal is recognized for 5 minutes.
	Ms. Jayapal. Thank you, Madam Chair. As this is my first
	hearing on the House Budget Committee, I just wanted to express
	my great appreciation to you and to our ranking member, Mr.
	Yarmuth, for your leadership and guidance. And I am looking
	forward to working with everyone on the committee.
	Madam Chair, last week over 2,000 people joined me in
	Seattle in support of the Affordable Care Act and demanded that
	it not be repealed without a replacement and that we in fact
	focus on expansion. I have heard from many who are seriously
	terrified that their health care will not only be stripped
	away, but that there is no replacement.
	Sally is a single, 80-year-old woman who told me that she
	would be severely affected if her Medicare benefits were cut.
	She worked for 30 years, was healthy until 3 years ago when she
	was diagnosed with a serious cancer. Medicare benefits covered
	much of her hospital and treatment costs which she could not
	have paid for on her own.
	She said, if Medicare is cut or reduced, ``I will be
	struggling to keep up with healthcare costs.'' Madam Chair, I
	agree with you that this is about real people. And this is just
	one story, I have heard hundreds.
	I would like us to consider the big picture in the State of
	Washington, my home State, a repeal of the ACA would mean
	three-quarters of a million people would lose their health
	care, almost 3 million people in Washington State with
	preexisting conditions would not be guaranteed coverage
	anymore. And speaking of preexisting conditions, being a woman,
	would once again be one of those preexisting conditions as we
	would have to pay out-of-pocket for cancer screening, PAP
	tests, and birth control.
	Our State benefited greatly from Medicaid expansion,
	605,000 people gained coverage and would once again be without
	health care. And 55,000 young people in Washington State who
	are barely getting by, would once again be kicked off of their
	parents' health insurance. There are no winners with an
	Affordable Care Act repeal, Madam Chair. And that is why I
	hope, that forums like this can be focused on what we can do to
	make it better, but a replacement plan, which has not been
	offered, instead of nothing.
	I wanted to say, I come from the State Senate where--which
	is controlled by Republicans and the chair of the Healthcare
	Committee in the Washington State Senate, Senator Randi Becker
	recently said, ``This is not a partisan issue, this is a bi-
	partisan issue.'' She believes that any replacement should
	build or improve the reach of Medicaid expansion funds. In
	Washington, this represents about $3 billion and the majority
	of the funding received under the ACA.
	So, Dr. Blumberg, can you speak to specifically Medicaid
	expansion and the states across the country who have benefited
	from Medicaid expansion?
	Ms. Blumberg. Sure, there has been a big infusion of
	Federal dollars into the states that expanded Medicaid allowing
	them to make all individuals, regardless of their family
	situations, eligible up to 138 percent of the poverty level for
	the first time. This has done a lot to improve the financial
	situations of hospitals in those states relative to the states
	that did not expand, as my colleague Fred Blavin has shown in a
	recent JAMA article. This is big financial benefits. In
	addition, these are comprehensive benefits with no cost
	sharing, so it makes coverage and access to care incredibly
	affordable for the low-income population.
	Ms. Jayapal. Thank you. I appreciated the concern for
	fairness throughout everybody's statements and so--but I am
	trying to understand exactly what you do believe should be
	covered and some of the provisions of the Affordable Care Act.
	So, just yes or no answers, if you would for all of our
	testifiers. Do you believe that young adults should be able to
	stay on their parents' plan until they are 26?
	Ms. Turner. As long as the $1,200 costs----
	Ms. Jayapal. Just a yes or no, Ms. Turner, thank you.
	Ms. Turner [continuing]. Is visible.
	Ms. Jayapal. Was that a yes?
	Ms. Turner. If they want to pay for it?
	Ms. Jayapal. So, that is a yes?
	Ms. Turner. If they want to pay for it, I guess.
	Ms. Jayapal. Dr. Book.
	Mr. Book. I think if employers want to offer that, it
	should be perfectly legal.
	Ms. Jayapal. Dr. Blumberg.
	Ms. Blumberg. I agree, it should stay.
	Ms. Jayapal. Dr. Haislmaier.
	Mr. Haislmaier. Irrelevant.
	Ms. Jayapal. Is that a----
	Mr. Haislmaier. It is irrelevant under either ACA or the
	replacement, because they will be treated as their own
	household, anyway.
	Ms. Jayapal. Let me ask about seniors on Medicare, a
	critical part of the Affordable Care Act. Do you believe
	seniors on Medicare should be able to afford their medications
	and not fall into a prescription drug gap? Ms. Turner.
	Ms. Turner. Yes, but there are creative ways to do that.
	Ms. Jayapal. Dr. Book. Dr. Book.
	Mr. Book. Could you repeat the question?
	Ms. Jayapal. Do you believe that seniors on Medicare should
	be able to afford their medications?
	Mr. Book. I think everybody should be able to afford
	everything.
	Ms. Jayapal. Great, thank you. Dr. Blumberg.
	Ms. Blumberg. I agree.
	Ms. Jayapal. Dr. Haislmaier.
	Mr. Haislmaier. I mean, comprehensive----
	Ms. Jayapal. Yes or no, Dr. Haislmaier.
	Mr. Haislmaier [continuing]. Drugs is fine, I mean that
	is----
	Ms. Jayapal. Thank you. How about making sure that
	insurance companies cannot deny coverage because of a person's
	medical history? Ms. Turner.
	Ms. Turner. That was the case before, and will continue to
	be the case moving forward.
	Ms. Jayapal. So, that is a yes. Dr. Book.
	Mr. Book. That was the case since 1996 and the ACA should
	never be able to----
	Ms. Jayapal. Dr. Blumberg.
	Ms. Blumberg. Yes, I agree, but that has not been the case,
	universally, by a long shot.
	Ms. Jayapal. Thank you. Can you say more about that, Dr.
	Blumberg?
	Ms. Blumberg. Yes.
	Interim Chair Black. Sorry, the gentlelady's time has
	expired.
	Ms. Jayapal. I yield back.
	Interim Chair Black. I apologize, but we have so many other
	members. So, I hate to cut you off, it is great conversation
	and thank you very much. Now, the gentleman from Arkansas, Mr.
	Westerman is recognized for 5 minutes.
	Mr. Westerman. Thank you Madam Chair and thank you to the
	panel for being here today. You know, it was mentioned that a
	lot of people want to keep the Affordable Care Act in place,
	they are fearful that it might go away, but I will remind the
	committee that millions of Americans were fearful that they
	might lose their doctor or their premiums would go up, but they
	were promised they could keep their doctor.
	They were told their premiums would go down by $2,500, but
	from the testimony here today, we have heard that there has
	been increased premium costs, there has been increased taxpayer
	costs, people indeed are seeing higher deductibles, they are
	seeing fewer benefits, they are seeing reduced access.
	There has been talk about Medicare and what might happen to
	Medicare, but I would also remind the committee that when the
	ACA was passed, that there were cuts to Medicare reimbursements
	in the Affordable Care Act to pay for Medicaid expansion and
	the exchange policies as much as or over $700 billion in those
	cuts to Medicare.
	I was visiting with a neurosurgeon from my State who has
	been affected by the cuts to Medicare. He explained it like
	this, certain surgery might take five steps to the surgery and
	Medicare pays for two of them. And he assured me that if there
	is anything he knows about how the Affordable Care Act was that
	whoever wrote it knew absolutely nothing about medical care.
	We have heard about the number of people who have benefited
	from the Affordable Care Act, there is really no consensus on
	that number from the panel. I believe there is consensus that
	most of the people that have benefited from the Affordable Care
	Act are in the Medicaid population. I know that was definitely
	true in my State. There is arguments about how many people
	could have already received Medicaid who have qualified for it,
	the woodwork effect, that actually signed up for Medicaid
	because of the expansion.
	And, you know, if we just take Dr. Blumberg's number of 20
	million people who benefited from the Affordable Care Act, if
	we look at the population of our country that is 6.2 percent of
	our country. So, we could say 6.2 percent possibly got more
	because of the Affordable Care Act, but I think we failed to
	remember that 93.8 percent of Americans are getting less for
	more because of the Affordable Care Act.
	As a State legislator in Arkansas, I lived through the
	debate on Medicaid expansion, and our State did expand
	Medicaid. It was supposedly an innovative plan that did not
	expand a traditional Medicaid, but used Medicaid dollars that
	come from an apparently bottomless pit of money in D.C. to buy
	private health insurance. So, the 320,000 Arkansans that are
	now on Medicaid that were not before, have a very nice health
	insurance plan. They have got a Blue Cross plan that they pay
	nothing for, they do not have a deductible, and it pays the
	providers very well, but it comes at a tremendous cost. And now
	over a third of my State is receiving benefits through the
	Medicaid program.
	So, Mr. Haislmaier, I want to ask you a question on the
	Medicaid part, was the traditional Medicaid system for the
	aged, the blind, the disabled, was it having any problems
	before the Affordable Care Act?
	Mr. Haislmaier. Well, it depends on the State, but, yes, I
	mean, there were clearly problems in the program.
	Mr. Westerman. Yeah, I know from my experience there were
	huge problems in the Medicaid program. And the follow-up to
	that is, did the ACA do anything to address the underlying
	problems with Medicaid, or did it simply add a new layer of----
	Mr. Haislmaier. It was mainly an expansion to it; it
	expanded to a new population. They did make some other changes
	to the program, but they were largely around the areas of
	eligibility.
	Mr. Westerman. So the 324,000 in my State, take away about
	7 percent of that for the woodwork, were all able-bodied,
	working age adults that are not even part of the traditional
	Medicaid system, the aged, blind, the disabled. Do you believe
	the traditional Medicaid population across the country has
	suffered any damage because of the expansion for the able-
	bodied adults?
	Mr. Haislmaier. The problem with it is not just so much the
	expansion, that increases the caseload, but the problem is that
	there is a sort of inequity in basically the Federal Government
	paying the states more for people who need the program less,
	and paying them less for people who need the program more. I
	mean, my classic example with this----
	Mr. Westerman. Do you think States need more flexibility to
	design their own Medicaid plans?
	Mr. Haislmaier. Well, in general, but I think also in
	particular with this population. I mean, one of the things we
	have learned both in terms of the Medicaid expansion and the
	subsidies for the very low income in the ACA is that these are
	people who will show up when they need medical care, but they
	are not going to stick with it afterwards. And you have to
	really direct them away from the emergency room. And Medicaid
	is not set up to do that.
	Interim Chair Black. The gentleman's time has expired. The
	gentlelady from Florida, Ms. Wasserman Schultz is recognized
	for 5 minutes.
	Ms. Wasserman Schultz. Thank you, Madam Chair, and
	congratulations to you, as well as to our ranking member. The
	chair noted that I served on the Budget Committee in the 112th
	Congress, but it appears that I have returned to the alternate
	facts committee, because that is what we have been subjected to
	throughout this hearing.
	Madam Chair, I respectfully want to share with you in case
	you are not aware, that I know you referenced 28,000 people in
	Tennessee supposedly, you know, losing coverage from TennCare
	which existed before the Affordable Care Act, but I wonder if
	it would surprise you to learn that 28 percent more Tennesseans
	gained coverage under the Affordable Care Act, that is 266,000
	people in Tennessee who now have coverage which is a far sight
	better than the 28,000 you referenced who supposedly lost it.
	I am also confident, if you checked, you would probably see
	that most of those 28,000, if not all of them, were able to
	gain more affordable coverage under that Affordable Care Act.
	In my State, 1.3 million Floridians gained the coverage who
	did not have it before, the most in the country and I will
	note, something that we have not really talked about here--
	let's focus for a moment on the fact that people with employer-
	based insurance would be gravely harmed from the significant
	benefits that they gained under the Affordable Care Act. The
	return of annual and lifetime coverage gaps, coverage limits,
	preventative care without a co-pay or a deductible like
	mammograms, colonoscopies, well-woman care, all of which made
	health care more affordable.
	By the way, the availability of birth control for free
	without a co-pay or deductible has contributed to a precipitous
	drop in the unwanted pregnancy rate. So, the majority of people
	who already had coverage before the Affordable Care Act will be
	significantly harmed by repeal.
	I want to note, also, that Dr. Book clearly referenced in
	one of his responses that he supports returning to ``health
	underwriting'' which was extremely dangerous and harmful and
	expensive, and contributed to death spirals when we had a
	purely private market-based system. Ms. Turner is clearly
	advocating returning to strict private market practices that
	were unaffordable and harmed millions of people.
	So, let's be very clear here, there has not been a
	replacement plan proposed and, respectfully, my colleagues on
	the aisle had 7 years to do that and still have not done it. We
	have millions of people who gained access to health care who
	did not have it before; millions of people who had healthcare
	coverage and got better coverage; millions of seniors who can
	have more affordable prescription drugs and, frankly, also have
	benefits like being able to go and get a check-up every year
	without a co-pay or deductible. Representing a State who has
	the largest percentage of seniors in the entire country, I can
	tell you that most of those folks were only able to go to the
	doctor when they were sick because they could not afford copays
	and deductibles on a well care visit for them, so we are
	keeping them healthier as a result.
	In my last--under 2 minutes, I want to ask Mr. Haislmaier,
	do you believe--and I would like, in the interest of time, just
	a yes or no answer--do you believe all Americans should have
	access to quality, affordable health care--all? Yes or no.
	Given the time constraints, again, please answer with a yes or
	no and can we agree that health care is a right and not a
	privilege?
	Mr. Haislmaier. That is the wrong question because----
	Ms. Wasserman Schultz. Yes or no. You do not get to
	dictate----
	Mr. Haislmaier. No, I am not going to answer yes or no on
	that because you are----
	Ms. Wasserman Schultz. Clearly, because you probably do not
	think it is.
	Mr. Haislmaier [continuing]. Because you are--because all
	health care is not----
	Ms. Wasserman Schultz. And before the ACA--if you will not
	answer my question, I do not----
	Mr. Haislmaier. You know, facelifts are not a right.
	Ms. Wasserman Schultz. I guess, add. See, my name is on the
	door, so I get to ask the questions and decide which ones are
	right.
	Mr. Haislmaier. Okay, but you do not----
	Ms. Wasserman Schultz. You clearly do not believe that
	health care is a right, not a privilege. None of the majority
	witnesses do. And before the ACA, there was no all-out band
	prohibiting discrimination against individuals with pre-
	existing conditions until age 26, correct?
	Mr. Haislmaier. No, that is not true.
	Ms. Wasserman Schultz. No, it is true.
	Mr. Haislmaier. No, the----
	Ms. Wasserman Schultz. There is no question that you were--
	an insurance company could drop people or deny them coverage--
	--
	Mr. Haislmaier. No, that is not true.
	Ms. Wasserman Schultz. Before the----
	Mr. Haislmaier. The 19--Congresswoman, if you actually read
	the 1996 HIPAA Law, you would understand that, that is not
	true.
	Ms. Wasserman Schultz. That would be news to the thousands
	of people that I know in my district who were dropped or denied
	coverage. As a breast cancer survivor, I can tell you that I
	have spoken to many of my sister survivors who were dropped in
	the middle of their treatment by their insurance company and
	had to choose to----
	Mr. Haislmaier. And that was illegal and they had recourse.
	Ms. Wasserman Schultz [continuing]. Between--excuse me, no,
	it was not illegal. It happened every day.
	Mr. Haislmaier. It was.
	Ms. Wasserman Schultz. And they had to choose between
	either the chemo or the radiation because they could not afford
	the copays or deductibles on both. That is the nightmare that
	the majority----
	Mr. Book. The ACA does not require coverage for either.
	Ms. Wasserman Schultz. Excuse me, I have not asked you a
	question, Dr. Book. Madam Chair, if you could return a few
	seconds of my time because I keep getting interrupted, I would
	appreciate it.
	Interim Chair Black. I am proffering you 5 seconds.
	Ms. Wasserman Schultz. Thank you so much. At the end of the
	day, the majority is clearly proposing to repeal the Affordable
	Care Act without assuring us that we would have universal
	access to quality affordable coverage. That is unconscionable,
	unacceptable and we will not allow you to do it without a
	fight.
	Interim Chair Black. The lady's time is expired. I do want
	to recommend to my colleagues that keep saying there are not
	plans out there, there is a Ryan, Price, Sessions, Roe, and
	then there is the Better Way with Guiding Principles. With
	that, the gentleman from Ohio, Mr. Johnson is recognized for 5
	minutes.
	Mr. Johnson. Thank you. Madam Chairman, I appreciate the
	opportunity and I appreciate our panel being here with us
	today. You know, we are holding this hearing today for one
	simple reason. Obamacare has failed and it has caused a series
	of very serious problems for the American people. I think we
	all remember the Democrat Minority Leader famously stating,
	``We have to pass Obamacare to find out what is in it.'' Well,
	we have done that, or they did that and it is full of broken
	promises that are harming American individuals, families and
	businesses.
	Instead of reducing healthcare costs, Obamacare has driven
	up premiums and deductibles and millions of Americans have lost
	affordable quality healthcare plans and their choice of doctors
	in many cases. The average annual family premium in the
	employer-sponsored market has soared, totaling more than 18,000
	annually, while deductibles for individual plans are up an
	average of 60 percent since 2010.
	At its core, the law did nothing to drive down the
	healthcare costs for the American people. During a time of
	economic recession and hardship, Obamacare employer mandate
	makes full-time workers more costly to hire, resulting in many
	cases in job reductions, lower wages, and reduced benefits. And
	these are just a few of Obamacare's harmful effects that we are
	exploring here during this hearing. And I have listened to some
	of the questions and comments by some of my colleagues on the
	other side of the aisle and I want to agree with one of the
	things they say.
	It is not about statistics, it is about people, but yet
	they cite statistics about coverage without acknowledging the
	fact that coverage does not necessarily mean affordable.
	Because I can tell you that in Appalachia, Ohio--along the Ohio
	River, there are thousands of people who, because of the high
	premiums and the high deductibles, they do not bother going to
	the doctor even though they might have coverage in the
	theoretical sense, or the technical sense, it is not affordable
	and it does not give them quality health care.
	So, Ms. Turner, under Obamacare, out-of-pocket costs, as I
	just mentioned for families and individuals, including the
	deductibles, are simply unaffordable and it constrains their
	budgets, so why in your view are costs so high?
	Ms. Turner. They are high primarily because the Federal
	Government decided it knew better than the American families to
	what needs to be covered in their health insurance policies. In
	addition, the Affordable Care Act included a trillion dollars
	in new and higher taxes, many of which get booked and built
	into the premiums, as well as rules and regulations that have
	discouraged the young people from entering. So, we, therefore,
	have many more young, older sick people in the pools not offset
	by the younger people who would otherwise be there to help
	lower premiums.
	Mr. Johnson. So, basically, you have got bureaucrats
	running our healthcare system instead of physicians and
	patients.
	Ms. Turner. Right, correct.
	Mr. Johnson. Dr. Book, what are the areas of spending in
	Obamacare with the greatest unforeseen cost overruns? Do you
	have some examples you can share with us quickly?
	Mr. Book. I would say the most unexpected thing from the
	standpoint of the proponents was the huge increases and
	deductibles and that was the result of a system that encourages
	sick people to sign up. It discourages healthy people to sign
	up especially if you are under 26. You know, why buy and
	exchange plan when you can get on your parents' plan. And then
	regulators try to crack down on premiums and they cannot cut
	covered services because there is a whole bunch of required
	covered services, so the only thing they have to do is increase
	deductibles.
	And what used to be a high deductible plan that qualified
	you for a tax break, if it was $2,400, it is now lower than any
	deductible you can find. Now, people are paying $9,000 for a
	deductible, which by the way, is double the statutory limit
	because the previous Administration issued a waiver allowing
	deductibles at the double the level the text of the ACA
	actually allows.
	Mr. Johnson. So, just one quick final question because I am
	out of time. So, has Obamacare successfully bent down the cost
	curve in healthcare spending?
	Mr. Book. No. In fact, during the last year that stat is
	available, costs went up 5 percent per capita. The 5-year
	average before was 2.9 percent.
	Mr. Johnson. Okay. Thank you, Madam Chair, I yield back.
	Interim Chair Black. Your time is expired. The gentleman
	from California, Mr. Carbajal, 5 minutes.
	Mr. Carbajal. Thank you, Chairman Black and thank you,
	Ranking Member Yarmuth and all my colleagues. I would like to
	thank all the witnesses that are here today, and I want to
	start by saying that, you know, the Affordable Care Act never
	purported to be perfect. So, it is important to recognize that
	as the baseline by which we are debating and discussing this.
	It did a lot of good. It continues to have some challenges, but
	it did a lot of good in attempting to fix a broken healthcare
	system that we all know we had and continue to have. We need to
	build on that.
	It has been three weeks since I was sworn in as a member of
	Congress. In this short time, I have seen the Republican
	majority take concrete action to begin dismantling the
	Affordable Care Act and I am deeply concerned about where we
	are headed. We have no substantive plans from the Republican
	majority to replace the ACA with a proposal that would match
	the benefits provided by the ACA. I would love any plans that
	have been proposed to become available so that I could see them
	first hand.
	Now, I want to be clear. I do not believe the Affordable
	Care Act is perfect. There are changes that can be made to make
	it better. I have heard from constituents who have greatly
	benefitted from the healthcare law and that is the reason I am
	here. I asked my constituents to share with me their stories
	about how a repeal would impact their lives. And I would like
	to share some of those stories with you, not statistics, but
	some of those stories.
	Jerry, a business owner in Los Osos in my district, lived
	without health insurance for years until the Affordable Care
	Act, hoping that their young son would not get sick or break a
	bone. Brian, in Santa Barbara, was uninsured for nearly 20
	years because he could not afford health care coverage. The
	Medicaid expansion under the ACA allowed him to get covered.
	Just last year, Brian was diagnosed with a degenerative disc
	disease and without surgery covered by this medical expansion,
	he would have been left severely disabled. He told me the ACA
	quite literally saved his life.
	Elle Donna in Balboa Beach, donated her kidney the same
	year the Affordable Care Act was signed into law, in 2010. If
	not for the Affordable Care Act, her life-saving act would have
	prevented her from obtaining health insurance due to a new pre-
	existing health condition as a living donor.
	These are just a few of the stories that I have heard about
	tangible life-saving impacts the Affordable Care Act has had. I
	see I am running out of time. Dr. Blumberg, can you elaborate
	more on how repealing the Affordable Care Act would impact my
	home State, California?
	Ms. Blumberg. I do not have my California specific figures
	in front of me, Congressman, but as the largest State----
	Mr. Carbajal. Let me ask you a second question then. What
	do the people losing coverage look like to you? Are they
	working families? Are they mostly poor or not?
	Ms. Blumberg. So, about over 80 percent of those who would
	lose coverage are in working families and the vast majority of
	those have at least one full-time worker in the household; 53
	percent have incomes between 100 percent and 400 percent of the
	Federal poverty level. That is about $24,300 for a family of
	four as poverty. It has spread very broadly across the age
	distribution, contrary to some of the things we have heard.
	There has been--the biggest uptake in coverage that has been
	among young adults and 80 percent are people who have not
	obtained a college degree.
	Mr. Carbajal. Thank you. I come from a working family. My
	dad was a farm worker. I have seen people back home struggle to
	pay their medical bills when a family gets sick. It is
	imperative that we continue to work together providing
	affordable health care coverage for all, especially these
	working families that stand to lose the most from repeal. I
	yield back.
	Interim Chair Black. The gentleman yields back. The
	gentleman from Minnesota, Mr. Lewis, is recognized for 5
	minutes.
	Mr. Lewis. Thank you, Madam Chair. For the record, anyone
	on the Panel can answer this, the HIPAA Law of 1996 does not
	allow or does cover by law, pre-existing conditions, employer-
	to-employer?
	Mr. Haislmaier. That is correct.
	Mr. Lewis. Oh, I just wanted to get that in for the record
	then. I do want to talk a little bit about what the ACA has
	done in Minnesota. Now, there is a lot of talk from the other
	side about how repeal would impact certain groups, but we know
	what the law has already done. In my home State of Minnesota,
	which is really at the epicenter of all this, the commerce
	commissioner there called it an emergency situation. Two years
	of back-to-back premium increases, 50 percent and 67 percent. A
	hundred thousand people being shoved into a default option.
	The governor, Governor Mark Dayton, whom we are all wishing
	well today, called the Affordable Care Act is, ``no longer
	affordable.'' It is an existential crisis in the State of
	Minnesota. So, we can talk all day long about what repeal and
	replace is going to look like, but we know what the current law
	looks like and it has been a disaster. One thousand counties in
	the United States have one insured to choose from.
	Now, I am going to focus a little bit about--on two things,
	one, employer coverage as well as what we call the age rating
	or the community rating in some circles. First of all, I
	believe Grace-Marie Turner has commented on the Affordable Act
	not just hitting the individual market, what we are hearing
	from the other side is, ``Well, gosh, you are just talking
	about 5 percent of the people in the individual market being
	hurt by all of this. It is no big deal, 95 percent of the
	people have coverage and their very healthy employer pool, but,
	in fact, the Affordable Care Act has really impacted employer
	coverage too, has it not?
	Ms. Turner. Absolutely, and as we heard earlier, the
	requirements of the law have significantly driven up costs and
	deductibles to the cost of the average family policy for
	employer is now $18,000 a year, more than the $4,000 higher
	than it was before, not the $2,500 savings that they were
	promised.
	Mr. Lewis. And Dr. Book, to your point, an acquaintance of
	mine was recently offered a plan, at work, again not the
	individual market, employer-based coverage, his deductible was
	$13,000. The family plan was well over $1,500 a month. This is
	living proof that health insurance is no longer health care.
	Mr. Book. Right, well, yes and that kind of deductible was
	unheard of before the ACA. Nobody had a $13,000 deductible
	before that.
	Mr. Lewis. It used to be in the market-based economy, it
	would work a little bit like the bond, 10-year bond. The
	interest rates go up, the bond goes down. Premiums go up, your
	co-pays and deductibles go down. Now, we are getting a massive
	hike in premiums along with massive hikes and co-pays, stricter
	drug formularies all sorts of things that were unheard of just
	a few years ago.
	Mr. Book. That is absolutely right.
	Mr. Lewis. Anybody else want to comment on that?
	Ms. Blumberg. I would like to comment. There was some
	turmoil in the early years of the ACA in Minnesota because of
	the problems with underpricing by the co-op and then the
	removal of the risk core where payments that were intended to
	pay and that was a congressional decision and that really
	financially harmed the market in Minnesota tremendously and I
	get that, but 380,000 people have gained insurance coverage
	through or at risk of losing their health insurance coverage
	through repeal. In Minnesota alone----
	Mr. Lewis. I can tell you the insurance companies are more
	than making up for that underpricing early on.
	Ms. Blumberg. No, and I understand that.
	Mr. Lewis. I mean, it is 50 percent, 67 percent the last 2
	years.
	Ms. Blumberg. And there are some strategies that we can
	discuss for stabilizing the market there and increasing
	competition within the framework of the Affordable Care Act.
	Mr. Lewis. I think it is just going to be, soon, one
	insurer left in MNsure, the State exchange. They are fleeing
	the State.
	Ms. Blumberg. But if you want to discuss it, I can give you
	some ideas of how you might increase competition.
	Mr. Lewis. I want to get one more question in for Mr.
	Haislmaier and that is, do you know of any economic model where
	freely floating prices are not a requirement for the proper
	allocation of assets?
	Mr. Haislmaier. No.
	Mr. Lewis. So, why are we putting price controls on the
	health insurance market that basically says, ``Well, gosh, the
	price has to be within a band for everybody,'' which is
	effectively jacked up premiums so high that we price young
	people out of the healthcare market.
	Mr. Haislmaier. Well, basically, that is a pricing
	convention and what you can do is you can sort of categorize
	them in bands. The problem there is, yes, you have compressed
	to the point where you have increased the costs for young
	adults----
	Mr. Lewis. And priced them out of the market.
	Mr. Haislmaier. You have reduced them for older people and
	priced them out of the market. Yeah, it was one of the things
	that really even from the perspective of a supportive of this
	law did not make a lot of sense to start with because those are
	people who are most likely to be price sensitive about
	insurance.
	Mr. Lewis. I think Milton Friedman warned us about price
	controls at one point, right, in the surpluses and charges. All
	right, thank you. Madam chair, I yield back my time.
	Mr. Rokita [presiding]. Gentleman yields. Mr. Boyle is
	recognized for 5 minutes.
	Mr. Boyle. Thank you and thank you for recognizing me and I
	very much appreciate being on this committee. Regret that this
	morning it was service on my other committee has a hearing
	meeting at exactly same time, so trying to run back and forth
	to the two. I will have questions for Dr. Blumberg, but I first
	just want to reiterate something that I said on the House floor
	last week and go into a little more detail since I have more
	than a minute.
	It is interesting that about 16 years ago, I was sitting in
	a graduate school class at Harvard's Kennedy School and there
	was a fellow from the Heritage Foundation, Stuart Butler,
	saying that he had an idea that was an alternative to what was
	then characterized as ``Hillary Care'' before it was demonized
	Obamacare, it was first demonized as Hillary Care.
	And the alternative to a government-run, single-payer
	system, essentially Medicare for all, was the pool the
	uninsured together through a series of taxes and tax credits
	combined with a mandate to purchase insurance and banning a
	discrimination against those with pre-existing conditions. Pool
	these people together and instead of having a government
	provided single payer, we would instead pool them together and
	enable them to purchase private health insurance plans.
	In fact, that was the genesis of the bill that was
	introduced by then, Republican Senate leader Bob Doyle and 17
	Republican senators in the mid-1990s. Fast forward two decades,
	we know it and the root of it is Obamacare and suddenly, it is
	an idea that is akin to socialism.
	So, if the other side really wants to repeal and replace
	what was the market solution to the Democratic plan of the
	1990s and wants to instead repeal it and maybe replace it with
	a single-payer system or some sort of Medicare for all, I would
	be someone on this side of the aisle that would be interested
	in that sort of repeal and replace conversation.
	Now, let me address some of the rhetoric we have heard
	recently in the media because I am confused about it. We keep
	hearing that Obamacare is in a ``death spiral'' and that it
	will ``collapse under its own weight,'' but then I actually
	look at the facts and I see 22 million people who are insured.
	I see that in 2010, the percentage of Americans uninsured was
	approximately 16 percent. Today, it is one half of that, 8
	percent. The lowest percentage in American history.
	So, Dr. Blumberg, could you rectify these clear
	discrepancies between the rhetoric of a ``death spiral'' and
	the actual facts?
	Ms. Blumberg. Sure. The Affordable Care Act markets are not
	in a death spiral. Coverage is increasing in them and there
	some--substantial percentage of the population lives in areas
	where there has been either modest increases in prices or
	actually, decreases and not--lowest options that are available
	there.
	So, there are some markets that have had bank percentage
	increases because they were correcting for earlier underpricing
	and then, there is a set of states that are having issues
	related to lack of competition and either their insurer or
	provider markets and adverse selection. And those are the
	markets that we should be addressing with policy, but we should
	not be presuming that this is one big market that is
	collapsing. That is absolutely not true.
	Mr. Boyle. Yeah, and I think a couple of those States are
	Minnesota, like we heard Arizona, I think is another one. They
	have their own unique challenges that are not necessarily
	representative of the Nation as a whole.
	Ms. Blumberg. That is correct.
	Mr. Boyle. I did want to--because I cited the figure of 22
	million people that are now enrolled through the exchanges,
	but, in fact, if we were to repeal the Affordable Care Act, the
	number of people that would lose their health insurance is
	upwards of 30 million. Is that not correct, and can you expand
	upon that?
	Ms. Blumberg. Our estimate is that 29.8 million would lose
	their coverage in 2019 and that would be a consequence of
	repealing all the financial assistance and the individual
	mandate that bring in the healthy population into the pool
	while leaving in place the consumer protections that prohibit
	discrimination against the sect. Those two things going
	together end up not just eliminating the coverage for people
	who gained it under the law, but collapse the market for people
	that were buying with their own funds.
	Mr. Boyle. Okay and of course, finally, since I am down to
	10 seconds, the 29.8 million figure does not even include the
	number of seniors in my districts that have gotten benefits
	such as, lower prescription drug costs because of other changes
	that came in with the Affordable Care Act.
	Ms. Blumberg. Right, because they would not become an
	insured.
	Mr. Rokita. The gentleman's time is expired. We will now
	hear from Mr. Bergman for 5 minutes.
	Mr. Bergman. First, thank you, Madam Chairman, for giving
	me the opportunity as a member of the new committee--Budget
	Committee to be here and ask questions today. As a new member,
	I came to Congress with a promise to my constituents of
	Michigan's First District to serve them and to make sure we are
	being responsible stewards of their hard-earned tax dollars.
	So, it is only fitting that we are here today to discuss the
	harmful effects of Obamacare.
	This law has raised taxes on families and small business,
	discouraged economic growth and job creation and has ultimately
	placed the government in the driver's seat for personal
	healthcare decisions. I am looking forward to working with my
	colleagues across the aisle, here in this committee, and in
	Congress in general on meaningful, real reform to our
	healthcare system.
	My first question for Ms. Turner. The authors of Obamacare
	tried to setup tools to help small business get access to
	health coverage, such as the small business tax credit, a
	special insurance exchange, known as the shop exchange. Are
	small businesses better off or worse off because of Obamacare?
	Ms. Turner. The polls that are taken by the National
	Federation of Independent Business and other organizations say
	absolutely not because their costs are still so high and they
	were very disappointed at the effect of the promise that they
	would have tax credits and relief which they have not seen and
	felt they had to jump through way too many bureaucratic hoops
	and the tax credits were far too restrictive to be of use to
	them.
	Mr. Bergman. Okay. Again, Ms. Turner, what are the lessons
	that we should take from our last 6 years of Obamacare to truly
	provide access of affordable health care for the small
	businesses? And my district has a tremendous number of small
	businesses. What are the lessons?
	Ms. Turner. The lessons are to listen to them; that they
	want to provide health insurance for their members. They cannot
	do it if the policies that they are required to offer are so
	extraordinarily full of benefits that the prices are
	prohibited. It hurts everyone to try to promise them everything
	and they cannot afford it.
	Mr. Bergman. Thank you. Dr. Book.
	Mr. Book. Yes.
	Mr. Bergman. As we prepare to legislate in this area to
	provide patient-centered healthcare reforms, what are the
	biggest lessons from the Obamacare experience that we should
	heed? Conversely, are there positive aspects of the healthcare
	law that have performed better than anticipated that we should
	be aware of? So, pros and cons.
	Mr. Book. So, I think the most important lesson is patients
	have a better idea of what type of coverage they want than
	people sitting here in Washington telling them what to want.
	People should have the right, if they wish, to buy a
	comprehensive healthcare plan that covers everything
	imaginable.
	If they wish to choose a more basic plan, that should be an
	option. If they wish to choose a more, you know, more
	catastrophic plan, which is with the $9,000 deductible, that
	should be an option as well. What they should not have to do is
	buy a comprehensive plan with a catastrophic deductible, which
	is basically the only option that people in the individual
	market have right now.
	I think the goal of allowing people to buy insurance
	without--even if they have pre-existing conditions is an
	admiral goal, is an important goal, it is an essential goal,
	however, the ACA went about this in a completely wrong way that
	left millions of people unable to afford coverage. It also left
	insurance companies not covering a lot of conditions.
	You know, in the first year of the ACA, there were actually
	fully compliant ACA health plans that did not cover cancer
	treatment at all because that was not one of the essential
	services required by law. I guess someone just forgot to list
	that.
	Mr. Bergman. Thank you.
	Mr. Book. Yeah, sorry.
	Mr. Bergman. Thank you. I want to get to--because I have
	about 30 seconds left. Mr. Haislmaier, can you explain the
	difference between subsidized and unsubsidized coverage and
	what that means for individuals who are purchasing coverage?
	Mr. Haislmaier. Well, the Affordable Care Act has a set of
	very general subsidies for people who meet income and other
	criteria and purchase through the Exchange. So, what I am
	talking about the market, those are the people I am referring
	to who are receiving subsidies, as subsidized enrollees. You
	could also refer to people who are on a public program as a
	subsidized enrollee. The other two are buying in the same
	market----
	Mr. Rokita. The gentleman's time is expired. We will now
	hear from the gentleman from Massachusetts, Mr. Moulton, for 5
	minutes.
	Mr. Moulton. Mr. Chairman, thank you. You know, there has
	been a lot of discussion here back and forth about conflicting
	ideas. Perhaps, alternative facts, but I just want to get down
	to some facts we can all agree on. Some simple things about the
	situation we find ourselves in now here in Congress.
	The first is that, Republicans have tried to repeal the ACA
	65 times; 65 times, they have voted to repeal the ACA without a
	replacement. Not on the first try; not on the fourth try; not
	on the 12th try; not on the 65th try. I heard Madam Chairman
	discuss at length, her anecdotal evidence for places where
	Obamacare has come up short. Not once did I hear her propose an
	alternative. If we want to fix this, then let's propose a plan,
	and hope is not a plan. Ideas are not a plan.
	Second, we get lectured in this committee a lot by the
	other side of the aisle about fiscal discipline; about how if
	American families and small businesses can balance their
	checkbook, then Congress ought to be able to, too. And you know
	what? I agree with that. I strongly agree with that and yet,
	here we are where repealing the ACA without a replacement as
	the Republicans have already begun to do, would cost roughly
	$350 billion through 2027.
	In fact, it will be so bad for the deficit that Republicans
	had to repeal the rule that bans reconciliation from being used
	to increase deficits. They had to repeal that rule so that they
	can increase the deficit dramatically by repealing Obamacare.
	It is going to break our bank.
	The gentleman from California said, ``Is it not shocking
	that we have a trillion dollars spent on health care and yet
	there are some people who are left out?'' What is shocking to
	me is that you want to spend even more than that and yet leave
	30 million people without health care.
	Now, the third thing that we can all agree on is that the
	Congressional Budget Office estimates that repealing the major
	coverage provisions of the Affordable Care Act will terminate
	coverage for--sorry, not 30, but 32 million people.
	I would just like to put that number in perspective. No,
	sorry, not the slide of the people who did not show up for the
	inauguration. Can you see the next slide? Yes, the Women's
	March, right. This Saturday, roughly 3 million Americans
	gathered in cities all over the country for the Women's March.
	The largest single day protest in American history. If you
	multiple that number by 10, that is how many Americans would
	lose their access to the affordable, quality care they receive
	from the ACA. We are just looking at Washington here.
	Three million Americans all over the country, multiply that
	by 10, that is now many people we are talking about losing
	their care. I am a veteran myself. I am particularly proud of
	the fact that between 2013 and 2015, the un-insurance rates for
	non-elderly veterans fell by an estimated 42 percent--42
	percent and we are going to put a lot of those vets out in the
	street without health care if we follow through on this. Two
	leading doctors at Harvard Medical School have concluded that
	43,000 people will be killed annually if the ACA is repealed
	without a replacement. And not just a replacement, but a
	comparable replacement, a comparable replacement.
	Madam Chairman lectured us on how we should govern by
	anecdote because she cited some people who are not happy with
	their current care. Those 43,000 people are not just anecdotes.
	They are people too, who will lose their care if this is
	repealed. For your Congressional district, that is about 1 in
	17 people in your Congressional districts, that is what that
	will mean; who will die if this is gone. Thank you, Mr. Chair.
	I yield back.
	Mr. Rokita. Gentleman yields back. I will remind the
	gentleman that in 2015, when the Obamacare appeal got to the
	President's desk, had he signed it, the deficit could have
	nearly been erased because CBO scored that as a $500 billion
	savings. Gentleman from New York, Mr. Faso, is recognized for 5
	minutes.
	Mr. Faso. Thank you, Mr. Chairman. A number of the
	witnesses have discussed the age banding, and we know that
	there are approximately 8 million people have chosen to not buy
	coverage either because they cannot afford it; they do not know
	enough about it; or, they have just simply decided it is a
	better deal for them to pay the penalty. I am wondering if--I
	know Ms. Turner and Dr. Blumberg have both referenced in their
	testimony the 3-to-1 ratio which is in statute as I understand
	it. What should--if the panel could each offer us--what should
	that ratio be if we are to amend that portion of the law?
	Ms. Turner. This would be a decision best left up to the
	States, but a 5-to-1 age band was previously considered a good
	standard, but it is something that is very difficult for the
	Federal Government to make one standard.
	Ms. Blumberg. From my perspective, you cannot change the--
	you should not change the 3-to-1 age band to something broader
	unless we provide more financial protection for older adults
	because the point of putting those tighter age bands in was to
	make it so coverage was not excessively unaffordable for older
	adults paying for their full premium.
	So, if you can put in where consumer protections, financial
	protections, everyone over 400 percent of poverty pays only--no
	more than eight and one-half percent of their income for a
	standard policy. Then you can loosen to 5-to-1 because what you
	are doing is you are redistributing these very high costs that
	we accrue as we get older by income instead of by age--but for
	now I would not move up----
	Mr. Faso. Thank you.
	Ms. Turner. But the effect has been to discourage young
	people to getting it and actually it harms older people now
	currently because the young people simply do not enroll because
	of this 3-to-1 band.
	Ms. Blumberg. It does not harm older people and I think you
	have far overstated the circumstances.
	Ms. Turner. But they are paying higher premiums.
	Ms. Blumberg. This is my turn now. You far overstated the
	circumstances because age is very inversely correlated with
	income. So actually, a very large percentage of our young
	adults are eligible for financial assistance, which caps what
	they have to pay relative to their income when they enroll
	through the marketplaces and that protects them. Our analyses
	found that there is no difference in coverage as a consequence
	of 3-to-1 versus 5-to-1. It is a matter of who is going to be a
	little more uninsured; older adults who need a lot more care or
	younger adults who need less.
	Mr. Faso. Thank you, Dr. Blumberg. Dr. Book, did you have
	something to add to that?
	Mr. Book. Yeah, thank you. To answer your first question, I
	would recommend not specifying that in that ratio in the
	statute. Prior to the ACA, some states did not have that in
	their State statutes either and the ratio was usually 5-to-1.
	We find with the ACA premiums even for older Americans have
	increased relative to what they were before. So, I do not think
	this 3-to-1 is necessarily saving them money, because they are
	paying more.
	Mr. Faso. Okay. Mr. Haislmaier, do you have something to
	add to that?
	Mr. Haislmaier. Congressman, yes. I can supply you with a
	study that was done by the American Academy of Actuaries that
	has looked at the relationship between age and health care
	expenditures. And basically, when you look at that, if you
	assume that there is a blended rate, meaning that you are not
	differentiating between men and women, because women tend to be
	more expensive younger and then that flips and men are more
	expensive when they are older, but if you assume a blended
	rate, then the approximately 5- to 6-to-1 range is the natural
	variation in health care spending.
	Mr. Faso. Thank you. One last question that the panel, if
	you could briefly answer since I have 1 minute and 19 seconds,
	the essential benefits, my understanding that is done through
	strictly regulation now at HHS. What changes would you
	recommend in that regard, Ms. Turner?
	Ms. Turner. There are 10 specified categories in the ACA.
	The HHS secretary has a broad license to redefine those and I
	think that is something that the American people would like to
	have looked at again so that they can have more flexibility.
	Mr. Faso. Dr. Book.
	Mr. Book. Yeah, I would like to say a word about
	preventative care, which is listed as a general category, but
	somehow, in reality, preventative care does not include
	anything that actually prevents you from getting sick. For
	example, high blood pressure medicine is not included,
	cholesterol medicine is not included, blood thinners for people
	who had strokes are not included. It just includes things like
	vaccines, screening tests, and contraception. So, a lot of the
	things that actually prevent people from getting sick and
	prevent people needing more expensive treatments are actually
	not counted as preventive care, according to the ACA and its
	regulations.
	Mr. Faso. Dr. Blumberg.
	Ms. Blumberg. One must remember before you remove something
	from an essential health benefit or remove all essential health
	benefit requirements, is that as soon as you take something out
	of that benefit package it is out of the sharing of healthcare
	risk across the population. Any individual who needs that
	particular type of care is going to have to pay for it
	completely out of their own funds, and this will make that
	unaffordable care, in many circumstances, for many individuals.
	Mr. Rokita. The gentleman's time has expired.
	Mr. Faso. Thank you, Mr. Chair.
	Mr. Rokita. The gentlelady from New Mexico, Ms. Lujan
	Grisham, is recognized for 5 minutes.
	Ms. Lujan Grisham. Thank you, Mr. Chair, and while I had
	not intended to have this be the focus of my question, and I
	hope I do not lose all my time as a result. What is really hard
	about these hearings is that both sides have a limited amount
	of time to shoot out their sound bite and these falsisms or
	truisms do not get us anywhere closer to dealing with real
	healthcare reform. For somebody who has worked in health care
	for more than 30 years--I remember HMOs and I remember Medicare
	Part D and the problems with formularies--I can tell you that
	insurance companies and pharmaceutical companies are not trying
	to make it affordable for anyone, and I know that we have had
	lots of debates that have been bipartisan in Congress about
	hospital costs, and I just am really struck by the conversation
	about what HIPAA does and does not do.
	Most people in Congress, I will bet, have no idea that it
	is a privacy portability law that made some changes to the
	prior COBRA protections, which basically means when you lose
	your job or change your job there ought to be some way to take
	that insurance protection with you. But what we do not talk
	about is it was the full cost and it is time limited out, and
	if you do not get into another group plan after 24 months and
	you do not know to appeal, and you do not have a lawyer or you
	do not have me, then you do not get an extension.
	And if you had cancer, you are in real trouble, which is
	why we have so many bankruptcies and why people are so
	frustrated because while somebody on my side of the aisle did
	not quite get that right, her point was it does not really work
	in the way that we thought it did and most high risk polls
	around the country did not provide subsidies, which meant you
	were still paying the full cost of your care when you were
	excluded by a pre-existing condition, which is why so many
	Americans are so frustrated and we in Congress are not dealing
	with the real perpetrators of cost.
	You want to talk to doctors, which I do nearly every month,
	bipartisan, all different practices and relationships. They do
	not want to work insurance companies, not worrying about
	bureaucrats nearly as much as they are worried about
	corporations that tell them what they can and cannot do.
	You want a patient-centered system, take out the people
	that I have no control over. I have access to my doctor, but I
	cannot deal with my insurance company or pharmaceutical company
	that will not put any of the drugs--Dr. Book, that you just
	mentioned--as preventative care.
	It is not the ACA. We do not allow any negotiations with
	any of those pharmaceutical companies and, until we start to do
	real work in that regard, then the issues that you have by both
	members of this committee, including the mother pregnant with
	twins, husband loses his job, without the ACA, no way--and they
	are born prematurely--can she deal with it with the ACA.
	Another one of my constituents because insurance companies
	and hospitals do all sorts of interesting things, including in
	hard to serve places like my State, but certainly not just like
	New Mexico, but all across the country. We do interesting
	things like this, so this hospital is in my network and this
	hospital does women's care, which means they do maternity care,
	which means they got to have a neonatal wing. But guess what,
	that hospital is going to contract out with a Florida company
	that is going to provide those neonatal services.
	Now, I do not have any access to that information. I choose
	a plan. I go to the hospital in my plan. I give birth to
	triplets, prematurely. Those triplets are very sick, one
	survives. No complaints about the quality of care by this
	neonatal team. Now you need specialty care for the twin that
	survives. It is severely disabled and guess what I got? I got a
	$30,000 bill just for the first couple of weeks in neonatal
	care. You know why? Because they were not part of that network,
	and the ACA did not prevent that, the ACA did not cause that.
	Insurance companies cause that. Now, I was able as a member of
	Congress to solve that problem.
	I have legislation, ladies and gentleman, that would
	prohibit that. I do not think it has ever gotten here, and
	anybody who wants to get on that bill call me after. There are
	plenty of problems with large corporations and hospitals who
	have created huge cost problems and practices in this country.
	The real, one of the real issues; it is not the only one; we do
	not embrace public health in this country. Every other country
	that deals with reasonable healthcare costs and you want to get
	to prevention, then let's do public health.
	So, my questions were, are there any proposals, to Linda
	Blumberg, that you have seen in Congress. I will not even pick
	on Republicans, because I know about the Health Savings Account
	and I know about privatizing Medicare that would actually
	reduce deductibles or out of pocket costs, which I would agree
	I would love to see those go down. Any?
	Ms. Blumberg. No.
	Ms. Lujan Grisham. Me either. Not for 30 years.
	Mr. Rokita. The gentlewoman's time has expired. We will
	hear from the gentleman from Pennsylvania. Thank you, Mr.
	Smucker, for 5 minutes.
	Mr. Smucker. Thank you, Mr. Chair. I would like to thank
	the panelists for being here today. You know, I think it is
	important we not lose sight of the goal that I think is shared
	by everyone up here today, both sides of the aisle, and that
	is, we want to ensure that individuals--Americans--have access
	to quality health care at a price they can afford. And I am
	looking forward to working with my colleagues on both sides of
	the aisle to design such a system, because we know ACA has not
	done that--has not worked--and granted there are some who have
	had access to health care for the first time through ACA.
	And we are not going to pull the rug out from under them.
	We want to ensure we have a system that gives them better
	coverage, better care, but what I have been hearing and I, of
	course, like so many others--I am a first-time freshman
	member--have come through a 12 months campaign primary in
	general and the Obamacare system has been top of the list in
	people's minds. And what I have heard from constituents in my
	district is what we have been talking about today.
	People have seen extraordinary increases. People who had
	health insurance before have seen extraordinary increases in
	the cost of their premiums, 25 percent average increase in
	premiums across the country. It is higher than that in my area.
	I have talked to people who have seen doubling of their
	premiums, and then I have heard of others who have lost their
	insurance altogether, who have been forced onto a plan that
	they did not want.
	So, clearly, what we have is not working. I think there are
	better solutions and I am looking forward to working with the
	college to achieve that. My background is small business owner.
	I have been a small business owner for 25 years prior to
	serving in the State Senate, and I have spoken to a lot of
	small business members over the last year as well.
	I will just share one brief story. A husband and wife team,
	who operated a small machine shop in Elizabethtown in the
	Lancaster County portion of my district, and they prided
	themselves--they have 10 to 15 employees, I forget the exact
	number--but have been in business for quite some time, have
	always prided themselves in creating a kind of family
	atmosphere among their employees. They see their employees as
	family.
	They have always provided quality health care, seen that as
	an important part of their pay and benefit package, and
	literally believed that they may not be able to do that any
	longer and were very, very worried, not only about how it would
	impact their business and their profitability, but how it would
	impact their employees and their employees' families.
	I think this is one of the impacts of the Affordable Care
	Act that we have to find better solutions to allow employers to
	continue to provide that kind of service to their employees
	that they think is very, very important. But I want to get
	back, and I have taken most of my time--but I do have a quick
	question and I think, Mr. Haislmaier, you had talked about
	self-insurance. As a business owner, myself, we were one of
	those businesses that were self-insured and we found it an
	effective way to control costs, because you created a
	partnership with your employees and with the company.
	You designed a system that worked for employees and then
	created incentives for control and costs and so on, and just
	recently I talked to a business owner who said over the last 5
	years they have not had the kind of increases that many others
	have seen in health insurance, many other businesses have seen.
	And when I asked why, he said well, we are self-insured.
	So, we have had a very, very good experience with that. I
	think you mentioned that we have seen a slight increase in
	self-insurance after ACA and I guess I would be interested in
	learning more about that and whether you see this is as an
	important part of the solution.
	Mr. Haislmaier. Yeah, the most notable shift has been a
	significant drop off in fully insured employer plans, which is
	where you go and buy the coverage from an insurer on a group
	basis, and the insurer retains the risk. Those tend to be
	smaller and medium size businesses. Up until recently, the
	self-insured market has largely been large employers, but it is
	moving down the firm size scale. That is, by far, just to give
	you a relative concept, that has grown, but it has been a
	steady two percent sort of growth every year, but it is already
	from high base of about 100.
	It started out at about 100 million people in that. One of
	the reasons that--and I have been looking for this--I have not
	seen a significant acceleration in the data, but because of the
	ACA, if you get out from under----
	Mr. Rokita. I am sorry, the gentleman's time is expired.
	The gentleman's time is expired. Mr. Gaetz of Florida, you are
	recognized for 5 minutes.
	Mr. Gaetz. Thank you, Mr. Chairman. Hope is not a plan, was
	the admonishment we received from the gentleman from
	Massachusetts. It is perhaps also a fitting title for the
	obituary of the last 8 years. Time and again, we have heard our
	Democratic colleagues on this committee say, ``There is no
	replacement. There is no plan that Republicans have offered.''
	And whether they are here with us or back in their offices
	admiring their names on the wall, I would suggest that they
	look at the legislation offered by Mr. Rokita, where he has
	said that we functionally block grant Medicaid to the states,
	then we can experience the great vibrance of a Federalist
	system, where best practices will be attempted and copied and
	sure, there will be some who miss the mark, but that is sort of
	the deal we get in a constitutional republic, and certainly
	join Mr. Rokita in attempting to advance those efforts.
	I want to, for a moment, speak about emergency room visits.
	There was a promise in Obamacare that we would see a reduction
	in emergency room visits, but I have noted a 2015 study from
	Northeastern University suggesting that emergency room visits
	post Obamacare in Illinois are up. Another 2015 survey from the
	American College of Emergency Room Physicians where three in
	four emergency room physicians are experiencing higher
	emergency room volume, not lower volume, following Obamacare.
	And a February 2016 study, from the Center of Disease
	Control, suggesting that there has really been no reduction in
	emergency room visits as a consequence of this law, and so I
	guess my question for Dr. Blumberg is, why has Obamacare failed
	to reduce the number of emergency room visits?
	Ms. Blumberg. Well, first of all, I think it is not fair to
	assume that any change in emergency room visits is
	inappropriate use. There are always provider shortage areas
	where people tended to use emergency room care more. Those
	provider shortage areas were prior to the ACA and they still
	exist. But in addition, when you see an increase under the
	Affordable Care Act, what you are doing is you are lowering the
	price of medical care to people. And so, people who could not
	afford necessarily to go and get an emergency room care when
	they needed emergency room care, now have financial access to
	do so. So, it is not necessarily just because you have seen an
	increase that that is an increase in inappropriate use.
	Mr. Gaetz. Reclaiming my time, I am glad you mentioned
	that. So, let's then turn to the State of California. The State
	that has perhaps most enthusiastically embraced the expansion
	of Medicaid, where currently one in every three Californians is
	on their Medicaid product--13 million people--across the board
	reductions in reimbursements to providers.
	We read in the Los Angeles Times the story of Kevin Hill,
	58 years old. He was one of these Americans who was added to
	the Medicaid roles. He had to call 15 doctors in the Long Beach
	area. Either the doctors were not even answering the phones or
	they were not taking California Medicaid patients anymore
	because reimbursement rates were so low. And where did Mr. Hill
	end up? Back in the emergency room. So, I guess, you know, the
	question is if you have got a circumstance where you have got
	enrollment that is spiking beyond the ability to raise taxes to
	pay for it and reductions in what we pay providers, what is the
	hope looking forward?
	Ms. Blumberg. Well, we should not make public policies
	based on anecdote, and I do appreciate the story of your one
	constituent. But there are a lot of people who are getting
	Medicaid coverage now who have a usual source of care and we
	can demonstrate this through household surveys that never had a
	usual source of care before, and that is outside of----
	Mr. Gaetz. Reclaiming my time. You know, it is sort of like
	shifting ground. When I state the statistics that indicate that
	there is rising participation in our emergency rooms, the
	statistics cannot be trusted. When we cite the individuals who
	cannot go and obtain care, then we cannot trust the anecdote.
	Ms. Blumberg. But I did say when you lower the price of
	medical care, more people have access to use it. But that does
	not mean we are not also increasing access to usual sources of
	care for people who are uninsured for the first time under the
	Medicaid program, because the evidence is very strong that we
	are.
	Mr. Gaetz. Well, then let me conclude my time with some
	bipartisan agreement with the gentlelady from New Mexico. I
	agree wholeheartedly with her statements that we have real cost
	problems and cost drivers. I think frequently aided by a
	hospital industrial complex and an insurance system that, for
	the most part, has been supportive of the Affordable Care Act
	and does not want its repeal, and so the very people that the
	Democrats on this committee criticize for being the drivers of
	cost are the very same entities that are bellied up to the
	trough draining resources away from those who are truly
	vulnerable.
	So, I join the bipartisan sentiment about trying to attack
	those cost drivers, but it seems as though focusing only on
	coverage, which is illusory, which does not lead to real care,
	it just leads to more folks in the emergency room. It is not
	the better way that we should all be pursuing.
	Mr. Rokita. I thank the gentleman. The gentleman yields
	back. The gentleman from Texas, Mr. Arrington, is recognized
	for 5 minutes.
	Mr. Arrington. Mr. Chairman, thank you, and I am honored to
	represent West Texas. I am honored to be on this committee and
	to the ranking member Mr. Yarmuth, I look forward to working
	you and our colleagues on the other side of the aisle. The jury
	is not out in West Texas on Obamacare. Never--and I have been
	around public policy and politics a long time--never has there
	been a greater disparity or irony between the title and intent
	of legislation and its outcomes for the American people.
	It is not affordable care. It is the Unaffordable Care Act.
	It is the Raise a Trillion Dollars in Tax on Americans Act. It
	is the Kill More Small Businesses and Jobs Act. It is Crush the
	American Economy When it is Coming Up for Air from the
	Recession Act.
	It is the Weaken the Medicare Act by taking $800 billion
	from that program. It is make it more difficult on middle class
	and working class families. Let me tell you something, in West
	Texas, we do not care about the names on the halls and walls of
	Congress. We care about the people that have their names on
	their shirts and on the back of their belts, and they are
	getting creamed. How serious is this that we act now? That we
	act swiftly and with confidence that this paradigm, that this
	top down government run, centrally planned, one size fits all
	health care has failed us? How urgent is it that we act? How
	serious is it that we act, Ms. Turner?
	Ms. Turner. Absolutely crucial, and a new system cannot be
	built on the wreckage of Obamacare. You have to repeal it
	first. That is why members of Congress could not pass or
	replace legislation because the President vetoed the repeal
	bill.
	Mr. Arrington. Other members of the panel?
	Mr. Book. It is clear that simply repealing the ACA will
	not bring back the system that was destroyed by the ACA. That
	previous system also had a lot of problems with it and this is
	an opportunity to create a more caring and more feasible and
	more affordable and more economically rational system in which
	people can actually obtain the care they need, instead of just
	obtaining their $9,000 deductibles.
	Mr. Arrington. See, I am just a freshman congressman, you
	know, and I am trying to make sense of all this and this
	alternate universe and facts that have been mentioned. And I
	see the American healthcare system as a patient on the
	operating table or in the emergency room bleeding out and we
	are expected to take an Ace bandage and an aspirin and somehow
	allow it to live to see another day. The people I represent do
	not believe that. I am not disparaging or questioning the
	intent. The intentions were to provide affordable care. The
	outcomes were that it did not, period.
	And it is only the responsible thing to do for those who
	lead our country and represent the good people of these United
	States to step in and do something, and provide solutions, real
	patient-centered solutions, market-oriented solutions,
	flexibility to States, empowerment of the patient, to actually
	be a consumer of health care and create real markets where
	health insurance companies are competing for our business,
	driving the cost down and quality up. Good old fashion free
	enterprise, American way. I come from middle America.
	I come from rural America, and as I said on the floor the
	other day, when America is sick and believe me, the folks in
	the 29 counties in Texas District 19 would reaffirm this
	statement. When America is sick, and they are sick from
	Obamacare, and they are sick of Obamacare, and they are sick of
	big government being thrust upon them as the solution for every
	problem that ails us. But when America is sick, rural America
	is in the ICU: small businesses, family farms, community banks,
	rural hospitals.
	Put the slide back up, please, if you would of the 80 rural
	hospitals that have gone away, 600 on the brink of going away.
	How are we going to bring the food, fuel, and fiber to America
	if we do not have health care infrastructure? But the $58
	billion in additional regulatory cost, we cannot do it. So, if
	you want to feed and clothe the American people.
	Mr. Rokita. I thank the gentleman. The gentleman's time is
	expired. Now, I will hear from the gentleman from Georgia, Mr.
	Ferguson, for 5 minutes.
	Mr. Ferguson. Mr. Chairman, Ranking Member, thank you so
	much for the opportunity to address the panel. I thank you each
	for your time and thank you all for coming. I am going to start
	with a question and I do not mean to sound facetious, how many
	of you all sitting at that panel have delivered health care as
	a provider to someone in a rural community living below the
	poverty level. You have--in the last 24 months?
	Ms. Blumberg. Yeah, I am a volunteer for Remote Area
	Medical, so I work in Appalachia delivering care.
	Mr. Ferguson. Good, okay. So, a lot of the conversation
	that we will have, we will be able to connect with, okay. As I
	go through this, one of the things that I want to explore is
	the regulatory cost that has been added to health care
	delivery. Can you all explain to me, in the Affordable Care
	Act, how there is an intentional effort to lower regulatory
	cost in the delivery of health care? And I will start with Dr.
	Book.
	Mr. Book. Within the ACA? Within the ACA, I do not believe
	there is any attempt to do any of that.
	Mr. Ferguson. Okay, thank you. Would you all agree that
	there is increased regulatory cost as a result of the
	Affordable Care Act? Mr. Haislmaier, I will ask you that
	question.
	Mr. Haislmaier. Yes, so it is not evenly spread. I mean,
	certainly more in certain sectors than others, but yeah, it is
	a significant increased regulatory cost.
	Mr. Ferguson. With that increased regulatory cost, as a
	provider, this is something that I live with every single day.
	We are spending more and more time on regulation and less and
	less time on the most important part of health care delivery
	and that is the intimate conversation between a doctor and a
	patient. As I move forward every day with treatment with my
	patients, the single most important thing that I have to be
	able to do is to communicate in an effective way with my
	patient the value of the health care that is being delivered.
	And I do that every single day.
	What I have seen in recent times is we have less and less
	time to do that. Just because you have access to health
	insurance does not mean you have access to care. I am sure that
	has been said many, many times around here. It is true. Has the
	Affordable Care Act looked at the other barriers to access to
	care besides simply access to insurance? I will tell you in my
	practice I treat patients every single day from folks that are
	trying to figure out how to get their next meal to a family
	with unlimited needs. I do it every single day in my dental
	practice. There are a lot of other barriers to care for those
	that are caught in the cycle of poverty.
	Dr. Blumberg, you working in Appalachia can probably see
	that, too. Transportation issues, education issues, all of
	those types of things. So, a lot of times we are trying to
	solve a problem by providing an insurance product that really
	does not address the fundamental issues of access. We all
	assume that the number one reason that people do not receive
	care is because they do not have insurance. I will argue that
	that certainly can be an issue, but it is also not the only
	problem there. So, Ms. Turner, have you looked at the other
	issues surrounding the cycle of poverty and the access to care?
	Ms. Turner. We have particularly looked at how discouraged
	physicians are--all medical providers are--because of the
	regulations that you point out. They went to medical school to
	treat patients and they are forced to deal with so much
	bureaucracy that it is really discouraging and forcing them out
	of the practice of medicine--far too many of them--reducing the
	supply of people that are available and this is particularly
	acute in rural areas. So, yes, I am very concerned about this,
	I hope, unintended consequence of the regulation,
	overregulation of our health sector, but it is very real for
	patients.
	Mr. Ferguson. Okay, thank you. Dr. Book, Ms. Turner touched
	on something that I think is very important and that is the
	brain drain out of the healthcare industry. Can you make a
	quick comment on that? Do you see that trend continuing or do
	you see it reversing as a result of the Affordable Care Act?
	Mr. Book. We have seen increases in physicians retiring
	early. I know very few physicians who would tell their children
	to become physicians. Most of them tell them not to, avoid as
	much as possible. On the regulatory side, I have heard comments
	from physicians that now that their mandated to keep electronic
	medical records, it sounds like a great idea, but none of the
	systems talk to each other and it ends up just taking more time
	to accomplish the same thing they accomplished before.
	Mr. Ferguson. Dr. Book, I am going to reclaim my last 20
	seconds. I hope that as we move forward with this and find
	solutions that we are able to truly drive the conversation back
	to the two most important people in the room, and that is the
	healthcare provider and the patient. That intimate conversation
	cannot be had by an insurance company or a government
	regulator. It has to be had between those two individuals.
	Thank you.
	Mr. Rokita. I thank the gentleman. The gentleman's time has
	expired. The gentleman from Wisconsin, Mr. Grothman, is
	recognized for 5 minutes.
	Mr. Grothman. We have a couple of questions. First thing,
	in general, I think one thing we have not touched upon is the
	degree to which Obamacare discourages work, discourages full
	time work, both because of, you know, discouraging hiring of
	full time employees and on an individual basis, cliffs where
	you can be substantially penalized for working overtime or
	getting a raise.
	I know one of the problems we have in our country is we are
	having a hard time getting the wages up on the middle class. I
	would like some of you to comment on the degree to which
	Obamacare, or the way it was set up, punishes people who want
	to work full time, sticks people in a situation in which maybe
	that have to go for two jobs into one job, as well as according
	to my account I talk to, forces people into a situation in
	which they have to make sure they do not make too much money.
	Ms. Turner. Well, one of the problems with the law is that
	it redefined a full-time work week as 30 hours, which very few
	employers felt the full-time work week was 30 hours, and I have
	talked to far too many, especially small business owners, who
	have said that what this means is that if they have more than
	50 employees, and are therefore subject to this, that they have
	to reduce the hours and often reduce hiring.
	Mr. Grothman. Right. Have you heard stories, and my
	accountant has told me stories, of people--depending upon where
	the cliff is--of people saying, see, I can make more than
	$50,000 a year, I cannot make more than $60,000 a year, it is
	going to cost me $3,000 or $4,000? Could you tell me if you
	aware of those stories or elaborate the degree to which we are
	discouraging people from improving their income? I mean, after
	all, if you are going to make $90,000 a year, first of all, you
	have to make $60,000 a year. And if you tell people you cannot
	make $60,000 or can make $50,000, it kind of stunts your growth
	in your career. Any comments on that, Dr. Blumberg?
	Ms. Blumberg. The economic research is very strong that
	there has not been employment related negative effects as a
	consequence of the Affordable Care Act. There may have been a
	small increase in part time work that was voluntary, but not
	required, and there has been no impact except for possibly a
	positive small one as a consequence of the Medicaid expansion.
	Mr. Grothman. Dr. Blumberg, honestly, talk to some
	accountants and you will have no problem finding people who are
	refusing to make more money because if they make more money it
	is going to cost them $3,000 or $4,000 or $5,000.
	Ms. Blumberg. There may be people you can find like that,
	but they are more than offset by other individuals who are
	behaving differently. So, on that, there is strong evidence
	that there has not been a significant negative impact of the
	Affordable Care Act.
	Ms. Turner. It is very, very difficult to capture the
	opportunity cost and what did not happen to people who did not
	get jobs, the people who were not offered jobs, the companies
	that did not grow as a result of this mandate.
	Mr. Grothman. Okay, I will give you one more quick
	question. Our minute thing here is--oh, there we are. I am
	familiar with what goes on in the private sector and there are
	incredible things being done, a combination of self-insurance,
	a combination of HSAs together with funding the HSAs on the
	part of the employer, a combination of in employer clinics in
	which we are having substantial reductions in health care
	costs. And this is going on and is one of the major reasons why
	health care costs have not gone up more at this time. Could
	somebody comment on a combination of those three things in the
	way in which private sector employers are reducing costs?
	Mr. Haislmaier. Yeah, actually, if you do not mind
	congressman, I will speak to that. I think it is not just
	private sector employers, but unfortunately, Congressman
	Ferguson is not here, it is also some of the providers who are
	just redesigning it. I think this is one of the interesting
	unintended consequences of the ACA, is the ingenuity that it
	sparked in trying to get around the obstacles. For example,
	large employers are now moving towards to find contribution
	through private exchanges.
	The other thing that I find very interesting is providers
	moving to direct primary care where in they get rid of all the
	fee-for-service paperwork. They do not even take the private
	insurance. You just go to them for primary care and you buy it
	like Netflix or cable, $130 a month. I mean, two-thirds of
	those practices charge $135 a month and if you need a doctor,
	they are on retainer. Interestingly enough, you know, they come
	up with terminology. The ACA actually allows for, I do not know
	whether they envisioned it, that to be offered with a
	wraparound coverage----
	Dr. Grothman. I am going to cut you off. I disagree that
	that is because of ACA. I think what is going on is there was a
	race between the private sector that was solving the medical
	crisis in this country and people who just wanted to throw in
	the towel. I think the innovation on the private sector would
	have happened with ACA or not, it is just that----
	Mr. Rokita. The gentleman's time has expired. I thank the
	gentleman.
	The chair recognizes himself for 5 minutes. I did not get a
	chance to ask questions yet, so I want to first start off by
	saying I appreciate the discussion that has occurred here
	today. I especially appreciate the members of the Budget
	Committee here for the first time or on record, and I think
	they did an excellent job.
	I want to say, on the record, that I associate myself with
	the comments of Mr. Lewis, Mr. Bergman, Mr. Faso, Mr. Smucker,
	Mr. Gaetz, Mr. Arrington, and Mr. Ferguson. Excellent job. I
	look forward to working with you all.
	There was some discussion, especially from my friends on
	the other side of the aisle that we voted to repeal this
	insidious law over 60 times and then little to replace it with.
	Well, I think, Ms. Turner, you are right. We did not have a
	partner in the White House to help us accomplish that, but we
	made the case to the American people about how insidious the
	law was. It was built on lies. If you wanted your plan, you
	could keep it. If you wanted your doctor, you could keep it;
	all that nonsense.
	But our conference also has a replacement plan, and we have
	several plans from individual members, and none of those
	plans--in fact, you can find The Better Way Plan right here at
	better.gov. None of the plans are contradictory. It is not a
	matter of not knowing what we need to replace these things
	with, it is a matter of the overlapping of wills, getting it
	done in a way where the American people have a chance to see
	what could be.
	I do not have to remind this panel that back under Speaker
	Pelosi, we had to pass a bill in order to find out what was in
	it. I cannot think of a more backward or wrong way to
	legislate. We are going to take our time and we are going to
	make sure that we get this right with patient-centered health
	care that is consumer driven, that allows for competition in a
	healthy marketplace.
	I do have some questions. This is not speechifying on my
	behalf, Mr. Ranking Member--you love to hear me talk--I wanted
	to hear from Dr. Book and Mr. Haislmaier about a particular
	part of CBO. Of course, this panel has exclusive jurisdiction
	over the Congressional Budget Office, but they got Obamacare
	wrong. Dr. Book, we understand that it could be a difficult job
	scoring out major pieces of legislation, but can you tell us
	how the original CBO cost estimates have aligned with reality
	under current law?
	Mr. Book. Yeah, original CBO cost estimates forecast much
	lower costs than we have seen and many more people being
	covered. They originally forecast, for example, a decrease in
	the uninsured population to five percent. They forecast 30
	million people covered in the exchanges. The true numbers are
	somewhere between 10 and 15 percent uninsured depending on how
	you count it and about 11 million people covering the exchange,
	and when they made their forecast on the repeal last week, they
	said that they counted as people losing their insurance, 7
	million of the 18 million people covered in the exchanges.
	When, in fact, there is 11 million people covered to start
	with.
	It was a very optimistic forecast. I understand it is
	difficult to make forecasts. In general, I have a lot of
	respect for the people who work at the CBO. I cannot
	specifically say why they made those mistakes, because they do
	not really reveal their methods.
	Mr. Rokita. Thank you for that. In your work, do you see
	anything systemically errant about the way CBO has chartered or
	required to score major pieces of legislation? Anything you
	want to help with this--you do not have to say it now. If you
	want to get back with us later, that is fine, but we have
	oversight jurisdiction here and we have pledged to do budget
	process reform, and this was a major error.
	Mr. Book. Yes, it was and I would like to look into that
	and get back to you with some specifics.
	Mr. Rokita. Okay.
	Mr. Book. In general, they tend to assume that the world
	looks exactly the same as it does, except for minor changes,
	and that people are not going to react and change their
	behavior in response to a change in the law. But, of course,
	that is the whole purpose of the law.
	Ms. Blumberg. Could I comment, sir, on that?
	Mr. Rokita. No, I want to get to Mr. Haislmaier. Sorry for
	butchering your name earlier. In the last 59 seconds that we
	have, what is your account of this? Why did CBO's projections
	so grossly overestimate coverage gains on the ACA?
	Mr. Haislmaier. I think it is pretty clear that they
	overestimated the effect that the individual mandate would have
	on inducing people who were otherwise healthy and not
	qualifying for subsidies to get coverage, and I think they are
	still holding to that as well. There are some other minor
	things that--I mean I cannot fault them on the Medicaid numbers
	because the court case came in and they sort of changed things;
	however, in terms of the enrollment and Medicaid, they
	overestimated the attractiveness of the exchange to people who
	were not being subsidized. Interestingly, when you compare to
	the Office of the Actuary at CMS, they expected the Medicaid
	expansion to ramp up slowly. In fact, it came in quite quickly
	and they both underestimated the cost of that.
	Mr. Rokita. Thank you, and my time is expired.
	And now in closing, I would like to yield my closing time
	to the ranking member, my friend, Mr. Yarmuth for a thank you.
	Mr. Yarmuth. I thank the chairman. I just want to thank all
	the witnesses and these discussions have been going on for a
	long time, in many different forms, and sometimes it gets
	pretty heated up. I apologize for any of the heat that was
	directed at any of the witnesses, but I thank you for your
	testimony and your thoughts.
	Mr. Rokita. I thank the gentleman, and I thank the
	witnesses as well--Ms. Turner, Dr. Book, Dr. Blumberg, Mr.
	Haislmaier--for appearing before us today. Please be advised
	that members may submit written questions to be answered later
	in writing and those questions and your answers will be made
	part of the formal hearing record.
	And, again, Dr. Book, I would love to get your answers in
	writing, and anything you would like to add Mr. Haislmaier. Any
	members who wish to submit questions or any extraneous material
	for the record may do so within 7 days, and with that bit of
	business completed, I see no other business before the
	committee, and we remain adjourned.
	[Whereupon, at 1:10 p.m., the committee adjourned subject
	to the call of the chair.]
	``Rep. Rokita submitted the following questions for the
	record.''

	[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



	</pre></body></html>