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	<title> - TEXAS v. U.S.: THE REPUBLICAN LAWSUIT AND ITS IMPACTS ON AMERICANS WITH PREEXISTING CONDITIONS</title>
	<body><pre>
	[House Hearing, 116 Congress]
	[From the U.S. Government Publishing Office]


	TEXAS v. U.S.: THE REPUBLICAN LAWSUIT AND ITS IMPACTS ON AMERICANS
	WITH PREEXISTING CONDITIONS

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

	HEARING

	BEFORE THE

	SUBCOMMITTEE ON HEALTH

	OF THE

	COMMITTEE ON ENERGY AND COMMERCE
	HOUSE OF REPRESENTATIVES

	ONE HUNDRED SIXTEENTH CONGRESS

	FIRST SESSION
	__________

	FEBRUARY 6, 2019
	__________

	Serial No. 116-2

	[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

	Printed for the use of the Committee on Energy and Commerce

	govinfo.gov/committee/house-energy
	energycommerce.house.gov

	___________

	U.S. GOVERNMENT PUBLISHING OFFICE

	35-377 PDF WASHINGTON : 2019



	COMMITTEE ON ENERGY AND COMMERCE

	FRANK PALLONE, Jr., New Jersey
	Chairman
	BOBBY L. RUSH, Illinois GREG WALDEN, Oregon
	ANNA G. ESHOO, California Ranking Member
	ELIOT L. ENGEL, New York FRED UPTON, Michigan
	DIANA DeGETTE, Colorado JOHN SHIMKUS, Illinois
	MIKE DOYLE, Pennsylvania MICHAEL C. BURGESS, Texas
	JAN SCHAKOWSKY, Illinois STEVE SCALISE, Louisiana
	G. K. BUTTERFIELD, North Carolina ROBERT E. LATTA, Ohio
	DORIS O. MATSUI, California CATHY McMORRIS RODGERS, Washington
	KATHY CASTOR, Florida BRETT GUTHRIE, Kentucky
	JOHN P. SARBANES, Maryland PETE OLSON, Texas
	JERRY McNERNEY, California DAVID B. McKINLEY, West Virginia
	PETER WELCH, Vermont ADAM KINZINGER, Illinois
	BEN RAY LUJAN, New Mexico H. MORGAN GRIFFITH, Virginia
	PAUL TONKO, New York GUS M. BILIRAKIS, Florida
	YVETTE D. CLARKE, New York, Vice BILL JOHNSON, Ohio
	Chair BILLY LONG, Missouri
	DAVID LOEBSACK, Iowa LARRY BUCSHON, Indiana
	KURT SCHRADER, Oregon BILL FLORES, Texas
	JOSEPH P. KENNEDY III, SUSAN W. BROOKS, Indiana
	Massachusetts MARKWAYNE MULLIN, Oklahoma
	TONY CARDENAS, California RICHARD HUDSON, North Carolina
	RAUL RUIZ, California TIM WALBERG, Michigan
	SCOTT H. PETERS, California EARL L. ``BUDDY'' CARTER, Georgia
	DEBBIE DINGELL, Michigan JEFF DUNCAN, South Carolina
	MARC A. VEASEY, Texas GREG GIANFORTE, Montana
	ANN M. KUSTER, New Hampshire
	ROBIN L. KELLY, Illinois
	NANETTE DIAZ BARRAGAN, California
	A. DONALD McEACHIN, Virginia
	LISA BLUNT ROCHESTER, Delaware
	DARREN SOTO, Florida
	TOM O'HALLERAN, Arizona
	------

	Professional Staff

	JEFFREY C. CARROLL, Staff Director
	TIFFANY GUARASCIO, Deputy Staff Director
	MIKE BLOOMQUIST, Minority Staff Director
	Subcommittee on Health

	ANNA G. ESHOO, California
	Chairwoman
	ELIOT L. ENGEL, New York MICHAEL C. BURGESS, Texas
	G. K. BUTTERFIELD, North Carolina, Ranking Member
	Vice Chair FRED UPTON, Michigan
	DORIS O. MATSUI, California JOHN SHIMKUS, Illinois
	KATHY CASTOR, Florida BRETT GUTHRIE, Kentucky
	JOHN P. SARBANES, Maryland H. MORGAN GRIFFITH, Virginia
	BEN RAY LUJAN, New Mexico GUS M. BILIRAKIS, Florida
	KURT SCHRADER, Oregon BILLY LONG, Missouri
	JOSEPH P. KENNEDY III, LARRY BUCSHON, Indiana
	Massachusetts SUSAN W. BROOKS, Indiana
	TONY CARDENAS, California MARKWAYNE MULLIN, Oklahoma
	PETER WELCH, Vermont RICHARD HUDSON, North Carolina
	RAUL RUIZ, California EARL L. ``BUDDY'' CARTER, Georgia
	DEBBIE DINGELL, Michigan GREG GIANFORTE, Montana
	ANN M. KUSTER, New Hampshire GREG WALDEN, Oregon (ex officio)
	ROBIN L. KELLY, Illinois
	NANETTE DIAZ BARRAGAN, California
	LISA BLUNT ROCHESTER, Delaware
	BOBBY L. RUSH, Illinois
	FRANK PALLONE, Jr., New Jersey (ex
	officio)


	C O N T E N T S

	----------
	Page
	Hon. Anna G. Eshoo, a Representative in Congress from the State
	of California, opening statement............................... 1
	Prepared statement........................................... 3
	Hon. Michael C. Burgess, a Representative in Congress from the
	State of Texas, opening statement.............................. 4
	Prepared statement........................................... 6
	Hon. Frank Pallone, Jr., a Representative in Congress from the
	State of New Jersey, opening statement......................... 8
	Hon. Greg Walden, a Representative in Congress from the State of
	Oregon, opening statement...................................... 10
	Prepared statement........................................... 12

	Witnesses

	Christen Linke Young, Fellow, USC-Brookings Schaeffer Initiative
	for Health Policy.............................................. 14
	Prepared statement........................................... 17
	Answers to submitted questions............................... 156
	Avik S. A. Roy, President, Foundation for Research on Equal
	Opportunity.................................................... 22
	Prepared statement........................................... 24
	Elena Hung, Cofounder, Little Lobbyists.......................... 32
	Prepared statement........................................... 34
	Answers to submitted questions............................... 161
	Thomas P. Miller, Resident Fellow in Health Policy Studies,
	American Enterprise Institute.................................. 48
	Prepared statement........................................... 50
	Answers to submitted questions............................... 163
	Simon Lazarus, constitutional lawyer and writer.................. 70
	Prepared statement........................................... 72

	Submitted Material

	Letter of January 9, 2019, from Ms. Castor, et al., to Hon. Ron
	DeSantis, Governor, State of Florida, submitted by Ms. Castor.. 116
	Letter of January 13, 2018, from Hon. Bill Nelson, a United
	States Senator from the State of Florida, et al., to Hon. Rick
	Scott, Governor, State of Florida, submitted by Ms. Castor..... 121
	Letter of January 26, 2017, from Mr. O'Halleran, et al., to Hon.
	Paul D. Ryan, Speaker of the House, and Hon. Mitch McConnell,
	Majority Leader, United States Senate, submitted by Mr.
	O'Halleran..................................................... 124
	Letter of April 23, 2018, from American Cancer Society Cancer
	Action Network, et al., to Hon. Alex Azar, Secretary,
	Department of Health and Human Services, et al., submitted by
	Ms. Eshoo...................................................... 128
	Letter of February 6, 2019, from Michael L. Munger, M.D., Board
	Chair, American Academy of Family Physicians, to Ms. Eshoo and
	Mr. Burgess, submitted by Ms. Eshoo............................ 139
	Statement of the American College of Physicians, February 6,
	2019, submitted by Ms. Eshoo................................... 141
	Editorial of December 16, 2018, ``Texas ObamaCare Blunder,'' The
	Wall Street Journal, submitted by Ms. Eshoo.................... 146
	Article of December 15, 2018, ``What the Lawless Obamacare Ruling
	Means,'' by Jonathan H. Adler and Abbe R. Gluck, The New York
	Times, submitted by Ms. Eshoo.................................. 149
	Amici Brief of June 14, 2018, American Medical Association, et
	al., Civil Action No.:4:18-cv-00167-O, submitted by Ms. Eshoo
	\1\
	Amici Brief of June 15, 2018, Families USA, et al., No. 4:18-cv-
	00167-O, submitted by Ms. Eshoo \1\
	Amici Brief of June 14, 2018, American Cancer Society Cancer
	Action Network, et al., Case No. 4:18-cv-00167-O, submitted by
	Ms. Eshoo \1\
	Amici Brief of June 15, 2018, AARP Foundation, Civil Action
	No.:4:18-cv-00167-O, submitted by Ms. Eshoo \1\
	Letter of February 5, 2019, from Mr. Walden and Mr. Burgess to
	Mr. Pallone and Ms. Eshoo, submitted by Mr. Burgess............ 153

	----------

	\1\ The information has been retained in committee files and also is
	available at https://docs.house.gov/Committee/Calendar/
	ByEvent.aspx?EventID=108843.




	TEXAS v. U.S.: THE REPUBLICAN LAWSUIT AND ITS IMPACTS ON AMERICANS WITH
	PREEXISTING CONDITIONS

	----------


	WEDNESDAY, FEBRUARY 6, 2019

	House of Representatives,
	Subcommittee on Health,
	Committee on Energy and Commerce,
	Washington, DC.
	The subcommittee met, pursuant to call, at 10:16 a.m., in
	room 2322, Rayburn House Office Building, Hon. Anna G. Eshoo
	(chairwoman of the subcommittee) presiding.
	Members present: Representatives Eshoo, Butterfield,
	Matsui, Castor, Lujan, Cardenas, Schrader, Ruiz, Kuster, Kelly,
	Barragan, Blunt Rochester, Rush, Pallone (ex officio), Burgess
	(subcommittee ranking member), Upton, Guthrie, Griffith,
	Bilirakis, Bucshon, Brooks, Mullin, Hudson, Carter, Gianforte,
	and Walden (ex officio).
	Also present: Representatives Veasey and O'Halleran.
	Staff present: Jeffrey C. Carroll, Staff Director;
	Elizabeth Ertel, Office Manager; Waverly Gordon, Deputy Chief
	Counsel; Zach Kahan, Outreach and Member Service Coordinator;
	Saha Khatezai, Professional Staff Member; Una Lee, Senior
	Health Counsel; Kaitlyn Peel, Digital Director; Tim Robinson,
	Chief Counsel; Samantha Satchell, Professional Staff Member;
	Andrew Souvall, Director of Communications, Outreach, and
	Member Services; C. J. Young, Press Secretary; Adam Buckalew,
	Minority Director of Coalitions and Deputy Chief Counsel,
	Health; Margaret Tucker Fogarty, Minority Staff Assistant;
	Caleb Graff, Minority Professional Staff Member, Health; Peter
	Kielty, Minority General Counsel; Ryan Long, Minority Deputy
	Staff Director; J. P. Paluskiewicz, Minority Chief Counsel,
	Health; Kristen Shatynski, Minority Professional Staff Member,
	Health; Danielle Steele, Minority Counsel, Health.

	OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN
	CONGRESS FROM THE STATE OF CALIFORNIA

	Ms. Eshoo. The Subcommittee on Health will now come to
	order. The Chair recognizes herself for 5 minutes for an
	opening statement, and the first thing that I would like to say
	is, ``Welcome.''
	Welcome back the 116th Congress under the new majority, and
	I want to thank my Democratic colleagues for supporting me to
	do this work, to chair the subcommittee.
	It is an enormous honor and it is--what is contained in the
	committee, of course, are some of the most important issues
	that the American people expressed at the polls in the midterm
	elections.
	To our Republican colleagues, I know that there are areas
	where we can really work together. In some areas, we are going
	to have to stretch. But know that I look forward to working
	with all of you, and to those that are new members of the
	subcommittee, welcome to each one of you.
	I know that you are going to bring great ideas and really
	be instructive to the rest of us, so welcome to you.
	As I said, healthcare was the single most important issue
	to voters in the midterm elections, and it is a rarity that
	there would be one issue that would be the top issue in every
	single congressional district across the country. So this
	subcommittee is front and center.
	We are beginning the Health Subcommittee's work by
	discussing the Texas v. United States lawsuit and its
	implications for the entire healthcare system, both public and
	private.
	For over a hundred years, presidents, including Teddy
	Roosevelt, Harry Truman, Richard Nixon, and others attempted to
	reform our Nation's health insurance system and provide access
	to affordable health insurance for all Americans.
	In 2010, through the efforts that began in this committee,
	the Affordable Care Act was signed into law and bold reforms to
	our public and private insurance programs were made.
	Since the Affordable Care Act was signed into law, over 20
	million Americans have gained health insurance that is required
	to cover preexisting conditions. The law disallows charging
	sick consumers more, it allows children to stay on their
	parents' health insurance policy to the age of 26, and provides
	coverage for preventive health services with no cost sharing.
	Last February, 20 attorneys general and Governors sued the
	Federal Government to challenge the constitutionality of that
	law. They claimed that, after the individual mandate was
	repealed by the Republicans' tax plan, the rest of the
	Affordable Care Act had to go, too.
	The Trump administration's Department of Justice has
	refused to defend the Affordable Care Act in court and in
	December Judge Reed O'Connor of the Northern District of Texas
	declared the entire ACA invalid.
	Twenty attorneys general, led by the attorney general from
	California, our former colleague, Xavier Becerra, have appealed
	Judge O'Connor's ruling.
	For those enrolled in the Affordable Care Act, if the
	Republican lawsuit is successful, the 13 million Americans who
	gained health insurance through the Medicaid expansion will
	lose their health insurance.
	The 9 million Americans who rely on tax credits to help
	them afford the insurance plan will no longer be able to afford
	their insurance and health insurance costs will skyrocket
	across the country when healthy people leave the marketplace
	for what I call junk insurance plans that won't cover them when
	they get sick--another implication leaving the sick and the
	most expensive patients in the individual market, driving up
	premiums for so many.
	The insurance reforms of the ACA protect every American,
	including those who get their health insurance through their
	employer. Every insurance plan today is required to cover 10
	basic essential health benefits.
	No longer are there lifetime limits. The 130 million
	patients with preexisting conditions cannot be denied coverage
	or charged more, and women can no longer be charged more
	because they are females.
	[The prepared statement of Ms. Eshoo follows:]

	Prepared statement of Hon. Anna G. Eshoo

	Welcome to the first Health Subcommittee hearing of the
	116th Congress, under a Democratic majority, and welcome to the
	new members of the Health Subcommittee.
	Healthcare was the single most important issue to voters in
	the 2018 election. It is a rarity for one issue to be so
	important in every Congressional District in the country.
	We're beginning the Health Subcommittee's work by
	discussing the disastrous Texas v. United States lawsuit and
	its implications for the entire healthcare system, both public
	and private.
	For over 100 years, presidents including Teddy Roosevelt,
	Harry Truman, and Richard Nixon attempted to reform our
	Nation's health insurance system and provide access to
	affordable health insurance for all Americans.
	In 2010, through efforts that began in this committee, the
	Affordable Care Act was signed into law and bold reforms to our
	public and private insurance programs were implemented.
	Since the Affordable Care Act was signed into law over 20
	million Americans have gained health insurance that is required
	to cover preexisting conditions; disallows charging sick
	consumers more; allows children to stay on their parent's
	health insurance until the age of 26 and provides coverage for
	preventive health services with no cost sharing.
	Last February, 20 attorneys general and Governors sued the
	Federal Government to challenge the constitutionality of that
	law. They claimed that after the individual mandate was
	repealed by the Republican's tax plan, the rest of the
	Affordable Care Act had to go, too.
	The Trump administration's Department of Justice refused to
	defend the Affordable Care Act in court and in December, Judge
	Reed O'Connor of the Northern District of Texas declared the
	entire ACA invalid. 20 attorneys general, led by California's
	Xavier Beccera, have appealed Judge O'Connor's ruling.
	For those enrolled in the Affordable Care Act, if the
	Republican lawsuit is successful, the 13 million Americans who
	gained health insurance through the Medicaid expansion will
	lose their health insurance; the 9 million Americans who rely
	on tax credits to help them afford their insurance plan will no
	longer be able to afford their insurance; and health insurance
	costs will sky rocket across the country when healthy people
	leave the marketplace for junk insurance plans that won't cover
	them when they get sick, leaving the sick and most expensive
	patients in the individual market, driving up premiums.
	The insurance reforms of the ACA protect every American,
	even those who get their health insurance through their
	employer. Every insurance plan today is required to cover ten
	basic Essential Health Benefits; there are no longer lifetime
	limits; the 130 million patients with preexisting conditions
	cannot be denied coverage or charged more; and women can no
	longer be charged more because they are females.
	Judge O'Connor's ruling in Texas v. United States declared
	the Affordable Care Act invalid in its entirety, threatening
	every one of the gains I just described. It is now up to the
	Democratic House to protect, defend and strengthen the ACA.
	Even if legislation to require insurance companies to cover
	these patients' preexisting conditions is passed, insurers
	could charge anything they want to cover these services if the
	ACA is overturned.
	On the very first day of this Congress, House Democrats
	voted to intervene in the Texas v. United States case as it
	moves through appeal. The House of Representatives will now
	represent the Government in this case to defend and uphold the
	ACA, because this administration refused to do so.
	In the majority's work to defend and strengthen the ACA,
	this subcommittee will explore how the Trump administration's
	junk insurance plans are affecting the individual insurance
	market and harming people with preexisting conditions.
	These plans aren't required to cover the same Essential
	Health Benefits as ACA-compliant plans and patients don't know
	that their health insurance won't pay for their treatments
	until they've gotten sick and it's too late.
	Next week, our subcommittee will explore specific
	legislation to reverse the Trump administration's actions to
	expand junk plans. We're also going to discuss legislation that
	would restore outreach and enrollment funding that has been
	slashed by the Trump administration so that we can ensure
	healthcare is more affordable and assessible. And we will also
	discuss legislation that would reverse the Trump
	administration's guidance on 1332 waivers that would allow
	States to undermine the ACA's protections for preexisting
	conditions and could harm people's access to care.
	We will work to reverse the harmful policies that have made
	healthcare more expensive for individuals who rely on the ACA
	and deliver on our promises to the American people to lower
	healthcare and prescription drug costs.
	Welcome to our witnesses, and I look forward to your
	testimony.

	Ms. Eshoo. I am going to stop here, and I am going to yield
	the rest of my time to Mr. Butterfield.
	Mr. Butterfield. Thank you, Chairwoman Eshoo, for holding
	this very important hearing on the absolute importance of the
	Affordable Care Act and thank you for giving us an opportunity
	to expose the poorly written Texas case.
	I want to talk a few seconds about sickle cell disease.
	More than one out of every 370 African Americans born with
	sickle cell disease and more than 100,000 Americans have this
	disease, including many in my State.
	The disease creates intense pain, that patients usually
	must be hospitalized to receive their care. Without preexisting
	condition protections, tens of thousands of Americans with
	sickle cell could be charged more for insurance, they could be
	dropped from their plans and be prevented from enrolling in
	insurance plans altogether.
	Republicans have tried and tried and tried to repeal the
	ACA more than 70 times. We, in this majority, have been sent
	here to protect the Affordable Care Act.
	Thank you for the time. I yield back.
	Ms. Eshoo. I thank the gentleman.
	Next week--I just want to announce this--our subcommittee
	is going to explore specific legislation to reverse the
	administration's actions to expand the skinny plans--the junk
	insurance plans--and we are also going to discuss legislation
	that would restore outreach in enrollment funding that has been
	slashed by the administration, so we can ensure that healthcare
	is more affordable and accessible for all Americans.
	We want to thank the witnesses that are here today. Welcome
	to you. We look forward to hearing your testimony. And now I
	would like to recognize Dr. Burgess, the ranking member of the
	Subcommittee on Health, for 5 minutes for his opening
	statement.

	OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
	IN CONGRESS FROM THE STATE OF TEXAS

	Mr. Burgess. Thank you, Chairwoman Eshoo.
	Let me just take a moment to congratulate you. As you are
	quickly finding out, you now occupy the most important
	subcommittee chair in the entire United States House of
	Representatives, and I know this from firsthand experience.
	We were the most active subcommittee in the United States
	House of Representatives in the last Congress. Hundreds of
	hours in hearings on health policy, and certainly look forward
	to that continuing through this term as well.
	I want to thank our witnesses all for joining us this
	morning. We are here to discuss the issue of protecting access
	to healthcare for individuals with preexisting medical
	conditions in addition to the Texas v. Azar case.
	So I think you heard the president say this last night in
	the State of the Union Address. There is broad bipartisan
	support for providing protections for patients with preexisting
	conditions.
	I am glad we are holding our first hearing of the year. It
	is the end of the first week of February. So it is high time
	that we do this. It is unfortunate we are having a hearing that
	actually doesn't move toward the development of any policies
	that actually would improve healthcare for Americans.
	To that effect, there are numerous options that you could
	bring before us that could moot the Texas v. Azar case. But the
	subcommittee apparently has chosen not to do so. For example,
	the bill to repeal the individual mandate is one that I have
	introduced previously.
	You can join me on that effort, and if the individual
	mandate were repealed the case would probably not exist.
	You could reestablish the tax in the individual mandate,
	which would certainly be your right to do so and, again, that
	would remove most of the argument for the court case as it
	exists today.
	You know, I hear from constituents in north Texas concerned
	about not having access to affordable healthcare. In the
	district that I represent, because of the phenomenon known as
	silver loading, as the benchmark silver plans' premiums
	continue to increase, well, if you are getting a subsidy--what,
	me worry? No problem--I got a subsidy so I am doing OK.
	But in the district that I represent, a schoolteacher and a
	policeman couple with two children are going to be covered in
	the individual market, and they are going to be outside the
	subsidy window.
	So they buy a bronze plan because, like everybody, they buy
	on price, so that is the least expensive thing that is
	available to them, and then they are scared to death that they
	will have to use it because the deductible is so high.
	If you get a kidney stone in the middle of the night and,
	guess what, that $4,500 emergency room bill is all yours. So I
	take meetings with families who are suffering from high
	healthcare and prescription drugs costs, and unfortunately we
	are not doing anything to address that today.
	We could be using this time to discuss something upon--to
	develop policies to help those individuals and families. But,
	again, we are discussing something upon which we all agreed,
	but we are taking no substantive action to address.
	Look, if you believe in Medicare for All, if you believe in
	a single-payer, Government-run, one-size-fits-all health
	system, let us have a hearing right here in this subcommittee.
	We are the authorizing committee. That is our job.
	Instead, we have the House Budget Committee holding those
	hearings, and Democrats on that committee are introducing
	legislation. But these bills belong in the jurisdiction of the
	Energy and Commerce Committee, and yet we have not scheduled a
	hearing to discuss this agenda.
	Do I agree with the policy or think it would be a good idea
	for the American people to have Medicare for All or one-size-
	fits-all health plans? No, I do not, and I would gladly engage
	in a meaningful dialogue about what such a policy would mean
	for the American people.
	Single-payer healthcare would be another failed attempt at
	a one-size-fits-all approach. Americans are all different, and
	a universal healthcare plan that does not meet the varying
	needs of each and every individual at different stages of their
	life will probably not be successful.
	Today, we should be focusing on the parts of the health
	insurance market that are working for Americans. Seventy-one
	percent of Americans are satisfied with employer-sponsored
	health insurance, which provides robust protections for
	individuals with preexisting conditions.
	Quite simply, the success of employer-sponsored insurance
	markets--it is not worth wiping that out with the single-payer
	healthcare policy. Yet, the bill that was introduced last term,
	that is exactly what it did.
	But today, there are a greater percentage of Americans in
	employer health coverage than at any time since the year 2000.
	Since President Trump took office, the number of Americans
	in employer health coverage has increased by over 2\1/2\
	million. Given that the United States economy added more than
	300,000 jobs in January, the number of individuals and families
	covered by employer-sponsored plans is likely even greater
	still.
	Instead of building upon the success of our existing health
	insurance framework, radical single-payer, Government-run
	Medicare would tear it down. It would eliminate the employer-
	sponsored health insurance, private health insurance, Indian
	health insurance, and make inroads against taking away the VA.
	Again, I appreciate that we have organized and we are
	holding our first hearing. I believe we could be using our time
	much more productively. There is bipartisan support for
	protecting patients with preexisting conditions. I certainly
	look forward to hearing the testimony of our witnesses.
	Thank you, I yield back.
	[The prepared statement of Mr. Burgess follows:]

	Prepared statement of Hon. Michael C. Burgess

	Good morning, everyone, and thank you for joining us this
	morning for our first Health Subcommittee hearing of the 116th
	Congress. I would like to take a moment to congratulate our new
	Chair, Anna Eshoo. I look forward to partnering with you
	throughout this Congress.
	Today, we are here to discuss the issue of protecting
	access to healthcare for individuals with pre-existing medical
	conditions in addition to the Texas v. U.S. court case. Let me
	be clear: This is an issue for which there is broad bipartisan
	support.
	While I am glad that we are finally holding our first
	hearing of the year, I am disappointed that we are holding a
	passive hearing that doesn't move toward the development of any
	policies to improve healthcare for Americans. To that effect,
	there are numerous options that you could bring before us that
	could moot the Texas v. U.S. case, but you have chosen not to
	do so.
	My constituents in North Texas are consistently concerned
	about not having access to affordable healthcare. In my
	district, that is the policeman and the schoolteacher with two
	children who have a bronze plan and cannot afford their high
	deductible. I take countless meetings with families suffering
	from high healthcare and prescription drug costs, but
	unfortunately that's not why you've convened us here today. We
	could be using this valuable time to develop policies to help
	those individuals and families, yet we are here discussing
	something upon which we all agree but are taking no substantive
	action to address.
	If you believe in Medicare for All, a single-payer,
	Government-run, ``one-size-fits-all'' healthcare system, we
	should have a hearing on it right here in this subcommittee.
	The House Budget Committee and others are having hearings on
	this, and Democrats are introducing legislation. These bills
	belong in the jurisdiction of Energy and Commerce, and yet we
	have not scheduled a hearing to discuss this agenda. Do I agree
	with the policy or think it would be good for the American
	people? No, I do not; however, I would gladly engage in a
	meaningful dialogue about what such a policy would mean for the
	American people.
	Single-payer healthcare would be another failed attempt at
	a one-size-fits-all approach to healthcare. Americans are all
	different and a universal healthcare plan will not meet the
	varying needs of each and every individual. Single-payer is not
	one-size-fits-all, it is really one-size-fits-no-one.
	Today, we should be focusing on the parts of the health
	insurance market that are working for Americans. For example,
	71 percent of Americans are satisfied with their employer-
	sponsored health insurance, which provides robust protections
	for individuals with preexisting conditions. Quite simply, the
	success of the employer-sponsored insurance market is not worth
	wiping out with single-payer healthcare. In fact, today there
	is a greater percentage of Americans in employer health
	coverage than at any time since 2000.
	Since President Trump took office, the number of Americans
	in employer health coverage has increased by more than 2.5
	million. Given that the United States economy added more than
	300,000 jobs in January, the number of individuals and families
	covered by employer-sponsored plans is likely even greater.
	Instead of building upon the successes of our existing
	health insurance framework, radical, single-payer, Government-
	run Medicare for All policy would tear it down. It would
	eliminate employer-sponsored health insurance, private
	insurance, the Indian Health Service, and Medicaid and CHIP,
	and pave the road to the elimination of the VA. Existing
	Medicare beneficiaries would not be exempt from harm, as the
	policy would raid the Medicare Trust Fund, which is already
	slated to go bankrupt in 2026.
	Again, while I appreciate that we have organized and are
	holding our first hearing, I believe that we could be using our
	time much more productively. There is bipartisan support for
	protecting individuals with preexisting conditions, and I look
	forward to future hearings where we can have substantive,
	bipartisan policy-based discussions. With that, I yield back.

	Ms. Eshoo. I thank the ranking member, and let me just add
	a few points. You raised the issue of employer-sponsored
	healthcare. Our employer is the Federal Government, and we are
	covered by the Affordable Care Act.
	Number two, we on our side support universal coverage, and
	so--but what the committee is going to be taking up is, and you
	pointed out some of the chinks in the armor of the Affordable
	Care Act--we want to strengthen it, and what you described
	relative to your constituents certainly applies to many of us
	on our side as well. So we plan to examine that, and we will.
	Mr. Burgess. Will the gentlelady yield on the point on
	employer coverage for Members of Congress?
	Ms. Eshoo. Mm-hmm.
	Mr. Burgess. I actually rejected the special deal that
	Members of Congress got several years ago when we were required
	to take insurance under the Affordable Care Act and we all were
	required to join the DC exchange.
	But we were given a large tax-free monthly subsidy to walk
	into that exchange. I thought that was illegal under the law. I
	did not take that. I bought a bronze plan--an unsubsidized
	bronze plan at healthcare.gov, the most miserable experience I
	have ever been through in my life.
	And just like constituents in my district, I was scared to
	use my health insurance because the deductible was so high.
	I yield back.
	Ms. Eshoo. I thank the gentleman. It would be interesting
	to see how many Members have accepted the ACA, they and their
	families being covered by it.
	And now I would like to recognize the chairman of the full
	committee, Mr. Pallone, who requested that this hearing be the
	first one to be taken up by the subcommittee--the Texas law
	case--and I call on the gentleman to make his statement.
	Good morning to you.

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

	Mr. Pallone. Thank you, Madam Chair, and thank you for all
	you have done over the years to help people get health
	insurance, to expand insurance, to address the price of
	prescription drugs and so many other things, and I am glad to
	see you in the chair of this subcommittee hearing.
	Now, I was going to try to be nice today. But after I
	listened to Mr. Burgess, I can't be. You know, and I am sure
	this is--he is going to see this as personal, but I don't mean
	it that way.
	But I just have to speak out, Mr. Burgess. Look, you were
	the chairman of this subcommittee the whole time that the
	Republicans tried unsuccessfully to repeal the Affordable Care
	Act.
	I have had so many meetings where I saw you come in and
	take out your copy of the hearings on the Affordable Care Act
	and repeatedly tell us that the Affordable Care Act was bad
	law, terrible law, it needs to be repealed.
	I saw no effort at all in the time that you were the
	chairman to try to work towards solutions in improving the
	Affordable Care Act. What I saw were constant efforts to join
	with President Trump to sabotage it.
	And the reason that this hearing is important--because the
	ultimate sabotage would be to have the courts rule that the ACA
	is unconstitutional, which is totally bogus.
	You found this, you know, right-wing judge somewhere in
	Texas--I love the State of Texas, but I don't know where you
	found him--and you did forum shopping to find him, and we know
	his opinion is going to be overturned.
	But we still had to join a suit to say that his opinion was
	wrong and it wasn't based in any facts or any real analysis of
	the Constitution, and the reason we are having this hearing
	today is because we need to make the point that the Republicans
	are still trying to repeal the Affordable Care Act.
	They are not looking to work with us to improve it. There
	were many opportunities when the senators--Senator Lamar
	Alexander and others--were trying to do things to improve the
	Affordable Care Act, to deal with the cost sharing that was
	thrown out by the president, to deal with reinsurance to make
	the market more competitive, and at no point was that brought
	up in this subcommittee under your leadership.
	You know, you talk about the employer-sponsored system.
	Sure, we all agree 60 percent of the people get their insurance
	through their employer.
	But those antidiscrimination provisions that you said are
	protected with employer-sponsored plans they came through
	actions of the Democrats and the Affordable Care Act that said
	that you could not discriminate--that you could not
	discriminate for preexisting conditions, that you had to have
	an essential benefit package. Those are a consequence of the
	ACA.
	So don't tell us that, you know, somehow that appeared
	miraculously in the private insurance market. That is not true
	at all.
	Talk about Medicaid expansion, your State and so many other
	Republican States blocked Medicaid expansion. So there is so
	many people now that could have insurance that don't because
	they refuse to do it for ideological reasons.
	You mentioned the Indian Health Service. I love the fact
	that the gentleman from Oklahoma had that Indian healthcare
	task force. Thank you. I appreciate that.
	But I asked so many times in this subcommittee to have a
	hearing on the Indian Health Care Improvement Act which, again,
	was in the Affordable Care Act, otherwise it would never have
	passed, and that never happened.
	We will do that. But talk about the Indian Health service--
	you did nothing to improve the Indian Health Service. And I am
	not suggesting that wasn't true for the gentleman of Oklahoma.
	He was very sympathetic.
	But, in general, we did not have the hearing and we would
	not have had the Indian Health Service Improvement Act but for
	the ACA.
	And finally, Medicare for All--who are you kidding? You are
	saying to us that you want to repeal the ACA and then you want
	to have a hearing on Medicare for All. You sent me a letter
	asking for a hearing on Medicare for All.
	When does a Member of Congress, let alone the chairman or
	the ranking member, I guess, in this case, ask for a hearing on
	something that they oppose? I ask for hearings on things that I
	wanted to happen, like climate change and addressing climate
	change.
	I don't ask for hearings on things that I oppose. I get a
	letter saying, ``Oh, we should have a hearing on Medicare for
	All but, by the way, we are totally opposed to it. It is a
	terrible idea. It will destroy the country.''
	Oh, sure. We will have a hearing on something that you
	think is going to destroy the country. Now, don't get me wrong.
	We will address that issue. I am not suggesting we shouldn't.
	But the cynicism of it all--the cynicism of coming here and
	suggesting that somehow you want--you have solutions? You have
	no solutions. I am more than willing to work with you. I am
	sure that Chairman Eshoo is willing to as well.
	But don't tell us that you had solutions. You did not, and
	you continue not to have solutions. And I am sorry to begin the
	day this way, but I have no choice after what you said. I mean,
	it is just not--it is just not--it is disingenuous.
	Thank you, Madam Chairwoman.
	Ms. Eshoo. Thank you.
	And now I will recognize the ranking member. Good morning.
	Mr. Walden. Good morning.
	Ms. Eshoo. The ranking member of the full committee, my
	friend Mr. Walden.
	Mr. Walden. Thank you, Madam Chair. Congratulations on
	taking over the subcommittee.
	Ms. Eshoo. Thank you very much. I appreciate it.
	Mr. Walden. I always enjoyed working with you on
	telecommunications issues, and I know you will do a fine job
	leading this subcommittee.
	Ms. Eshoo. Thank you.
	Mr. Walden. I look forward to working with you. As we--I
	cannot help but respond a bit.

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

	Mr. Walden. I do wish we were meeting to pass bipartisan
	legislation and protect Americans with preexisting health
	conditions from losing their coverage, given the pending court
	case. And let me speak on behalf of Republicans because we
	fully support protecting Americans with preexisting conditions.
	We have said this repeatedly, we have acted accordingly,
	and we mean it completely. We could and should inject certainty
	into the system by passing legislation to protect those with
	preexisting conditions, period.
	On the opening day of the 116th Congress, House Republicans
	brought a powerful but simple measure to the floor that called
	on this body to legislate on what we all agree needs to be
	done, and that is to lock in protections for patients with
	preexisting conditions.
	Unfortunately, that went down on a party-line vote. Our
	amendment was consistent with our long-held views with respect
	to the American Health Care Act, which our Democratic
	colleagues, frankly, in some cases, continue to misrepresent.
	We provided protections for those with preexisting
	conditions under the AHCA. Insurance companies were prohibited
	from denying or not renewing coverage due to a preexisting
	condition, period.
	Insurance companies were banned from rescinding coverage
	based on a preexisting condition, period. Insurance companies
	were banned from excluding benefits based on a preexisting
	condition, period.
	Insurance companies were prevented from raising premiums on
	individuals with preexisting conditions who maintain continuous
	coverage, period.
	The fact is, this is something we all agree on, and we
	should and could work together to expeditiously guarantee
	preexisting condition protections for all Americans and do so
	in a manner that can withstand judicial scrutiny. That is
	something I think we could find common ground on.
	And while a status check on the ACA lawsuit is interesting
	and important, the ruling has been stayed. The attorneys
	general across the country have filed appeals. Speaker Pelosi
	has moved to intervene in the case I think three times and
	Americans' premiums and coverage for this year are not
	affected.
	But what really does affect American consumers is out-of-
	control costs of healthcare. That is what they would like
	Congress to focus on and something I think we need to tackle as
	well.
	The fact of the matter is that for too many Americans
	health insurance coverage exists solely on paper because
	healthcare costs and these new high deductibles are putting
	family budgets in peril.
	When the Affordable Care Act passed, Democrats promised
	people that their insurance premiums would go down $2,500.
	Unfortunately, the exact opposite has occurred for many
	Americans, and not only have premiums gone up, not down, but
	think of what out-of-pocket costs have done. They have
	skyrocketed.
	The latest solution from my friends on the other side of
	the aisle is some sort of Medicare for All proposal. And yes,
	we did ask for a hearing on it because I think it's something
	that Democrats ran on, believe in fully, and we should take
	time to understand it.
	We know this plan would take away private health insurance
	from more than 150 million Americans. We are told it would end
	Medicare as we know it and would rack up more than $32 trillion
	in costs, not to mention delays in accessing health services.
	So, Madam Chairwoman, other committees in this body have
	announced plans to have hearings on Medicare for All. Speaker
	Pelosi has said she is supportive of holding hearings on this
	plan, and Madam Chairwoman, I think I read you yourself said
	such hearings would be important to have.
	A majority of House Democrats supported Medicare for All in
	the last Congress. In fact, two-thirds of the committee--
	Democrats' 20 Members, 11 whom are on this subcommittee--have
	cosponsored the plan.
	I think it is important for the American people to fully
	understand what this huge new Government intervention to
	healthcare means for consumers if it were to become law.
	Yesterday, Dr. Burgess and I did send you and Chairman
	Pallone a letter asking for a hearing on Medicare for All and
	we think, as the committee of primary jurisdiction, that just
	makes sense.
	So as you're organizing your agenda for the future, we
	thought it was important to put that on it. The American people
	need to fully understand how Medicare for All is not Medicare
	at all but actually just Government-run, single-payer
	healthcare.
	They need to know about the $32 trillion price tag for such
	a plan and how you pay for it. They need to know that it ends
	employer-sponsored healthcare, at least some versions of it do,
	forcing the 158 million Americans who get their health
	insurance through their job or through their union into a one-
	size-fits-all, Government-run plan.
	So if you like waiting in line at the DMV, wait until the
	Government completely takes over healthcare. Seniors need to
	fully understand how this plan will affect the Medicare trust
	fund that they've paid into their entire lives and the impacts
	on access to their care.
	Our Tribes need to understand how this plan could impact
	the Indian Health Service and our veterans deserve to know how
	this plan could pave the way to closing VA health services.
	So the question is, when will we see the bill and when we
	will have a hearing on the legislation? Meanwhile, we need to
	work together to help States stabilize health markets damaged
	by the ACA.
	Cut out-of-pocket costs, promote access to preventive
	services, encourage participation in private health insurance,
	and increase the number of options available through the
	market.
	And I want to thank Mr. Pallone for raising the issue
	involving Senator Lamar Alexander. He and I and Susan Collins
	worked very well together to try and come up with a plan we
	could move through to deal with some of these issues.
	Unfortunately, we could not get that done. So let us work
	together to lock in preexisting condition protections. Let's
	tackle the ever-rising healthcare costs and help our States
	offer consumers more affordable health insurance, and if you
	are going to move forward on a Medicare for All plan, we would
	like to make sure we have a hearing on it before the bill moves
	forward.
	So with that, Madam Chair, thank you and congratulations
	again, and I yield back.
	[The prepared statement of Mr. Walden follows:]

	Prepared statement of Hon. Greg Walden

	Good morning, Madam Chair. Congratulations on taking over
	the helm of this very important subcommittee. I only wish we
	were meeting today to pass bipartisan legislation to protect
	Americans with preexisting health conditions from losing
	coverage. Let me speak on behalf of Republicans: We fully
	support protecting Americans with preexisting conditions. We've
	said this repeatedly, we we've acted accordingly, and we mean
	it completely. We could-and should-inject certainty into the
	system by passing legislation to protect those with preexisting
	conditions.
	On the opening day of the 116th Congress, House Republicans
	brought a powerful but simple measure to the floor that called
	on this body to legislate on what we all agree needs to be
	done--locking in protections for patients with preexisting
	conditions. Unfortunately, House Democrats voted it down.
	Our amendment was consistent with our long-held views. With
	respect to the American Health Care Act, which our Democratic
	colleagues continue to mispresent, we provided protections for
	those with preexisting conditions. Under the AHCA:
	<bullet> Insurance companies were prohibited from denying
	or not renewing coverage due to a preexisting condition.
	Period.
	<bullet> Insurance companies were banned from rescinding
	coverage based on a preexisting condition. Period.
	<bullet> Insurance companies were banned from excluding
	benefits based on a preexisting condition. Period.
	<bullet> Insurance companies were prevented from raising
	premiums on individuals with preexisting conditions who
	maintain continuous coverage. Period.
	The fact is, we agree on this issue. And we can work
	together expeditiously to guarantee preexisting condition
	protections for all Americans and do so in manner that can
	withstand judicial scrutiny.
	And while a status check on the ACA lawsuit is interesting,
	the ruling has been stayed, Attorneys general across the
	country have filed appeals, Speaker Pelosi has moved to
	intervene in the case, and Americans' premiums and coverage for
	this year are not affected.
	But what really does affect American consumers is the out-
	of-control costs of healthcare. That's what they would like
	Congress to focus on. When will we tackle the high cost of
	healthcare?
	The fact of the matter is that for too many Americans
	health insurance coverage exists solely on paper because
	healthcare costs and high deductibles are putting family
	budgets in peril. When the Affordable Care Act passed,
	Democrats promised people their insurance premiums would go
	down $2500. Unfortunately, the exact opposite has occurred for
	many Americans. And not only have premiums gone up-not down-but
	also out-of-pocket costs have skyrocketed.
	The latest ``solution'' from the Democratic Party is a
	Government takeover of healthcare, called Medicare for All. We
	know that this plan would take away private health insurance
	from more than 150 million Americans, end Medicare as we know
	it, and rack up more than $32-trillion in costs, not to mention
	delays in accessing health services.
	Madam Chairwoman, other committees in this body have
	announced plans to have hearings on Medicare for All. Speaker
	Pelosi has said she is supportive of holding hearings on this
	radical plan. Madam Chairwoman, in fact, you yourself called
	for such hearings.
	A majority of House Democrats supported Medicare for All in
	the last Congress--in fact, two-thirds of committee Democrats,
	20 Members, 11 of whom serve on the Health Subcommittee,
	cosponsored the plan.
	I think it is important for the American people to fully
	understand what this huge, new, Government intervention into
	healthcare means for consumers. Yesterday, Dr. Burgess and I
	sent a letter to you and Chairman Pallone asking for a hearing
	on Medicare for All, as we are the committee with primary
	jurisdiction over healthcare issues.
	The American people need to fully understand how Medicare
	for All is not Medicare at all, but actually just Government-
	run, single-payer healthcare. They need to know about the $32
	trillion price tag for such a plan, and the tax increases
	necessary to pay for it. They need to know that it ends
	employer-sponsored healthcare, forcing the 158 million
	Americans who get their healthcare through their job or union
	into a one-size-fits-all, Government-run plan. If you like
	waiting in line at the DMV, wait until the Government
	completely takes over healthcare.
	Seniors need to fully understand how this plan does away
	with the Medicare Trust Fund that they have paid into their
	entire lives, and the impacts on their access to care. Our
	tribes need to understand how this plan impacts the Indian
	Health Service, and our veterans deserve to know how this plan
	paves the way to closing the VA.
	So the question is, When will we see the bill, and when
	will we have a hearing on the legislation?
	Meanwhile, we need to work together to help States
	stabilize health markets damaged by the ACA, cut out-of-pocket
	costs, promote access to preventive services, encourage
	participation in private health insurance, and increase the
	number of options available through the market.
	So let's work together to lock in preexisting condition
	protections, tackle ever-rising healthcare costs, and help our
	States offer consumers more affordable health insurance. And if
	Democrats must move forward on a complete Government takeover
	of healthcare, please pledge to give the American people a
	chance to read the bill so that we'll all know what's in it
	before we have to vote on it.

	Ms. Eshoo. I thank the ranking member of the full committee
	for his remarks. Several parts of it I don't agree with, but I
	thank him nonetheless.
	Now we will go to the witnesses and their opening
	statements. We will start from the left to Ms. Christen Linke
	Young, a fellow, USC-Brookings Schaeffer Initiative for Health
	Policy.
	Welcome to you, and you have 5 minutes, and I think you
	know what the lights mean. The green light will be on, then the
	yellow light comes on, which means 1 minute left, and then the
	red light.
	So I would like all the witnesses to stick to that so that
	we can get to our questions of you, expert as you are. So
	welcome to each one of you and thank you, and you are
	recognized.

	STATEMENTS OF CHRISTEN LINKE YOUNG, FELLOW, USC-BROOKINGS
	SCHAEFFER INITIATIVE FOR HEALTH POLICY; AVIK S. A. ROY,
	PRESIDENT, THE FOUNDATION FOR RESEARCH ON EQUAL OPPORTUNITY;
	ELENA HUNG, COFOUNDER, LITTLE LOBBYISTS; THOMAS P. MILLER,
	RESIDENT FELLOW IN HEALTH POLICY STUDIES, AMERICAN ENTERPRISE
	INSTITUTE; SIMON LAZARUS, CONSTITUTIONAL LAWYER AND WRITER

	STATEMENT OF CHRISTEN LINKE YOUNG

	Ms. Young. Good morning, Chairwoman Eshoo, Ranking Member
	Burgess, members of the committee. Thank you for the
	opportunity to testify today.
	I am Christen Linke Young, a fellow with the USC-Brookings
	Schaeffer Initiative on Health Policy. My testimony today
	reflects my personal views.
	The Affordable Care Act has brought health coverage to
	millions of Americans. Since the law was passed, the uninsured
	rate has been cut nearly in half. The ACA's marketplaces are
	functioning well and offering millions of people comprehensive
	insurance.
	Thirty-seven States have expanded Medicaid, and many of the
	remaining States are considering expansion proposals. Beyond
	its core coverage provisions, the ACA has become interwoven
	with the American healthcare system.
	As just a few examples, the law put in place new consumer
	protections in employer-provided insurance, closed Medicare's
	prescription drug doughnut hole, changed Medicare reimbursement
	policies, reauthorized the Indian Health Service, authorized
	biosimilar drugs, and even required employers to provided space
	for nursing mothers.
	One of the core goals of the ACA was to provide healthcare
	for Americans with preexisting conditions, and I would like to
	spend a few minutes discussing how the law achieves the
	objective.
	By some estimates, as many as half of nonelderly Americans
	have a preexisting condition, and the protections the law
	offers to this group cannot be accomplished in a single
	provision or legislative proclamation.
	Instead, it requires a variety of interlocking and
	complementary reforms threaded throughout the law. At the
	center are three critical reforms.
	Consumers have a right to buy and renew a policy regardless
	of their health needs, have that policy cover needed care, and
	be charged the same price. Further, the ACA prohibits lifetime
	limits on care received and requires most insurers to cap
	copays and deductibles.
	Crucially, the law ensures that insurance for the healthy
	and insurance for the sick are part of the single risk pool and
	it provides financial assistance tied to income to help make
	insurance affordable.
	However, a recent lawsuit threatened this system of
	protections. In Texas v. United States, a group of States argue
	that changes made to the ACA's individual mandate in 2017
	rendered that provision unconstitutional.
	Therefore, they puzzlingly argue that the entire ACA should
	be invalidated, stripping away protections for people with
	preexisting conditions and everything else in the law.
	The Trump administration's Department of Justice has agreed
	with the claim of a constitutional deficiency, and they further
	agree that central pillars of the preexisting condition
	protection should be eliminated.
	But, unlike the States, DOJ argues that the weakened
	remainder of the law should be left to stand. Other scholars
	can discuss the weakness of this legal argument. I would like
	to discuss its impacts on the healthcare system.
	DOJ's position, that the law's core protections for people
	with preexisting conditions should be removed, would leave
	Americans with health needs without a reliable way to access
	coverage in the individual market.
	Insurers would be able to deny coverage and charge more
	based on health status. In many ways, the market would look
	like it did before the ACA. Components of the law would
	formally remain in place, but it is unclear how some of those
	provisions would continue to work.
	The States' position would wreak even greater havoc and
	fully return us to the markets that predated the ACA. In
	addition to removing central protections for those with
	preexisting conditions, the financial assistance for families
	purchasing coverage, and the ACA's funding for Medicaid
	expansion would disappear.
	The Congressional Budget Office has estimated the repeal of
	the ACA would result in as many as 24 million additional
	uninsured Americans, and similar results could be expected
	here.
	In addition, consumer protections for employer-based
	coverage would be eliminated, changes to Medicare would be
	undone, the Indian Health Service would not be reauthorized,
	the FDA couldn't approve biosimilar drugs. Indeed, these are
	just some of the many and far-reaching effects of eliminating a
	law that is deeply integrated into our healthcare system.
	Before I close, I would like to briefly note that Texas v.
	United States is not the only recent development that threatens
	Americans with preexisting conditions. Recent policy actions by
	the Trump administration also attempt to change the law in ways
	that undermine the ACA.
	As just a few examples, guidance under Section 1332 of the
	ACA purports to let States weaken protections for those with
	health needs. Nationwide, efforts to promote short-term
	coverage in association health plans seek to give healthy
	people options not available to the sick and drive up costs for
	those with healthcare needs.
	Additionally, new waivers in the Medicaid programs allows
	States to place administrative burdens in front of those trying
	to access care.
	To summarize, the Affordable Care Act has resulted in
	significant coverage gains and meaningful protections for
	people with preexisting conditions. Texas v. U.S. threatens
	those advances and could take us back to the pre-ACA individual
	market where a person's health status was a barrier to coverage
	and care.
	The lawsuit would also damage other healthcare policies,
	and this litigation coincides with administrative attempts to
	undermine the ACA's protections for people with preexisting
	conditions.
	Thank you.
	[The prepared statement of Ms. Young follows:]
	[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

	Ms. Eshoo. Thank you very much.
	Next, Mr. Avik Roy, president of the Foundation for
	Research and Equal Opportunity. Welcome.

	STATEMENT OF AVIK S. A. ROY

	Mr. Roy. Chairwoman Eshoo, Ranking Member Burgess, and
	members of the Health Subcommittee of the House Energy and
	Commerce Committee, thanks for inviting me to speak with you
	today.
	I am Avik Roy and I am the president of the Foundation for
	Research on Equal Opportunity, a nonpartisan nonprofit think
	tank focussed on expanding economic opportunity to those who
	least have it.
	When we launched in 2016, our first white paper showed how
	universal coverage done the right way can advance both the
	progressive and conservative values at the same time, expanding
	access while reducing Federal spending and burdensome
	regulations.
	In my oral remarks, I am going to focus on a core problem
	that, respectfully, Congress has failed to solve: how to
	protect Americans with preexisting conditions while also
	ensuring that every American has access to affordable health
	insurance.
	Thirty-two million U.S. residents go without coverage
	today. Fewer than half of those eligible for subsidies in the
	ACA exchanges have enrolled in ACA-based coverage.
	This failure is the result of the flawed theory first
	articulated by MIT economist Jonathan Gruber underlying Title 1
	of the Affordable Care Act--that if Congress requires that
	insurers offer coverage to those with preexisting conditions
	and if Congress forces insurers to overcharge the healthy to
	undercharge the sick, Congress must also enact an individual
	mandate to prevent people from jumping in and out of the
	insurance market.
	We should all know by now that Professor Gruber is not
	omniscient. After all, in 2009, Gruber said, what we know for
	sure about the ACA is that it will, quote, ``lower the cost of
	buying nongroup health insurance.''
	In reality, premiums have more than doubled in the ACA's
	first 4 years, and the ACA subsidies only offset those
	increases for those with incomes near the poverty line.
	There are two flaws with Gruber's theory, sometimes called
	the three-legged stool theory. First, the two ACA provisions
	that have had the largest impact on premiums have nothing to do
	with preexisting conditions.
	Second, the ACA's individual mandate was so weak with so
	many loopholes that its impact on the market was negligible.
	Guaranteeing offers of coverage for those with preexisting
	conditions has no impact on premiums because the ACA limits the
	enrollment period for guaranteed issue plans to six weeks in
	the fall or winter.
	The limited enrollment period, not the mandate, ensures
	that people can't game the system by dropping in and out. While
	community rating by health status does cause some adverse
	selection by overcharging healthy people who buy coverage,
	thereby discouraging healthy people from signing up, among
	enrollees of the same age this is not an actuarially
	significant problem.
	The largest impact is from the ACA's 3-to-1 age bans which
	on their own double the cost of insurance for Americans in
	their 20s and 30s, forcing many to drop out of the market
	because younger people consume one-sixth of the healthcare that
	older people do.
	In the court cases consolidated as NFIB v. Sebelius,
	President Obama's Solicitor General, Neal Katyal, repeatedly
	argued that if the individual mandate were ruled to be
	unconstitutional, much of the ACA should remain but that the
	ACA's guaranteed issue and health status community rating
	provisions, the ones that impact those with preexisting
	conditions, should also be struck from the law.
	The Trump Justice Department has merely echoed this belief.
	Both administrations are more correct than the district judge
	in Texas v. Azar, who, in an egregious case of judicial
	activism, argued that the entirety of the ACA was inseparable
	from the mandate.
	However, it is clear that both Justice Departments are also
	wrong. The zeroing out of the mandate penalty has not blown up
	the insurance market. Indeed, it has had no effect.
	To be clear, it is not just ACA enthusiasts who have bought
	into Gruber's flawed theories. Many conservatives have as well.
	A number of conservative think tank scholars have argued that,
	because they oppose the individual mandate, we should also
	repeal the ACA's protections for those with preexisting
	conditions--that is, guaranteed issue and community rating by
	health status.
	These scholars have argued that a better way to cover those
	with preexisting conditions is to place them in a separate
	insurance pool for high-risk individuals.
	I want to state this very clearly: Those scholars are
	wrong. The most market-based approach for covering those with
	preexisting conditions is not to repeal the ACA's guaranteed
	issue and health status provisions but to preserve them and to
	integrate the principles of a high-risk pool into a single
	insurance market through reinsurance.
	I have been pleased to see Republicans in Congress support
	legislation that would ensure the continuity of preexisting
	condition protections irrespective of the legal outcome in
	Texas v. U.S. I hope both parties can work together to achieve
	this.
	Both parties can further improve the affordability of
	individual insurance by enacting a robust program of
	reinsurance and restoring 5-to-1 age bans.
	On these and other matters, I look forward to working with
	all members of this committee both today and in the future to
	ensure that no American is forced into bankruptcy by high
	medical bills.
	Thank you.
	[The prepared statement of Mr. Roy follows:]
	[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

	Ms. Eshoo. Thank you very much, Mr. Roy.
	You have testified here before, and we appreciate you being
	here again today. I would like to just suggest that, for the
	benefit of Members, that you get your testimony to us much
	earlier, all right?
	Mr. Roy. I apologize.
	Ms. Eshoo. Yes.
	Mr. Roy. I was, of course, officially invited to testify
	before this committee on Monday. I had some personal and
	professional obligations that limited my ability to get the
	testimony in a timely fashion.
	Ms. Eshoo. Yes.
	Mr. Roy. I will be happy to brief any members of this
	committee or their staffs at another time.
	Ms. Eshoo. Well, we thank you. I just--I have a bad habit,
	I read everything, and it wasn't there. So--but I heard today,
	and then we will all ask you our questions. Thank you.
	The next witness is Ms. Hung, and she is the cofounder of
	Little Lobbyists. You are recognized for 5 minutes, and
	welcome.

	STATEMENT OF ELENA HUNG

	Ms. Hung. Thank you. Good morning.
	Thank you, Chairwoman, Ranking Member, and members of the
	subcommittee for the opportunity to tell my story and share my
	concerns with you today.
	My name is Elena Hung, and I am a mom. I am a proud mom of
	an amazing 4-year-old. My daughter, Xiomara, is a happy child.
	She is kind and smart and funny and a little bit naughty. She
	is the greatest joy of my life.
	She is at home right now, getting ready to go to school.
	She attends an inclusive special education pre-K program, and I
	asked her if she wanted to come here today. She said she wanted
	to go to school instead.
	It has been a long road to this moment. Xiomara was born
	with chronic complex medical conditions that affect her airway,
	lungs, heart, and kidneys. She spent the first 5 months of her
	life in the neonatal intensive care unit.
	She uses a tracheostomy tube to breathe and a ventilator
	for additional respiratory support. She relies on a feeding
	tube for all of her nutrition. She participates in weekly
	therapies to help her learn how to walk and talk. But I am
	thrilled to tell you that Xiomara is thriving today.
	This past year was her best year yet healthwise, and
	ironically it was also when her access to healthcare has been
	the most threatened. I sit before you today because families
	like mine--families with medically complex children--are
	terrified of what this lawsuit may mean for our kids.
	You see, our lives are already filled with uncertainty--
	uncertainty about diagnoses, uncertainty about the effects of
	medications and the outcomes of surgeries. The one certainty we
	have is the Affordable Care Act and the healthcare coverage
	protection it provides.
	We don't know what Xiomara's future holds, but with the
	ACA's protections in place we know this: We know Xiomara's 10
	preexisting conditions will be covered without penalty, even if
	we switch insurance plans or employers.
	We know a ban on lifetime caps means that insurance
	companies cannot decide that her life isn't worth the cost and
	cut her off care just because she met some arbitrary dollar
	amount.
	We know we won't have to worry about losing our home as a
	result of an unexpected hospitalization or emergency. We know
	Medicaid will provide the therapies and long-term services and
	supports that enable her independence.
	I sit before you today on behalf of families like mine who
	fear that the only certainty we know could be taken away,
	pending the outcome of this lawsuit--this lawsuit that seeks to
	eliminate protections for people with preexisting conditions--
	and if that happens our children's lives will then depend on
	Congress where every so-called replacement plan proposed over
	the last 2 years has offered far less protection for our kids
	than the ACA does.
	I sit here before you today on behalf of Isaac Crawley, who
	lost his insurance in 2010 after he met his lifetime limit just
	a few weeks after his first birthday but got it back after the
	ACA became law;
	Myka Eilers, who was born with a preexisting congenital
	heart defect and was able to obtain health insurance again when
	her dad reopened his own business after being laid off;
	Timmy Morrison, who spends part of his childhood in
	hospitals, both inpatient and outpatient, because his insurance
	plan covers what is essential to his care;
	Claire Smith, who has a personal care attendant and is able
	to live at home with her family and be included in her
	community, thanks to Medicaid;
	Simon Hatcher, who needs daily medications to prevent life-
	threatening seizures, medications which would cost over $6,000
	a month without insurance;
	Colton Prifogle, who passed away on Sunday and was able to
	spend his final days pain-free with dignity, surrounded by
	love, because of the hospice care he received.
	These are my friends, my friends that I love. These are
	Xiomara's friends. This is our life. I cofounded the Little
	Lobbyists, this group of families with medically complex
	children, some of whom are here today, because these are
	stories that desperately need to be told and heard alongside
	the data and numbers and policy analysis.
	There are children like Xiomara in every State. That's
	millions of children with preexisting conditions and
	disabilities across the country. I sit before you today on the
	eve of another trip to the Children's Hospital.
	Tomorrow I will hold my daughter's hand as I walk her to
	the OR for her procedure, and as I have done every time before,
	I know I will drown in worry, as a mother does.
	But the thing that has always given me comfort is knowing
	that my Government believes my daughter's life has value and
	that the cost of medical care she needs to survive and thrive
	should not financially bankrupt us. It is my plea for that to
	always be true.
	Thank you.
	[The prepared statement of Ms. Hung follows:]
	[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

	Ms. Eshoo. Thank you, Elena. Beautiful testimony. Beautiful
	testimony. I wish Xiomara were here. Maybe we can provide a
	tape so that when she gets older she can hear her mother's
	testimony in the Congress of the United States. Thank you.
	I now would like to recognize Mr. Thomas Miller, resident
	fellow at the American Enterprise Institute. Welcome, and thank
	you. You have 5 minutes.

	STATEMENT OF THOMAS P. MILLER

	Mr. Miller. Thank you, Chairwoman Eshoo. The mortifying
	silent C in my written testimony in your name must have been
	due to the speed with which I delivered the testimony on time.
	But I apologize for that.
	Thank you also, Ranking Member Burgess and members of the
	subcommittee. Now let us all take a deep breath and get to it.
	The Texas case remains in its relatively early stages. Its
	ultimate fate is as much as another 16 months away. The
	probability of a Supreme Court ruling that would overturn the
	entire ACA remains very, very low, just by last December's
	decision at the Federal district court level.
	Any formal enforcement action to carry out that decision
	has been stayed while the case continues on appeal. We have
	been here before. Two longer-term trends in health policy
	persist: our overreliance on outsourcing personal healthcare
	decisions to third-party political intermediaries and then our
	chronic inability to reach compromises and resolve health
	policy issues through legislative mechanisms. They have fuelled
	a further explosion in extending health policy battles to our
	courts.
	So welcome back to Groundhog Day, ACA litigation version.
	The plaintiff's overall case is not frivolous, but it does rely
	heavily on taking the actual text of the ACA literally and
	thereby limiting judicial scrutiny to what the Congress that
	enacted appeared on the limited record of that time to intend
	by what it did.
	The plaintiffs are attempting to reverse engineer and
	leverage the unusually contorted Supreme Court opinion of Chief
	Justice Roberts in NFIB v. Sebelius.
	Now, come critics insist that the 115th Congress that
	zeroed out the mandate tax also expressed a clear intent to
	retain all other ACA provisions. This ignores the limited scope
	of what that Congress had power to do through the vehicle of
	budget reconciliation in the tax-cutting Jobs Act. All that its
	Members actually voted into law was a change regarding
	individual mandate.
	It did not and could not extend to the ACA's other
	nonbudgetary regulatory provisions, nor did it change the
	findings of fact still in statutory law first made by the 111th
	Congress that insisted the individual mandate was essential to
	the functioning of several other ACA provisions, notably,
	guaranteed issue and adjusted community rating.
	The plaintiffs are not out of bounds in trying to hold
	Congress to its past word--it happens once in a while--and in
	building on the similar reasoning used by other Supreme Court
	majorities to strike down earlier ACA legal challenges.
	Since that's the story for ACA defenders, they should have
	to stick to it, at least until a subsequent Congress actually
	votes to eliminate or revise those past findings of fact
	already in permanent law.
	But, even if appellate courts also find some form of
	constitutional injury in what remains of the ACA's individual
	mandate as a tax-free regulatory command, the severability
	stage of such proceedings will become far more uphill for the
	plaintiffs.
	Most of the time, the primary test is functionality in the
	sense of ascertaining how much of the remaining law with the
	Congress enacting it believe could be retained and still
	operate as it envisioned.
	Given the murkiness of divining or rewriting legislative
	intent in harder cases like this one, it remains all but
	certain that an ultimate Supreme Court ruling would, at a
	minimum, follow up previous inclinations revealed in the 2012
	and 2015 ACA challenges and try to save as much of the law as
	possible.
	Even appellate judges in the Fifth Circuit will note
	carefully the passage of time, the substantial embedded
	reliance costs, and the sheer administrative and political
	complexity of unwinding even a handful of ACA provisions on
	short notice.
	So don't bet on more than a narrow finding that could sever
	whatever remains of an unconstitutional individual mandate
	without much remaining practical impact from the rest of the
	law.
	On the health policy front, we might try to remember that,
	when congressional action produces as flawed legislative
	product justified in large part by mistaken premises and
	misrepresentations, it won't work well.
	The ACA's architects and proponents oversold the
	effectiveness and attractiveness of the individual mandate,
	claiming it could hold the law's insurance coverage provisions
	together while keeping official budgetary costs and coverage
	estimates within the bounds of CBO's scoring.
	But what worked to launch the ACA and keep it viable in
	theory and politics did not work well in practice, and, to be
	blunt, one of the primary ways that the Obama administration
	sold its proposals for health policy overhaul was to exaggerate
	the size, scope, and nature of the potential population facing
	coverage problems due to preexisting health conditions.
	Of course public policy should address remaining problems.
	It could and should be improved in other less proscriptive and
	more transparent ways than the ACA attempted.
	My written testimony suggests a number of option available
	to lawmakers if some of the ACA's current overbroad regulatory
	provisions were stricken down in court in the near future.
	However, we are not back in 2012 or 2010 or even 2017
	anymore, at least outside of our court system. Changes in
	popular expectations and health industry practices since 2010
	are substantial breaks on even well-structured proposals for
	serious reform. But that is where the real work needs to be
	restarted.
	It is often said with apocryphal attribution that God takes
	care of children, drunks, or fools, and the United States of
	America. Well, let's not press our luck. To produce better
	lawsuits, fewer lawsuits, let us try to write and enact better
	laws.
	Thank you.
	[The prepared statement of Mr. Miller follows:]
	[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

	Ms. Eshoo. Thank you.
	And now our last witness, Mr. Thomas Miller, resident
	fellow--I am sorry--Mr. Simon Lazarus, constitutional----
	Mr. Miller. I think he's younger than I am.
	Ms. Eshoo [continuing]. Constitutional lawyer and writer.
	Welcome. It is lovely to see you, and thank you for being here
	to be a witness and be instructive to us.
	You have 5 minutes.

	STATEMENT OF SIMON LAZARUS

	Mr. Lazarus. Thank you, Chair Eshoo, and Ranking Member
	Burgess and members of the subcommittee. My name is Simon
	Lazarus. I am a lawyer and writer on constitutional and legal
	issues relating to, among other things, the ACA.
	I have had the privilege of testifying before this
	subcommittee and other congressional committees numerous times.
	I am currently retired, and the views that I express here are
	my own and cannot be attributed to any of the organizations for
	which I previously worked or other organizations.
	I have to say that I am not sure how important my task is,
	because I think all of the witnesses have pretty much agreed
	with the bottom line, and that includes the witnesses invited
	by the minority, and that is that this decision to invalidate
	the entire ACA is, in significant respects, and I think many of
	us agree that in all respects, completely baseless legally and
	has close to zero chances of being upheld on appeal.
	And in light of all of that, Tom, I have to--I am puzzled
	by your assertion that the lawsuit is not frivolous, because
	that sounds to me like the definition of frivolousness in a
	lawsuit.
	In any event, I think it should be underscored that it is
	not a coincidence that even the minority witnesses think very
	little of this lawsuit, because, as soon as the decision came
	down, it was attacked in extremely strong terms across the
	political spectrum.
	As the Wall Street Journal editorialized, ``While no one
	opposes Obamacare more than we do, Judge O'Connor's decision is
	likely to be overturned on appeal.'' Legal experts, including
	prominent anti-ACA conservatives, have blistered Judge
	O'Connor's result.
	For example, Phillip Klein, the executive editor of the
	Washington Examiner, called the decision ``an assault on the
	rule of law.'' Professor Jonathan Adler, who is an architect of
	the second fundamental legal challenge to the ACA--that's King
	v. Burwell--which I think the idea for which was hatched at a
	meeting that you probably hosted----
	Mr. Miller. I have been here before.
	Mr. Lazarus. OK. And that effort to kill the ACA was
	rejected by the Supreme Court in 2015. In any event, Professor
	Adler called the decision, quote, ``an exercise of raw judicial
	power unmoored from the relevant doctrines concerning when
	judges may strike down a whole law because of a single alleged
	legal infirmity buried within it.''
	And on the courts, if one is going to be a prognosticator,
	just look at the basic facts. Chief Justice John Roberts'
	pertinent opinions nearly ensure at least a 5-4 Supreme Court
	majority to reverse Judge O'Connor, and moreover it should be
	noted that Justice Brett Kavanaugh, looking at his prior
	decisions as a DC circuit judge, also looks very likely to join
	a larger majority to reverse Judge O'Connor.
	So my job here is just to try to explain what the legal
	reasons are for this negative judgment on O'Connor's decision,
	so I am going to try to briefly do that.
	To begin with, the court could well dismiss the case for
	lack of standing to sue on the part of any of the plaintiffs
	who brought the case. The State government plaintiffs barely
	pretend to have a colorable standing argument.
	The two individual plaintiffs complain that, though it is
	enforceable, the mandate nonetheless imposes a legal obligation
	to buy insurance and they would feel uncomfortable violating
	that obligation.
	The problem with this is that Chief Justice Roberts in his
	2012 NFIB v. Sebelius decision, which upheld the mandate,
	expressly ruled that and based his decision, really, on the
	determination that, if individuals did not buy insurance--thus,
	quote, ``choosing to pay the penalty rather than obtain
	insurance''--they will have fully complied with the law.
	Now, post-TCJA--the Tax Cut and Jobs Act--a nonpurchaser
	will still not be in violation of the law simply because
	Congress reduced to zero the financial incentive to choose the
	purchase option.
	So no one is compelled to buy insurance in order to avoid a
	penalty since none exists nor to follow the law, because he
	will be following or she will be following the law.
	So there is no injury period, no standing to sue. That is a
	very likely result, even in the Fifth Circuit, I would say.
	Ms. Eshoo. Mr. Lazarus, can you just summarize----
	Mr. Lazarus. OK. I am sorry.
	Well, in addition, I would just say on the merits the ACA's
	mandate provision remains a valid exercise of the tax power and
	that is pretty much for the same reasoning that there is no
	standing, and that is because Congress' determination after the
	original ACA passed to drop the penalty to zero did not strip
	Congress of its constitutional power under the tax authority.
	And nor can its subsequent determination sensibly mean that
	it was no longer using that power. And finally, I would just
	want to add really to what other people have said and some of
	the members of the subcommittee have eloquently said, that to
	take the further leap that, if the mandate provision is
	unconstitutional after the reduction of the penalty to zero--
	which it really should not be found, but if it is--there is
	absolutely no basis whatsoever for striking down the rest of
	the ACA.
	[The prepared statement of Mr. Lazarus follows:]
	[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

	Ms. Eshoo. Thank you very much.
	All right. I am going to--we have how concluded the
	statements of our witnesses. We thank you again for them. Each
	Member will have 5 minutes to ask questions of the witnesses,
	and I will start by recognizing myself for 5 minutes.
	I appreciate the discussion about the legalities, and of
	course we are discussing Texas v. United States today. But the
	issue of preexisting conditions keeps coming up, and I would
	like Ms. Young and anyone else to chime in.
	This issue of what our Republican colleagues say that they
	are for, and I listen to C-SPAN a lot and especially during the
	days running up to the election, and they covered Senate races
	and House races, and I heard Republicans over and over and over
	again in those debates with their opponents saying, ``I am for
	preexisting conditions.''
	Now, can anyone address how you extract that out of what we
	have now, the Affordable Care Act, and have standalone
	insurance policies? Where is the guarantee about what the price
	would be for that policy?
	Would you like to----
	Ms. Young. The Affordable Care Act--absolutely. The
	Affordable Care Act requires that all insurance plans charge
	consumers the same price regardless of----
	Ms. Eshoo. That I understand. That's what we put in. But
	the minority is saying that they are for preexisting
	conditions, except they have voted against the ACA countless
	times.
	So if you were to extract just that one issue and write a
	bill on it, where is the guarantee on what the price would be
	for that standalone policy?
	Ms. Young. In my view, it is very difficult to put together
	a system of protections for people with preexisting conditions
	that doesn't include a panoply of reforms similar to many of
	the reforms that were included in the Affordable Care Act.
	So you need to ensure people can buy a policy. You need to
	ensure that that policy doesn't exclude coverage for their
	particular healthcare needs.
	You need to ensure that they are able to purchase at a fair
	price and you need to surround that with reforms that really
	create a functioning insurance market by providing financial
	assistance, stable risk adjustment, and other associated
	provisions like that.
	Ms. Eshoo. I want to get to something that is out there,
	and that is what I refer to in my opening statement. I refer to
	them as junk plans. It is my understanding that many of these
	plans exclude coverage for prescription drugs, for mental
	health and substance use disorders.
	Who would like to address this? Is this correct?
	Ms. Young. I can address that.
	Ms. Eshoo. Uh-huh. Go ahead.
	Ms. Young. I believe you are referring to short-term
	limited duration coverage.
	Ms. Eshoo. Right. Mm-hmm.
	Ms. Young. Those plans are not required to cover any
	particular benefit, and many of them can and likely will
	exclude coverage for benefits like prescription drugs,
	maternity care, substance use and mental health services,
	things like that.
	Ms. Eshoo. Now, are these plans medically underwritten?
	Ms. Young. Many of them are, yes.
	Ms. Eshoo. And how does that differ from the process by
	which Americans get health insurance on the individual market
	today?
	Ms. Young. Medical underwriting refers to a process where
	insurance companies require individuals to fill out a detailed
	health history questionnaire and then use the results of that
	to determine if the individual can purchase a policy and if so
	on what terms.
	That was a common practice in the individual market before
	the Affordable Care Act. It is permitted for short-term limited
	duration plans today.
	In contrast, in the ACA-compliant individual market,
	insurers are not prohibited to medically underwrite. Consumers
	sign up for a policy based only on information about their age
	and their income if they are seeking tax credits with no health
	history screening.
	Ms. Eshoo. I see. Mr. Lazarus----
	Mr. Miller. Chairwoman Eshoo, could you ask the rest of the
	panel, and we are getting a one-sided view of this. The ACA's
	protections are----
	Ms. Eshoo. I didn't call on you. I would like to call on
	Mr. Lazarus. Are you giving us comfort that the lawsuit is not
	going to go anywhere? Is that what you believe?
	Mr. Lazarus. I think all of the witnesses have basically
	said that, at least with respect to the notion that, if the
	mandate provision is now found to be unconstitutional, which I
	don't think it will be or should be, the quantum leap that the
	Republican attorneys general and Judge O'Connor took to then
	say the whole law has to go, I don't think any member of the
	panel thinks that there is much chance of that occurring.
	So I don't know whether that answers your--that doesn't
	mean, however, that the fact that there is this dagger pointed
	at the heart of our healthcare system is out there causing
	uncertainty, that it was--basically, opponents of the ACA have
	outsourced to a judge, which Chairman Pallone correctly said
	was a target of forum shopping who has a widespread reputation
	of, one article said, tossing out Democratic policies that
	Republican opponents don't like.
	Ms. Eshoo. I think my time has more than expired. Thank
	you.
	I now would like to recognize the ranking member of the
	subcommittee, Dr. Burgess.
	Mr. Burgess. I thank you for the recognition.
	Mr. Miller, let me just give you an opportunity. You were
	trying to respond with something about the ACA protections.
	Mr. Miller. Sure. It is a complex issue, but we need to
	remember that in the best of the world, the ACA left a lot of
	other folks unprotected. If you didn't comply with the
	individual mandate, you didn't get coverage. You got fined. You
	got insult on top of injury, and there is no coverage to it.
	So there are breakdowns in any imagined perfect system.
	There are other approaches which can also fill that hole. You
	are going to have to put some money in. You are going to have
	to resolve----
	I don't think the Republicans did a good job of it in 2017
	in explaining and defining what that meant. They began
	backfilling as they went along with reinsurance. There are ways
	to extend HIPAA over to the individual market.
	Those are all thoughtful alternative approaches, and if you
	don't have an individual mandate, you should come up with
	something else. And we are not going to have an individual
	mandate. That appears to be the case.
	So you are leaving a hole there and there are other ways to
	provide stronger incentives, and it requires some robust
	protections where if you went into something like a high-risk
	pool or an invisible risk pool you could requalify for that
	full-scale portability after 18 months.
	So there are ways to connect the dots. It is heavier
	lifting, and it is more work than just waving your arms and
	saying, ``We mandated it, it must work,'' even though it
	doesn't.
	Mr. Burgess. And I thank you for that clarification, and
	just--continuous coverage was part of the bill that we worked
	on 2 years ago.
	Mr. Miller. A number of options. Yes.
	Mr. Burgess. Which, of course, is what exists in Medicare.
	I mean, if you do not purchase Medicare within 3 months of your
	65th birthday, guess what? You get an assessment for the rest
	of your life in Part B of Medicare.
	So, Mr. Miller, I actually agree with you and, I guess,
	other witnesses. My expectation is that this case will not be
	successful on appeal, and I base that on the fact that I have
	been wrong about every assumption I have made about the
	Affordable Care Act ever since its inception in 2009.
	So perhaps I can be wrong about that assumption, but I do
	assume that it will not survive on appeal.
	Let me just ask you, because I have had difficulty finding
	this information--you may have some sense--how much money has
	been collected under the individual mandate? The fines that
	have been paid--do we have an idea what that dollar figure is?
	Mr. Miller. Yes. I did that a couple years ago in the Ways
	and Means. I knew it was going to come up today. I can supply
	it for you.
	Mr. Burgess. Great.
	Mr. Miller. This is--with a bit of a lag it ends up being
	calculated. Not a lot, and it's somewhat randomly distributed.
	It tends to be the lower-income people who didn't know how to
	get out of the individual mandate who ended up paying it,
	surprisingly enough. But it did not amount to a large amount,
	and it didn't have a lot of coverage effects.
	Mr. Burgess. So, basically, the effect of the Tax and Jobs
	Act of 2017 was current law because no one behaved as if it was
	a real thing anyway.
	Mr. Miller. Well, it had some other ripple consequences.
	But in that, practical consequences were not as significant as
	is often said.
	Mr. Burgess. Well, let me ask you this. I mentioned in my
	opening statement that perhaps ways to end this lawsuit would
	be to either repeal the individual mandate outright or
	reestablish the tax within the individual mandate. Do you agree
	that either of those activities would----
	Mr. Miller. That requires actually legislating, which is a
	hard thing to do these days on Capitol Hill.
	Mr. Burgess. I think--yes, sir. But it would achieve the
	goal of breaking the lawsuit.
	Mr. Miller. Sure. And there is lots of other things. I
	mean, States could pay us their own individual mandate. As I
	said, you could also just rescind your findings of fact in the
	old Congress and say, ``We were wrong, we are sorry.''
	Mr. Burgess. I don't think that is going to happen.
	Let me just ask you. I mentioned the phenomenon of silver
	loading in my opening statement. Would you walk us through, for
	people who are not familiar with that as a technical term----
	Mr. Miller. Sure.
	Mr. Burgess [continuing]. The phenomenon of silver loading?
	Mr. Miller. It is a bit of a ripple of the other litigation
	over the cost-sharing reduction subsidies, and that has got a
	tangled web in itself.
	But, cleverly, a number of States, insurance regulators,
	and insurers figured out a way to game the system, which is how
	do you get bigger tax credits for insurance by increasing your
	premiums.
	There was also worry about what those market were doing,
	which fueled some of that increase, and a lot of spikes in the
	individual market over the previous 2 years as a result of
	that, and the silver loading embellished that.
	Now, that was great for folks who were already covered
	where, because of the comprehensiveness of their subsidy income
	related, they weren't out any extra dollars as those premiums
	went up.
	But the folks in the rest of the individual market--and
	Avik can talk to this as well--that is where we had our
	coverage losses, and that is where you got the damage being
	done. Those are the victims--the byproducts of doing good on
	one hand and it spills over into other people.
	Mr. Burgess. That's the teacher and policeman that I
	referenced in my district who have two children. They are
	outside the subsidy window.
	Mr. Roy, could you just briefly comment on the effect of a
	Medicare for All policy on what union members receive as their
	health insurance?
	Mr. Roy. Well, I mean, of course, there are many different
	definitions of Medicare for All, but if we define it as the
	elimination of private insurance then, obviously, union members
	who have either Taft-Hartley-based plans or employer-sponsored
	insurance, that would be replaced by a public option or
	something like that. I assume that is what you mean.
	Mr. Burgess. Yes, sir. Thank you. Thank you for being here.
	I yield back.
	Ms. Eshoo. Thank you, Ranking Member.
	And who are we going to? To recognize the gentlewoman from
	the great State of California and its capital, Sacramento, Ms.
	Matsui.
	Ms. Matsui. Thank you, Madam Chair.
	Thank you all for joining us today. The topic of this
	hearing is incredibly important to me and my constituents and
	all Americans whose lives have been changed by the Affordable
	Care Act.
	A special thank you to Ms. Hung for sharing your daughter's
	story and for your incredible advocacy work on behalf of
	children and families everywhere.
	When we started writing the ACA 9 years ago, I consulted
	with a full range of healthcare leaders in my district in
	Sacramento. They called together the hospitals, the health
	plans, the community health centers, the patients, and all
	those who contribute to our healthcare systems and all those
	who use it also.
	Everything was carefully constructed. We tried to think
	about everything but, obviously, you can't think of everything.
	But we consulted as widely as possible because we also knew
	that each policy would affect the next and the system as a
	whole.
	You simply cannot consider radical changes to the law in a
	vacuum, yet that is exactly what this ruling of the lawsuit
	does. By using the repeal of the individual mandate in the GOP
	tax bill as justification of this suit, the court has declared
	the entire Affordable Care Act invalid.
	Millions of Californians and Americans stand to lose
	critical health protections, including protections for people
	especially with preexisting conditions. Vital protections for
	Medicare beneficiaries including expanded preventive services
	and closing the prescription drug doughnut hole will be thrown
	into chaos.
	I was pleased to join my colleagues to vote for the House
	of Representatives to intervene in this lawsuit and defend the
	ACA in our continued fight to protect people with preexisting
	conditions and for the healthcare of all Americans, and I think
	you know that that is something that all Americans care about
	when you think about preexisting conditions. Everybody has some
	sort of preexisting conditions.
	For me, the potential consequences of the lawsuit are too
	great to not fully consider, especially for the impact on
	people confronting mental illness and substance abuse.
	The passage of the ACA was a monumental step forward in our
	fight to confront the mental health and substance abuse crisis
	in this country and led to the largest coverage gains for
	mental health in a generation through the expansion of
	Medicaid.
	Ms. Linke Young, can you briefly discuss why the consumer
	protections of the ACA are so important to individuals
	struggling with mental illness or substance abuse?
	Ms. Young. Absolutely. Preexisting law--law that existed
	prior to 2009--established a baseline protection for people
	with mental illness that said that, if their insurance plan
	covered mental illness--mental health needs--then it had to do
	so on the same terms that it covered their physical treatment.
	But it didn't require any insurance product to include
	coverage of mental health benefits. And so it was typical for
	coverage in the individual market to exclude mental health
	benefits completely.
	With the Affordable Care Act, plans were required to
	include coverage for mental health and substance use disorder
	services and to do so at parity on the same terms as they
	include coverage for physical health benefits, and that brought
	mental health benefits to about 10 million Americans who
	wouldn't have otherwise had it.
	In addition, the Medicaid expansion in the 37 States and DC
	and that have taken that option has enabled many, many people
	with serious mental health needs, including substance use
	disorder, to access treatment that they would not otherwise
	have been able to access.
	Ms. Matsui. So this would be very serious, and I am
	thinking about the 37 States that did expand Medicaid, if this
	decision was upheld.
	I just really feel, frankly, that it is difficult enough
	when you have mental illness or someone in your family does,
	the stigma that is attached to it, whereas with the Medicaid
	expansion I believe that most people will seek the treatment
	that they really need.
	And what do you foresee with the loss of this expansion if
	it were to happen?
	Ms. Young. If Federal funding for Medicaid expansion was no
	longer available, then the States that have expansion in place
	would need to choose whether to find State funding to fill that
	gap or to scale back their expansion or cut benefits or reduce
	provider rates or some combination of those policies.
	The Congressional Budget Office and most experts expect
	that many States would retract the expansion and move those
	residents that were covered through expansion off the Medicaid
	rolls, and most of them are likely to become uninsured and
	would not continue to have access to mental health and
	substance use disorder coverage.
	Ms. Matsui. So, in essence, we will be going backwards then
	once again. OK.
	Thank you very much, and I yield back the balance of my
	time.
	Ms. Eshoo. Thank you, Ms. Matsui.
	I would now like to recognize the gentleman from Kentucky,
	Mr. Guthrie.
	Mr. Guthrie. Thank you very much, and again,
	congratulations on your----
	Ms. Eshoo. Thank you.
	Mr. Guthrie [continuing]. On being the chair. I enjoyed
	being vice chair a couple of times and learned a lot about the
	healthcare system and moving forward.
	And I know today the title is how does the Texas case
	affect preexisting conditions, and I think we are hearing from
	everybody that it would probably be near unanimous if we did a
	legislative fix to preexisting conditions regardless of where
	the case goes, and so I was listening to Dr. Burgess talk
	earlier about having a hearing for Medicare for All, and I
	think the chair of the full committee said that, well, ``Why
	would you want to have a hearing for a piece of legislation you
	say you're not for?''
	I think it is important for us to talk about and the issues
	that would come because there are, I think, at least four or
	five presidential candidates that already said they were for
	it.
	So it is not just some obscure bill that somebody files
	every year. It has now gotten into the public space that we
	need to discuss.
	And Ms. Hung, I appreciate your testimony. I have nothing
	compared to your issues with your child, but I had a son that
	had some issues when he was a boy. He is 23 now, and so about a
	month of just, ``What is going to happen?''--so I understand
	the preexisting conditions--and then another year and a half,
	maybe 2 years, in and out of children's hospitals. But we got
	the best words a parent can hear when a physician walks in:
	``We know what the problem is now, and we can fix it.''
	Matter of fact, just last fall he thought he was having
	some problems--so he lives in Chicago, west of Chicago. I went
	to see a--to a doctor with him and the doctor said, ``Hey, it
	is something else, it is something routine we can treat.'' He
	goes, ``By the way, you had a really great surgeon when he was
	8.'' So we were just reinforced with it. So everything kind of
	works.
	And so what has kind of impressed me, and I guess I am
	going to just talk a little bit instead of ask questions, but
	what has always impressed me about the care--Vanderbilt
	Children's Hospital is where we were--that he has received and
	just the innovation our healthcare system is producing.
	It is absolutely amazing innovation coming out in our
	healthcare system. The artificial pancreas is real now. People
	can have it now. You can cure hepatitis C with a pill. It is
	just amazing what is happening with some people, not a lot. It
	is not universal, but stage four melanoma is being cured with
	precision medicine.
	I mean, those things are happening in our healthcare
	system. They are expensive, and my biggest concern if we go to
	a Government-run, that we just lose that healthcare. We
	innovate, and the world--and President Trump talked about it a
	little last night--is living off our investment in innovation.
	But if we don't invest and innovate, who is going to do it and
	who is going to have the care that we have?
	As a matter of fact, we are investing and innovating so
	quickly, this committee spent an awful lot of time over the
	last couple of years to put 21st Century Cures in place so the
	Government regulatory structure can keep up with the vast
	investment.
	I know we spent a lot of time in the last couple years
	doing oversight. I hope we will continue to do oversight of
	implementation of 21st Century Cures.
	So my only point is, and I will yield back in just a couple
	seconds, is that it is important when we look at such massive
	changes to our healthcare system, the way people get health
	insurance.
	You know, most people still get it through their employer.
	Is that going to go away? People get it through--we talked
	about the Indian Health Services. Is that going to go away? Is
	it a road to get rid of the VA?
	Just, there is so much change that is proposed in what
	people boil down to one--a bumper sticker, Medicare for All--
	that it has implications for everybody. It has implications for
	the whole country, and universal coverage is a positive thing.
	But if you get to the--I tell you, if you get to the
	Medicare reimbursements throughout the entire healthcare
	system, I am convinced we won't have the innovation that
	completely--my son is completely healed--that had some
	innovative surgeries--for his privacy I won't say--but 15 years
	ago that now are probably completely different on what you see.
	My cousin is a NICU doctor, and the stuff that--the babies
	that he now sees that are surviving, and we have a colleague
	here that had a daughter born without kidneys who, I guess--
	Abby must be about 5 or 6 now.
	And so it is just--that is a concern, and I think that when
	we are going to have a piece of legislation that has kind of
	been boiled down to a bumper sticker but it is going to have
	impact on everybody living in this country and everybody
	throughout the world--because I wish the world would help
	subsidize some of the innovations that we are producing--that
	it is worthy for us to have serious discussions and not just
	dismiss it as we are not being serious.
	So and I can tell you I am, I know Dr. Burgess is and I
	think the rest of the committee would be, and I appreciate you
	guys all being here and sharing your stories.
	But we can fix preexisting conditions. I think we are all
	on board with that, and Madam Chair, I yield back.
	Ms. Eshoo. I thank you, Mr. Burgess. Always a gentleman.
	Let us see. Who is next? The chairman of the full
	committee, Mr. Pallone.
	Mr. Pallone. Thank you.
	I wanted to ask Ms. Young a couple questions--really, one
	question. On the day of the Texas district court's ruling,
	President Trump immediately praised Judge O'Connor's decision
	to strike down protections for preexisting conditions.
	The next day he referred to the ruling as, quote, ``great
	news for America,'' and just last week in an interview with The
	New York Times, President Trump boasted that the Texas lawsuit
	will terminate the ACA and referred to the ruling as a victory.
	In his testimony, Mr. Roy claims that President Trump
	supports protecting people with preexisting conditions. I think
	that could not be further from the truth. The truth is,
	President Trump has sought to undermine and unravel protections
	for more than 130 million Americans living with preexisting
	conditions and, understandably, that is not a record that
	Republicans want to promote.
	But I also want to remind folks that, since this is not a
	fact that my colleagues on the other side seem to want to
	acknowledge, and that is that the Republican lawsuit brought by
	Republican attorneys general, who asked the district court to
	strike down the entire ACA.
	So the fact that my colleagues and our minority witnesses
	today are trying to disassociate themselves from Judge
	O'Connor's ruling, which did exactly what the Republican AGs
	asked for, I think is quite extraordinary.
	Mr. Roy asserts in his written testimony that Congress
	should pass a simple bill reiterating guaranteed issue and
	community rating in the event that the district court's
	decision is upheld by the Supreme Court.
	So, and then we have this GOP bill or motion during the
	rules package where they said that, you know, they would do
	legislation that would only include guaranteed issue and
	community rating, and that would ensure sufficient protections
	for preexisting conditions, whatever the courts decide.
	So, basically, Ms. Young, I have one question. Can you
	explain why what Mr. Roy is asserting--that reinstating only
	these two provisions on guaranteeing issue and community
	rating--is insufficient to protect individuals with a
	preexisting condition and the same, of course, is with the
	House GOP bill that would do that.
	Why is this not going to work to actually guarantee
	protection for individuals with preexisting conditions?
	Ms. Young. The district court's opinion, as you note,
	struck down the entirety of the ACA. So not just its
	protections for people with preexisting conditions, but the
	financial assistance available to buy marketplace coverage,
	funding for Medicaid expansion, a host of provisions in
	Medicare, protections through the employer insurance and
	associated reforms.
	So a standalone action that reinstated two preexisting
	conditions protections without wrapping that in the financial
	assistance and the risk adjustment and the Medicaid expansion
	and the other components of the ACA that are, in my view,
	important to make the system function, would not restore the
	system that we have today where people with preexisting
	conditions have access to a functioning market where they can
	buy coverage that meets their health needs.
	In fact, there have been some efforts by the Congressional
	Budget Office to score various proposals that keep some types
	of preexisting condition protections in place but eliminate the
	financial assistance, and the Congressional Budget Office,
	under some scenarios, actually finds that those lead to even
	greater coverage losses than simply repealing the Affordable
	Care Act.
	So implementing those two provisions on their own without
	financial assistance and other protections would be
	insufficient.
	Mr. Pallone. I mean, I think this is so important because,
	you know, again, Mr. Roy--and he is just reiterating what some
	of my Republican colleagues say. They just neglect all these
	other things that are so important for people with preexisting
	conditions.
	You didn't mention junk plans. I mean, my intuition tells
	me, and I am not--you know, I talk to people about it in my
	district--you know, that if you start selling these junk plans
	that don't provide certain coverage, one of the things is it is
	important for people with preexisting conditions to have a
	robust plan that provides coverage for a lot of things that
	didn't exist before the ACA.
	I mean, that is, again, important--the fact that you have a
	robust essential benefits is also important for people with
	preexisting conditions, too, right?
	Ms. Young. Those are both critical protections. In
	particular, the ACA seeks to ensure that insurance for the
	healthy and insurance for the sick are part of a single
	combined risk pool.
	Efforts to promote short-term plans or other policies that
	don't comply with the ACA protections siphon healthy people out
	of the central market and drive up costs for those with
	preexisting conditions and anyone else seeking----
	Mr. Pallone. Yes. So you are pointing out the very fact
	that you have a larger insurance pool, which has resulted from
	the ACA, in itself is important for people with preexisting
	conditions and if you take out the healthier or the wealthier
	because you don't have a mandate anymore, that hurts them too,
	correct?
	Ms. Young. Efforts to move healthier people out of the
	individual market will increase premiums for those that remain
	in complaint coverage, yes.
	Mr. Pallone. All right. Thank you so much.
	Ms. Eshoo. Thank you, Mr. Pallone.
	And now I want to recognize the ranking member of the full
	committee, Mr. Walden.
	Mr. Walden. Thank you, Madam Chair, and I want to thank all
	of our witnesses. We have another hearing--an important one--
	going on downstairs. That is why some of us are bouncing back
	and forth between climate change and healthcare.
	And I want to again say thank you for being here and
	reiterate that as Republicans we believe strongly in providing
	preexisting condition protection for all consumers, and if you
	go back to 1996, when HIPAA was passed under Republicans, we
	provided for continuous coverage protection for people with
	pre-ex.
	I mean, this is something we believe in before ACA and
	something I believe in personally and deeply and something that
	we are ready to legislate on, and I think at least giving that
	guarantee and certainty to people would make a huge level of
	comfort for them.
	And I just--you know, I didn't mean to shake things up this
	morning, but asking for a hearing on Medicare for All was
	something I thought was appropriate, given that other
	committees are already announcing their hearings, and that
	going back to when ACA was shoved through here and then Speaker
	Pelosi saying we had to pass it so you could find out what is
	in it--we don't want to repeat that. We need to know what is in
	it. We need thoughtful consideration. I think this committee is
	the place to have that. So I still think that is important.
	I want to thank both Tom and Avik for being here--Mr. Roy--
	for being here on short notice. You said, Mr. Roy, that
	Congress should pass a simple standalone measure guaranteeing
	that insurers offer coverage in the individual health insurance
	market to anyone regardless of prior health status.
	Mr. Roy. Yes, I did.
	Mr. Walden. And do you want to respond? You didn't get a
	chance to kind of respond here. So do you want to respond to
	what was asked of the other witnesses around you?
	Mr. Roy. Well, thank you, Mr. Walden. I appreciate the
	opportunity to actually explain my written testimony----
	Mr. Walden. Go ahead.
	Mr. Roy [continuing]. In this setting. The key here is that
	three-fourths of the variation of the premiums in health
	insurance in a fully underwritten market are associated with
	age, not health status or gender or anything else--preexisting
	conditions.
	Mr. Walden. OK.
	Mr. Roy. So the point is, if everybody of the same age--all
	27-year-olds, all 50-year-olds, all 45-year-olds--if all 45-
	year-olds are charged the same premium, the variation in
	premiums between the healthy paying a little more and the sick
	paying a little less is not that big of a difference. It
	doesn't cause a lot of adverse selection.
	What drives adverse selection in the ACA is the fact that
	younger people are forced to pay, effectively, double or triple
	what they were paying before----
	Mr. Walden. Right.
	Mr. Roy [continuing]. To allegedly subsidize the premiums
	for older people. So revising age bands would be a huge step in
	moving in the right direction. Reinsurance, which is
	effectively a high-risk pool within a single-risk pool, would
	help basically also reduce the premiums that healthy people pay
	so that people with preexisting conditions could get better
	coverage.
	So you can have a standalone bill that would ensure that
	people with preexisting conditions have access to affordable
	coverage.
	Mr. Walden. I would hope so. I think it is really
	important. I mean, we were for preexisting protections. I was
	for getting rid of the insurance caps before ACA. I thought
	they were discriminatory against those who through no fault of
	their own had consequential health issues that could have blown
	through their lifetime caps.
	And so I think there are things we could still find common
	ground on, and I wonder if you want to address the Medicare for
	All proposal as well.
	Now, we haven't seen it spelled out. I know the Budget
	Committee is, I guess, having it scored and hearings on it. But
	I am concerned about the impacts it may have on delay in terms
	of getting healthcare. I am concerned about what it might do to
	the Medicare trust fund.
	Do you have--do you want to opine on that while you are
	here?
	Mr. Roy. Well, I have written a lot at Forbes and elsewhere
	about how Medicare for All from a fiscal standpoint is
	unworkable because of the gigantic transfers it would assign to
	the Federal Government.
	It would increase Federal spending by somewhere between 28
	and 33 trillion dollars over a 10-year period, which would be
	an increase in overall Federal spending of 71 percent.
	Now, that is not if--that excludes the impact of cutting
	what you pay hospitals and doctors and drug companies by 50
	percent, which is what you would have to do to effectively make
	the numbers work.
	I do want to urge you, Mr. Walden, and your colleagues that
	while Medicare for All is unworkable, and I think most people
	know that, the status quo is unacceptable, too.
	Mr. Walden. Right.
	Mr. Roy. And I think it is extremely important for this
	committee in particular to tackle the high cost of hospital
	care, the high cost of drug prices.
	Mr. Walden. Yes. That was--if I had stayed on as chair that
	was going to be our big priority this cycle. Surprise billing--
	I mean, you go in, you have a procedure, you have played by all
	the rules, and it turns out the anesthesiologist that put you
	under wasn't in your program and you get billed. That is wrong.
	That is just--I think we can find common ground on that one.
	We took on the issue of getting generic drugs into market,
	and under the change in the law we passed last year, Dr.
	Gottlieb now has set a record for getting new generics in the
	market and driving both choice and innovation but also price
	down, and this administration--I have been in the meetings with
	the president and CEOs of the pharmaceutical companies. He is
	serious about getting costs down on drugs and getting to the
	middle part of this, too.
	We need to look from one end to the other and, Madam Chair,
	I think we can find common ground here to do that and get
	transparency, accountability so consumers can have choice and
	so we can drive down costs.
	I have used up my time, and I thank our witnesses again.
	Madam Chair, I yield back.
	Ms. Eshoo. I thank the ranking member.
	We plan to examine all of that, and I think--I hope that we
	can find common ground on it because these are issues that
	impact all of our constituents, and they need to be addressed.
	And on the surprise billing, I know that the Senate is
	trying to deal with it, and we should here as well. I think
	that your clock is not working at the witness table.
	Mr. Roy. That is correct.
	Ms. Eshoo. But it is working up here, OK. So maybe you can
	refer to that one.
	Now I would like to call on the gentlewoman from Florida,
	Ms. Castor.
	Ms. Castor. Thank you, Madam Chair. Witnesses, thank you
	very much for being here, and colleagues, thank you for all of
	your attention here.
	I just think it is so wrong for the Trump administration
	and Republicans in Congress to continue to try to rip
	affordable health coverage away from American families,
	especially our neighbors with preexisting conditions.
	This lawsuit is just a continuation of their efforts to do
	that. When they couldn't pass the bill here in the Congress--in
	the last Congress, despite Republican majorities--and I am
	sorry to say that my home State of Florida under Rick Scott's
	administration joined that Federal lawsuit.
	Thirteen Democratic members of the Florida delegation have
	written to our new Governor and attorney general, asking--
	urging them to remove the State of Florida from the Federal
	lawsuit that would kill the Affordable Care Act and rip health
	coverage away from American families, including individuals
	with preexisting health conditions.
	This follows the letter we sent to Rick Scott as well, and
	I would like to ask unanimous consent that these letters be
	admitted into the record of this hearing.
	[The information appears at the conclusion of the hearing.]
	Ms. Castor. American families are simply tired of the
	assault on affordable healthcare and, Chairwoman Eshoo, you
	raised the point about the skimpy junk insurance plans, because
	one way that the Trump administration and Republicans are
	trying to undermine affordable care are these junk health plans
	that do not provide fundamental coverage.
	When you pay your hard-earned copayment and premiums, you
	should actually get a meaningful health insurance policy, not
	some skimpy plan that is just going to subject you to huge
	costs.
	These subpar and deceptive junk plans exclude coverage for
	preexisting conditions. They discriminate based on age and
	health status and your gender.
	Consumers are tricked into buying these junk plans,
	mistakenly believing that they are the comprehensive ACA plan,
	but then they are faced with huge out-of-pocket costs. For
	example, in a recent Bloomberg article, Dawn Jones from Atlanta
	was enrolled in a short-term junk plan when she was diagnosed
	with breast cancer. Her insurer refused to pay for her cancer
	treatment, leaving her with a $400,000 bill.
	Another patient in Pennsylvania faced $250,000 in unpaid
	medical bills because her junk short-term policy did not
	provide for prescription drug coverage and other basic
	services.
	The Trump administration now is actively promoting these
	junk plans, and I want American families and consumers across
	the country to be on alert. Don't buy in to these false
	promises.
	Ms. Young, you have talked a little bit about this, but
	will you go deeper into this? Help us educate families across
	the country. I understand that these plans often impose
	lifetime and annual limits. Is that correct?
	Ms. Young. It is, yes.
	Ms. Castor. And that is something the Affordable Care Act
	outlawed?
	Ms. Young. Correct.
	Ms. Castor. Can you describe what these plans typically
	look like and what kind of coverage they purport to provide?
	Ms. Young. Short-term limited duration insurance is not
	regulated at the Federal level. None of the Federal consumer
	protections apply. Some State law protections may apply or----
	Ms. Castor. Consumer protections--name them.
	Ms. Young. The requirement that plans cover essential
	health benefits, the prohibition on annual and lifetime limits,
	the requirement that the insurance company impose a cap on the
	total copays and deductibles an individual can face over the
	year, requirements to cover preventive services, to not exclude
	coverage for preexisting conditions and other----
	Ms. Castor. Wait a minute. Wait a minute. I have heard some
	of my Republican colleagues say they are all in favor of that.
	But can you be in favor of preexisting condition protection on
	the one hand and then say, ``Oh, yes, we believe these junk
	insurance plans are the answer,'' like the Trump administration
	and Republicans in Congress are promoting?
	Ms. Young. Short-term limited duration plans do not have to
	comply with the requirements about preexisting conditions. That
	is correct.
	Ms. Castor. Can you describe why an individual who is
	healthy when they sign up for one of these junk plans could
	still be subject to hundreds of thousands of dollars in medical
	bills?
	Ms. Young. There is no requirement that short-term plans
	cover any particular healthcare cost. So an individual who
	doesn't read the fine print behind their policy might discover,
	for example, that the plan only covers hospital stays of a few
	days and individuals are on the hook for all additional
	hospital expenses.
	They may find that the plan has a very low annual limit, so
	that once they have spent 10 or 20 thousand dollars, they are
	responsible for bearing the full cost or any variation like
	that where they simply discover when they need to access the
	healthcare system that the plan doesn't include the coverage
	that they had hoped to purchase.
	Ms. Castor. Thank you very much, and we will be working to
	ensure that consumers are protected and, when they pay their
	premiums and copays, they actually get a meaningful health
	insurance policy.
	Thank you, and I yield back.
	Ms. Eshoo. I thank the gentlewoman.
	I now would like to call on Mr. Griffith from Virginia. You
	are recognized for 5 minutes.
	Mr. Griffith. Thank you very much, Madam Chair. I
	appreciate it.
	Here is the dilemma that we have. In my district, which is
	financially stressed in many parts of it--I represent 29
	jurisdictions in rural southwest--always put the pause in
	there--Virginia.
	So when ACA came in so many of my people immediately came
	to me, long before the Trump administration came in, and in
	their minds the ACA was junk insurance, because when they were
	promised that their premiums would go down, they now had
	premiums that were financially crippling.
	When they were promised that they would have better access,
	they now found that they had high deductibles and they now
	found that their copays had gone through the roof.
	So there is no question--I never argued--that the
	preexisting condition was a problem that should have been dealt
	with long before the ACA, and I understand the concerns and the
	frustration that people had who had preexisting conditions, and
	we need to take care of that and we will take care of that.
	I don't see anybody who would argue at this point that we
	shouldn't deal with people with preexisting conditions and make
	sure they have access to affordable healthcare, which is why I
	supported our attempts to get an amendment put in on day one of
	this Congress that would say, get the committees of
	jurisdiction.
	In fact, it referenced the Energy and Commerce Committee--
	this committee--and the Ways and Means Committee to report out
	a bill that took care of all of the concerns we have heard
	today and said it guarantees no American citizen can be denied
	health insurance coverage as the result of a previous illness
	or health status and guarantees no American citizen can be
	charged higher premiums or cost sharing as the result of a
	previous illness or health status, thus ensuring affordable
	health coverage for those with preexisting conditions.
	That is where we are. That is what we stand for. So, you
	know, I find it interesting that this debate has become--you
	know, and I am hearing about junk insurance and how Republicans
	are evil, that they want junk insurance.
	I hear it on a regular basis that my people think that what
	they have got now is junk. It is all they can afford, and it is
	costing them a fortune.
	So, Mr. Roy, what do you have to say about that?
	Mr. Roy. I have found the conversation we have been having
	about so-called junk insurance interesting because nobody seems
	to be asking the question as to why people are voluntarily
	buying so-called junk insurance.
	They are buying it because the premiums are half or a third
	or a quarter of what the premiums are for the Affordable Care
	Act for them.
	Mr. Griffith. And if you can't afford something else, you
	are going to buy something that you can afford. Isn't that
	correct?
	Mr. Roy. A hundred percent. So a plan that has all the
	bells and whistles but it is unaffordable to you is
	effectively, worthless, whereas a plan that may not have all
	the bells and whistles but at least provides you some coverage
	is.
	And the great tragedy of the Affordable Care Act is that we
	did not have to have that dichotomy. We could have had plans
	that had robust coverage for people with preexisting conditions
	and protections for people regardless of health status and yet
	were still affordable.
	I have outlined it both in my written testimony, in my oral
	testimony, and many, many other documents that I have presented
	to this committee in the past, how we could achieve that.
	Mr. Griffith. Now, you would agree with me for those people
	who may have bought the junk insurance without knowing what
	they were getting into that we probably ought to pass something
	that says that the things that aren't going to be covered--if
	you're only getting $20,000 worth of care and then you have to
	take the full bill after that, as Ms. Castor talked about--we
	should have that in bold language on the front of the policy.
	You would agree that we should put some consumer protection
	in that and make sure there is transparency so people are well-
	advised of what they are getting or not getting. Isn't that
	true?
	Mr. Roy. I have no problem with robust disclosure about
	what is in a short-term limited duration plan versus an ACA-
	compliant plan. To a degree, we already have that in the sense
	if you are buying off the ACA plan, I think most consumers know
	that those plans have fewer protections, but more disclosure,
	and more clarity in disclosure would be a good thing.
	Mr. Griffith. Absolutely. I agree with that.
	You know, what is interesting is everybody seems to have
	gone after Judge O'Connor. I don't know him. I haven't studied
	his opinions.
	But I do find this interesting. I thought it was the right
	thing to do. He put a stay on his ruling so it didn't create a
	national catastrophe or suddenly people are having to scramble
	to figure out what to do.
	Mr. Miller, isn't that a little unusual in this day--I
	mean, people have accused him of being biased or having a
	political bent and using his power. But I seem to recall all
	kinds of opinions by judges that I thought were coming from a
	slightly different philosophical bent but who went out there on
	a limb, stretched--pushed the envelope of the law.
	But instead of saying, ``Now, let us wait until the appeal
	is over and make sure this is right before we affect the
	average citizen,'' they just let it go into effect. But Judge
	O'Connor said, ``No, in case this is overturned, I want to make
	sure nobody is adversely impacted'' and put a stay on his own
	ruling.
	Isn't that unusual, and wasn't that the right thing to do?
	Mr. Miller. No, it is not--it is hopscotch. We have had
	some Federal judges who have had nationwide injunctions
	reaching way beyond what you would think would be the normal
	process.
	Mr. Griffith. Yes. I have noticed that.
	Mr. Miller. I think all the parties understood what
	practically was going on here. I would just point out on the
	legalities of this, just to clean up the record, one of the
	things about----
	Ms. Eshoo. Just summarize quickly, because your time is up.
	Mr. Miller. My time is up. OK.
	Mr. Griffith. You could summarize, she said.
	Ms. Eshoo. Quickly.
	Mr. Miller. I will just say, real fast, we left out the
	argument about tax guardrails, which was in Chief Justice
	Roberts' opinion, and Si is exaggerating what is there and
	isn't there.
	The problem is that, when you take it apart, there is
	nothing left behind.
	Ms. Eshoo. OK. I think your time is expired.
	Mr. Miller. It was his testimony, was that this tax didn't
	exist anymore.
	Ms. Eshoo. All right. We are now going to go to and
	recognize Dr. Ruiz from California.
	Mr. Ruiz. Thank you. It is so wonderful to be on this
	committee finally. So thank you to all----
	[Laughter.]
	Ms. Eshoo. He hasn't stopped celebrating.
	Mr. Ruiz. Thank you to all the witnesses for joining us
	today. We have over 130 million Americans that have preexisting
	conditions. The ACA defended full protections for people with
	preexisting conditions, and those are three components.
	One is that insurance companies cannot deny insurance to
	people with preexisting conditions; two, they cannot deny
	coverage of specific treatments related to the preexisting
	condition illness; and three, they cannot discriminate by
	increasing the prices towards people who have a preexisting
	condition.
	Let me give you some examples of some of the benefits and
	hardships that people would face if this lawsuit is completed.
	My district is home to Desert AIDS Project, an FQHC that
	was founded in 1984 to address the AIDS crisis. It is the
	Coachella Valley's primary nonprofit resource for individuals
	living with HIV/AIDS. They have grown to become one of the
	leading nonprofits and effective HIV/AIDS treatment in the
	Nation.
	And the folks at Desert AIDS Project know how to end the
	HIV/AIDS epidemic. Basically, you need prevention and you need
	treatment. They told me that the ACA has been critical in
	providing treatment to the HIV--in order to get the HIV viral
	load at an uninfectious low level.
	So the problems before the ACA was that insurance companies
	didn't used to have to pay for HIV tests, for example, or
	individuals with HIV couldn't get Medicaid coverage until they
	were really sick on full-blown AIDS, many already on their
	death beds.
	Now, because of the ACA, insurance companies must cover
	essential health benefits like HIV tests and antiviral
	medications, which by the way the folks on the other side have
	attempted to repeal.
	Because of the ACA and the Medicaid expansion many HIV-
	infected middle class families now have health insurance for
	the very first time. Unfortunately, I can't say that for HIV
	patients throughout our country including in States like Texas
	that didn't expand the Medicaid coverage.
	And, by the way, this is another example of ACA that those
	on the other side attempted to repeal. Before the passage of
	the ACA, 90 percent of Desert AIDS Project clients did not have
	health insurance, and now, with the ACA, 99.9 percent of
	clients have health insurance coverage in Desert AIDS Project.
	Let me repeat that statistic. Insurance coverage for these
	patients went from only 10 percent to 99.9 percent because of
	the ACA. And yet, the president, while claiming to be committed
	to eliminating the HIV/AIDS epidemic in 10 years, is actively
	taking measures to take away these protections of this very
	population by rolling back the Medicaid expansion and weakening
	and undermining preexisting conditions protections.
	This would be devastating to Desert AIDS Project clients
	and patients, and yet this is just one example of the
	devastation that repeal of the ACA would cause on individuals
	with preexisting conditions.
	Ms. Young, could you discuss the potential impact of the
	lawsuit on individuals with preexisting conditions if the
	district court's decision is upheld?
	Ms. Young. If the district court decision were to be upheld
	as written, it would disrupt the coverage for people with
	preexisting condition in all segments of the insurance market.
	So we talked a lot about the individual market. The core
	protections in the individual market today would be eliminated
	along with the financial assistance that enables them to afford
	coverage and make those markets stable.
	In employer coverage, people with preexisting conditions
	would also face the loss of certain protections. They would
	once again be exposed to lifetime or annual limits and they
	could face unlimited copays.
	Mr. Ruiz. Let me get to another point because, you know, we
	are hearing a lot of political trickery here in the
	conversations. A number of the folks on the other side have
	introduced bills that will pick and choose which one of these
	three components that make up full protections for preexisting
	conditions that they want to have in certain bills.
	For example, one bill says, we want guaranteed issue and
	community rating which will help keep the costs low for
	everybody but don't include the prohibition on preexisting
	coverage exclusions.
	Another bill includes guaranteed issue and the ban on
	preexisting coverage exclusion but does not include the
	community rating, saying, well, let us charge people with
	preexisting more than other folks.
	So they claim these bills are adequate to protect consumers
	with preexisting conditions. Can you explain why these bills
	are inadequate to protect individuals with preexisting
	conditions?
	Ms. Young. Very briefly, requiring insurance companies to
	sell a policy but allow preexisting condition exclusions
	requires them to sell something but it doesn't have to have
	anything in it. It is a little bit like selling a car without
	an engine.
	And allowing unlimited preexisting condition rate-ups tells
	the consumer that they can buy a car but they could be charged
	Tesla prices even if they are buying a Toyota Camry. That is
	not what the Affordable Care Act does. It puts in place a
	comprehensive series of protections.
	Mr. Ruiz. Thank you.
	Ms. Eshoo. Your time has expired. I thank the gentleman.
	I now would like to recognize Dr. Bucshon from Indiana.
	Mr. Bucshon. Thank you, and congratulations on your
	chairmanship. Look forward to working with you.
	I am a physician. I was a heart surgeon before I was in
	Congress, and we all support protections for preexisting
	conditions. Look, I had a couple of patients over the years who
	I did heart surgery on who had--one had had Hodgkin's disease
	in his 20s, and his entire life after that he could not afford
	health coverage, and that is just plain wrong. We all know
	that.
	I had an employee of mine whose wife met her lifetime cap
	because of a serious heart condition and had to ultimately go
	onto Medicaid. That is not right.
	So I think Republicans for many years have supported
	protecting people with preexisting conditions. I think we are
	in a policy discussion about the most appropriate way to do
	that.
	And so I really think what we should be focusing on is to
	make sure that people actually have coverage that they can
	afford--quality affordable health coverage, and under the ACA,
	as was previously described, the deductibles can be very high.
	You couldn't keep your doctor and your hospital, as everyone
	said that supported the ACA, and so we are not meeting that
	goal.
	And now we have heard from the Democrats about Medicare for
	All and their bill in the last Congress, H.R. 676, would have
	made it illegal for private physician practices to participate
	in a Government healthcare program. And by the way, Medicare
	for All doesn't even solve the main problem we have in
	healthcare, which is the huge cost.
	I keep telling people if you continue to debate how to pay
	for a product that is too expensive, you are not going to catch
	up. It doesn't matter who is paying for it. It doesn't matter
	if the Government is paying for it or a partial hybrid system
	like we have now.
	So I am hoping we can have some hearings on how we get the
	cost down, and the insurance problem kind of almost can solve
	itself if we can do that.
	We should be talking about the fact that people with
	preexisting conditions really don't have protections, and it
	doesn't work if you don't have actual access to a physician.
	So Mr. Miller and Mr. Roy--I will start with Mr. Roy--can
	you talk about what could happen in the U.S. if private
	physician practices were not allowed to participate in a
	single-payer program, hypothetically, and would that create
	access issues for patients?
	Mr. Roy. Well, we already have access issues for patients
	in the Medicaid program. A lot of physicians don't accept
	Medicaid----
	Mr. Bucshon. That is correct.
	Mr. Roy [continuing]. Even though they theoretically
	participate in the Medicaid program. That is also an increasing
	problem in Medicare because there are disparities in the
	reimbursement rates between private insurers, Medicare, and
	especially Medicaid.
	And this is one of the other flaws in the ACA, is it relied
	on a program with very poor provider access to expand coverage.
	I think the exchanges at least have the virtue of using private
	insurers to expand coverage rather than the Medicaid program
	with its much lower reimbursement rates.
	Mr. Bucshon. So I would argue that, you know, then if you
	go to a Medicare for All, you have access issues on steroids,
	potentially, and especially if you don't allow private practice
	physicians--what I am saying, nonhospital or Government-
	employed physicians, which is what we would all be--to
	participate in the program, which is actually not what other
	countries do.
	In England, for example, you can have your private practice
	and also participate in the National Health Service.
	Mr.----
	Mr. Miller. You are more likely to have Medicaid for All
	than Medicare for All until you solve the--and say ``Stop, we
	can't deal with that.'' The problem is we would love to give
	away all kinds of stuff. We just don't want to pay for it.
	Now, we can shovel it off into ways in which you get less
	than what was promised and say, ``We have done our job.'' We
	did that to an extent with the ACA. You find the lowest-cost
	way to make people think they are getting something that is
	less than what they actually received.
	That is why the individual market as a whole has shrunk in
	recent years. It is because those people who are not well-
	subsidized in the exchanges are finding out they can't afford
	coverage anymore.
	Mr. Bucshon. So, I mean, and I will stick with you, Mr.
	Miller. Do you think if the iteration of Medicare for All bans
	private practice physicians not to be able to participate that
	we would put ourselves at risk of creating a two-tiered system
	where the haves can have private coverage and there can be
	private hospitals as there is in other countries?
	Mr. Miller. Well, already we have got plenty of tiers in
	our system to begin with. It would exacerbate those problems
	and I don't think we would live with it politically, which is
	why it would probably short circuit.
	But it is at least a danger when people believe in the
	theory of what seems easy but the reality is very different.
	Mr. Bucshon. Yes. I mean, I would have an ethical problem
	as a physician treating patients differently based on whether
	or not they are wealthy or whether or not they are subjected to
	a Medicare for All system, right.
	So, ethically, I can tell you physicians would have a
	substantial problem with that. Other countries kind of do that
	because that is just the way it is there and I think in many
	respects their citizens don't have a problem with it because
	that is just what they have always lived with.
	But I would agree with you that in the United States there
	would be some issues.
	Mr. Roy, do you have any comments on that?
	Mr. Roy. I do. I would just like to add that at the
	Foundation for Research on Equal Opportunity we put together a
	detailed proposal for private insurance for all, where everyone
	buys their own health insurance with robust protections for
	preexisting conditions and health status and robust financial
	assistance for people who otherwise can't afford coverage in a
	way that is affordable, that would actually reduce Federal
	spending by $10 trillion over three decades but would ensure 12
	million more people have access to health insurance than do
	today under current law.
	So there are ways to address the problem of affordability
	and access of health insurance while also reducing the
	underlying cost of coverage and care and making the fiscal
	system more sustainable.
	Mr. Bucshon. Yes. I mean, I think we should be also putting
	focus on the cost of the product itself, right, and the reasons
	why it costs so much are multi-factorial. It is a free market
	system.
	The other thing is, I told my local hospital administrators
	that if we get Medicare for All, get ready to have a Federal
	office in your private hospital that tells you how to run your
	business.
	I yield back.
	Ms. Eshoo. I thank the doctor.
	And last, but not least, Mr. Rush from Illinois is
	recognized for 5 minutes for questioning.
	Mr. Rush. Thank you, Madam Chair.
	Madam Chair, I also want to congratulate you for your
	becoming chair of the subcommittee and----
	Ms. Eshoo. I thank you very much.
	Mr. Rush [continuing]. I have been a Member of Congress for
	quite--for, as you have, for over 26 years, and this is my
	first time being a member of this subcommittee, and I am
	looking forward to working with you and other members of the
	subcommittee.
	I want to--as I recall, when this Affordable Care Act was
	passed, there were millions of Americans who were without
	health insurance totally. They were uninsured. They had no help
	at all, no assistance from anyone to deal with their illnesses
	and their diseases.
	And since the Act was passed, approximately 20 million
	Americans have gained health coverage, including over a million
	in my State, and I don't want to overlook that fact. I don't
	want to get that fact lost in the minutia of what we--of any
	one particular aspect of our discussion.
	In 2016, almost 14,000 of my constituents received
	healthcare subsidies to make their healthcare more affordable.
	One aspect of the ACA that I like is insurance companies must
	now spend at least 80 percent of their premium on actual
	healthcare as opposed to other kinds of pay for CEOs and also
	for an increase of their profits.
	And the insurance rate has increased between--the uninsured
	rate, rather, has increased between the years 2013 and 2017--
	since 2017 in my State.
	Ms. Young, how many Americans would expect to lose coverage
	if this court decision in Texas were upheld?
	Ms. Young. The Congressional Budget Office has estimated
	that repeal of the Affordable Care Act against their 2016
	baseline would result in 24 million additional uninsured
	Americans, and upholding the district court's decision we could
	expect sort of broadly similar results with adjustments for the
	new baseline.
	Mr. Rush. Mm-hmm.
	I want to ask Ms. Hung, you've been sitting here patiently,
	remarkably, listening to a lot of discussion between experts.
	But how do you feel about your daughter? How do you feel? What
	is your reaction to all of this as it relates to the looming
	problem that you have if this case is upheld?
	Ms. Hung. Thank you. No one is going to sit here and say
	that they are not going to protect preexisting conditions,
	right. No one is going to say that. But that is what we have
	seen. That is what families like mine have seen--repeal
	efforts, proposals that don't cover preexisting conditions or
	claim to give a freedom of choice to choose what kind of
	insurance we want.
	Well, the choice that I want is insurance that covers, that
	guarantees that these protections are in place. I don't want to
	sit in the NICU at my daughter's bedside wondering if she is
	going to make it and also then have to decide what kind of
	insurance I am going to buy and imagine what needs that she
	will have in order to cover that.
	So I sit here and say, well, what worked for me is that I
	got to spend 169 days at my daughter's bedside without worrying
	about whether we would go bankrupt or lose our home, and that
	is the guarantee that we need.
	Mr. Rush. Madam Chair, I yield back.
	Ms. Hung. Thank you.
	Ms. Eshoo. I thank the gentleman.
	I now would like to call on another new member of the
	subcommittee, and we welcome her. Ms. Blunt Rochester from the
	small but great State of Delaware.
	[Laughter.]
	Ms. Blunt Rochester. Thank you, Madam Chairwoman.
	First of all, thank you so much for your leadership. It is
	an honor for me to be on this subcommittee. And excuse me, I
	had competing committees for my first day of subcommittees and
	so I have been running back and forth.
	But this is a very important topic, and I want to
	acknowledge Ms. Hung. The last time I saw you we were at a
	press event with then-Leader Pelosi highlighting the Little
	Lobbyists and the work that you do and have been doing, and
	just your support of protecting preexisting conditions for
	children across the country.
	And it is really admirable that you advocate not only for
	your child but for all children across the country and have
	been fighting for decades. And I was hoping that you could talk
	a little bit about the formation of the Little Lobbyists and
	who they are, what it is all about, how it formed.
	Ms. Hung. Thank you, Congresswoman, and thank you for your
	support. I did not set out to start the Little Lobbyists. It
	kind of just happened. We were following the news, where
	families like mine, families with children with complex medical
	needs and disabilities, were very concerned, were very worried.
	And we decided to speak up and tell our stories.
	And I tell my story because I know that many have been
	fortunate to not experience the challenges and hardships that
	we have seen. I also know that many have not experienced the
	joy and gratitude that I had in being Xiomara's mother.
	So I feel a responsibility to uplift these stories that we
	weren't seeing being represented. Now, I have spent more than
	my fair share of time in the hospital. I have witnessed my baby
	on the brink of life and death one too many times.
	I know what is possible with access to healthcare--quality
	healthcare--and I think I can say that I have a profound
	understanding, more than many Americans, how fragile life is,
	and it is with that understanding that I have chosen to spend
	my time raising that awareness.
	I acknowledge my privilege. I acknowledge my proximity to
	Washington, DC, to come here. There are so many stories like
	mine across the country of families who are just fighting for
	their children, who want to spend that time on their kids and
	not worrying about filing for bankruptcy or losing their home
	or wondering if they can afford lifesaving medication.
	Ms. Blunt Rochester. Yes, that was going to be my next
	question. How does this uncertainty affect your family? How is
	it affecting individuals that you work with and are talking to
	and other Little Lobbyists?
	Ms. Hung. It is everything. It is everything. So the
	uncertainty is not knowing. I mean, we don't know what the
	future holds. None of us do. But to add this on top of what we
	are going through, on top of the NICU moms that I know that are
	worrying, who are trying to keep their jobs and trying to be
	there for their children, to add this level of uncertainty on
	top of it is just devastating.
	Ms. Blunt Rochester. I wanted to have your voice heard. I
	know from hearing that we have a lot of great experts and a
	great panel here, and I would like to bring it back to what
	this is all about. Maybe--I don't know if I am the last one
	speaking or--but I wanted to bring it back to why we are doing
	this and why we are here.
	I have served the State of Delaware in different
	capacities, as our deputy secretary of health and social
	services, I have been in State personnel, so I have seen
	healthcare from that perspective and also from an advocacy
	perspective as CEO of the Urban League.
	But hearing your story makes this real for us and is really
	one of the reasons why I wanted to be on this committee. So I
	thank you for your testimony. I thank the committee for your
	expert testimony, and I yield back the balance of my time.
	Ms. Eshoo. Thank you very much.
	I don't see anyone else from the Republican side.
	Mr. Burgess. There's some people coming back, but proceed.
	Ms. Eshoo. OK. All right. We will move on.
	I now would like to recognize the gentleman from
	California, Mr. Cardenas.
	Mr. Cardenas. Thank you, and thank you, Chairwoman Eshoo
	and Ranking Member Burgess, and all the staff for all the work
	that went into holding this hearing of this committee, and I
	appreciate all the effort that has gone into all of the
	attention that we are putting forth to healthcare both at the
	staff level and at the Member level, and certainly for the
	advocates in the community as well.
	Thank you so much for your diverse perspectives on what is
	important to the health and well-being of all Americans.
	I think, while the legal arguments and implications of this
	case are important, I want to take a few minutes to focus on
	the very personal threats posed by these attacks to the
	Affordable Care Act.
	This ruling, if upheld, would take away healthcare for tens
	of millions of Americans, including our most vulnerable,
	especially children and seniors. They are especially at risk,
	and people with preexisting conditions, we would see them just
	be dropped from the ability to get healthcare.
	For some of us, this is literally a life-and-death
	situation and, as lawmakers, I hope that we don't lose sight of
	the fact of how critical this is, and as the lawmakers for this
	country, I hope that we can move expeditiously with making sure
	that we can figure out a way to not allow the courts to
	determine the future and the fate of millions of Americans when
	it comes to their healthcare and healthcare access.
	Also, I want to thank everybody who is here today, and also
	the court's ruling would ideologically and politically, you
	know, follow through with the motivation that I believe close
	to 70 times or so in this Congress there was an effort to end
	it, not mend it, when it comes to the Affordable Care Act, and
	I think it is inappropriate for us to look at in such a black-
	and-white manner.
	There are cause and effects should the Affordable Care Act
	go away. I happen to be personally one of those individuals
	that, through a portion of my childhood, did not have true
	access to healthcare, and it's the kind of thing that no parent
	should go through and the kind of situation that no American
	should ever have to contemplate, waiting until that dire moment
	where you have to go to the emergency room instead of just
	looking forward to the opportunity to, you know, sticking out
	your tongue and asking the doctor questions and they ask you
	questions and they find out what is or is not wrong, and that
	is the kind of America that used to be.
	And since the Affordable Care Act, imperfect as it is, that
	is not the America of today. The America of today means that,
	if a young child has asthma, that family can in fact find a way
	to get an equal policy of healthcare just like their neighbor
	who doesn't have a family member with a preexisting condition.
	So with that, I would like to, with the short balance of my
	time, ask Ms. Hung, could you please expand on the uncertainty
	that you have already described that your family would face
	should this court decision end the Affordable Care Act as we
	know it?
	And then also could you please share with us, are you
	speaking only for you and your family or is this something that
	perhaps hundreds of thousands if not more American families
	would suffer that fate that you are describing?
	Ms. Hung. Thank you. I am here on behalf of many families
	like mine. The Little Lobbyists families are families with----
	Mr. Cardenas. Dozens or thousands?
	Ms. Hung. Thousands, across the country, families with
	children with complex medical needs and disabilities. And these
	protections that we are talking about today, they are not just
	for these children. They are for everyone. They are for
	everybody. Any one of us could suddenly become sick or disabled
	with no notice whatsoever. Any one of us could go suddenly from
	healthy to unhealthy with no notice and have a preexisting
	condition. An accident could happen, a cancer diagnosis, a sick
	child.
	There is no shame in being sick. There is no shame in being
	disabled. Let us not penalize that. There is no shame in
	Xiomara needing a ventilator to breathe or needing a wheelchair
	to go to the playground.
	But there is shame in allowing insurance companies to
	charge her more money just because of it, more for her care,
	and there is shame in allowing families like mine to file for
	bankruptcy because we can't afford to care for our children.
	It is that uncertainty that is being taken away or at risk
	right now. Our families are constantly thinking about that
	while we are at our children's bedside.
	Mr. Cardenas. I just want to state with the balance of my
	time that this court case could be the most destructive thing
	that could have ever happened in American history when it comes
	to the life and well-being of American citizens.
	I yield back the balance of my time.
	Ms. Eshoo. I thank the gentleman.
	I now would like to recognize my friend from Florida, Mr.
	Bilirakis.
	Mr. Bilirakis. Thank you, Madam Chair, and congratulations
	on chairing the best subcommittee in Congress, that's for
	sure--the most important.
	Ms. Eshoo. Oh, thank you.
	Mr. Bilirakis. Mr. Miller, the Texas court decision hinges
	on the individual mandate being reduced to zero in the law. Can
	you explain the court's reasoning in their decision?
	Mr. Miller. Well, I mean, we have to go back to a lot of
	convoluted reasoning in prior decisions in order to get there.
	So this is a legacy of trying to save the Affordable Care Act
	by any means possible, and it gets you into a little bit of a
	bizarre world.
	But if you take the previous opinions at their face--it was
	somewhat of a majority of one by Chief Justice Roberts--he
	basically saved the ACA, which otherwise would have gone down
	before any of this was implemented, by having a construction
	which said, ``I found out it is a tax after all,'' and he had
	three elements as to what that tax was.
	The problem is, once you put the percentage at zero and the
	dollar amount at zero, it is not a tax anymore. It is not
	bringing in revenue. You don't pay for it in the year you file
	your taxes. It is not calculated the way taxes are.
	So that previous construction, if you just look in a
	literal way at the law, doesn't hold anymore. What we do about
	it is another issue beyond that. But on the merits, we have got
	a constitutional problem, and in that sense that court decision
	was accurate. People then say, ``Where do you go next?,'' and
	that is the mess we are in.
	Mr. Bilirakis. Yes. Could legislation be passed that would
	address the court's concern, such as reimposing the individual
	mandate?
	Mr. Miller. All kinds of legislation. You are open for
	business every day, but sometimes business doesn't get
	conducted successfully. There are a wide range of things that I
	can imagine and you can imagine that would deal with this in
	either direction.
	You have to pass something. What we are doing is we are
	passing the buck. We are trying to uphold some odd contraption,
	which is the only one we have got, as opposed to taking some
	new votes and saying, ``What are you in favor of and what are
	you against?'' and be accountable for it and build a better
	system.
	Mr. Bilirakis. Thank you.
	Mr. Roy, you have written extensively on how to build a
	better healthcare system. The goal of the individual mandate,
	when the Democrats--now the majority party--passed the ACA, was
	to create a penalty to really force people to buy insurance.
	Are there alternative ways to provide high-quality
	insurance at low prices without a punitive individual mandate?
	Mr. Roy. Absolutely. So, as we have discussed already and I
	know you haven't necessarily been here for some of that
	discussion, simply the fact that there is a limited open
	enrollment period in the ACA prevents the gaming of jumping in
	and out of the system, and that is a standard practice with
	employer-based insurance. It is a standard practice in the
	private sector parts of Medicare. That is a key element.
	Another key element is to reform the age bands--the 3-to-1
	age bands in the ACA--because that actually is the primary
	driver of healthy and particularly younger people dropping out
	of the market.
	Another key piece is to actually lower, of course, the
	underlying cost of healthcare so that premiums will go down and
	making sure that the structure of the financial assistance that
	you provide to lower-income people actually matches up with the
	premium costs that are affordable to them.
	And a big part of it is, again, making the insurance
	product a little bit more flexible so plans have the room to
	innovate and make insurance coverage less expensive than it is
	today.
	Mr. Bilirakis. All right. Thank you very much.
	I yield back, Madam Chair, the rest of my time.
	Ms. Eshoo. Thank you, Mr. Bilirakis.
	I now would like to recognize the gentleman from Oregon,
	Mr. Schrader.
	Mr. Schrader. Thank you, Madam Chair. I appreciate that.
	I think sometimes we forget that the ACA was a response to
	a bipartisan concern about the construction of the healthcare
	marketplace prior to the ACA.
	It was a pretty universal opinion, not a partisan issue,
	that healthcare costs were completely out of control. Whether
	you were upper middle class or low income or extremely wealthy,
	it was unsustainable.
	And the ACA may not be perfect but, as pointed out at the
	hearings, it gave millions of Americans healthcare that didn't
	have it before. It started to begin the discussion that we are
	talking about here: How do you create universal access in an
	affordable way to every American?
	Certainly, I am one of the folks that believe healthcare is
	a right, not a privilege, in the greatest country in the world.
	We are discussing about different ways to get at it.
	I think one of the most important things that doesn't get
	talked about a lot is the importance of the essential health
	benefits. It gets demonized because, well, geez, ``I am not a
	woman so I shouldn't have to pay for maternity. You know, I am
	invincible. I am never really going to get sick, so I don't
	need to pay for, you know, emergency healthcare.''
	Those things are ancillary. I guess, Ms. Young, talk to us
	a little bit about why the essential health benefits are part
	of the Affordable Care Act, and there have been some attempts
	by the administration and different Members not, I think,
	realizing how important they are with these often, you know,
	cheaper plans. Just get the cost down--they are ignoring maybe
	the health aspects of that. Could you talk a little bit about
	that?
	Ms. Young. Absolutely.
	Prior to the Affordable Care Act, insurers could choose
	what benefits they were going to place in their benefit
	policies.
	The Affordable Care Act essential health benefit
	requirements require that all insurers in the individual and
	small group markets cover a core set of 10 benefits--things
	like hospitalizations and doctors visits as well as maternity
	care, mental health and substance use disorder, prescription
	drugs, outpatient services.
	So, really, ensuring that the insurance that people are
	buying offers a robust set of benefits that provides them
	meaningful protection if they get sick.
	If you return to a universe where an issuer can choose what
	benefits they are going to put inside of a policy, you could
	have an insurance benefit that, for example, excludes coverage
	for cancer services and another policy that excludes coverage
	for mental health needs, and one that excludes coverage for a
	particular kind of drug.
	Mr. Schrader. And that might be in the fine print and
	people may not realize that as they sign up for policies.
	Ms. Young. That is correct, yes. So it would require
	consumers to really pile through the insurance--different
	policies to understand what they were buying.
	It also provides a back-door path to underwriting because
	insurers, for example, that exclude coverage for cancer from
	their benefit won't attract any consumers who have a history of
	cancer, who have reason to believe that they may need cancer
	coverage.
	And so it really takes our insurance market from one that
	successfully pools together the healthy and the sick to one
	that becomes more fragmented.
	Mr. Schrader. Right. Well, and another piece of the
	Affordable Care Act that gets overlooked--and, again, it has
	been alluded to by different Members and some of you on the
	panel--is the innovation, the flexibility--I mean, the Center
	for Medical Innovation, the accountable care organizations.
	Instead of--you know, it seems to me we are focused just on
	cost: How do I itemize this cost? We ask you guys these
	questions--the rate bands and all that stuff. We should be
	concerned about healthcare.
	I mean, the goal here is to provide better health. It's not
	to support the insurance industry or my veterinary office or
	whoever. The goal is to provide better healthcare, and the way
	you do that is by, I think, you know, having the experts in
	different communities figure out what is the best healthcare
	delivery system.
	Do you need more dentists in one community? Need more
	mental health experts in another community?
	I am very concerned that, if the Affordable Care Act is
	undone, that a lot of this innovation that has been spawned,
	the accountable care organizations that are going, would begin
	to dissolve. There would be no framework for them to operate
	in.
	Just recently in Oregon, where I come from, we had a record
	number of organizations step up to participate in what we call
	our coordinated care organizations that deal with the Medicaid
	population and have over 24 different organizations vying for
	that book of business.
	Could you talk just real briefly--I am sorry, timewise--
	real briefly about, you know, what would happen if those all
	went away?
	Ms. Young. As you note, the Affordable Care Act introduced
	a number of reforms and how Medicare pays to incentivize more
	value-based and coordinated care.
	If the district court's decision were to be upheld, then
	the legislative basis for some of those programs would
	disappear and there would really be chaos in Medicare payment
	if that decision were upheld.
	Mr. Schrader. OK. Thank you, and I yield back, Madam Chair.
	Ms. Eshoo. I thank the gentleman.
	I can't help but think that this was a very important
	exchange in your expressed viewpoints and counterpoint to Mr.
	Miller's description of the ACA as an odd contraption.
	I now would like to----
	Mr. Miller. I would respond on that if I had the
	opportunity.
	Ms. Eshoo. I am sure you would.
	Let us see, who is next? Now I would like to recognize Mr.
	Carter from Georgia.
	Mr. Carter. Well, thank you, and thank all of you for being
	here. Very, very interesting subject matter that we have as our
	first hearing of the year. I find it very interesting.
	Mr. Miller, let me ask you, just to reiterate and make sure
	I understand. I am not a lawyer. I am a pharmacist, so I
	don't----
	Mr. Miller. Good for you.
	Mr. Carter. Yes. I don't know much about law or lawyers
	and----
	Mr. Miller. It is a dangerous weapon.
	Mr. Carter. Well, let me ask you something. Right now, this
	court case, how many patients is it impacting?
	Mr. Miller. Well, people hypothetically might react
	thinking it is real, but otherwise, nobody.
	Mr. Carter. But it is my understanding it is still in
	litigation.
	Mr. Miller. Correct. Correct. And it is going to take a
	while, and it is going to end up differently than where it
	starts. But we are doing this, you know, make believe because
	it scores a lot of points.
	Mr. Carter. Well, I--make believe--I mean, we are in
	Congress. We are not supposed to be make believe.
	Mr. Miller. Well----
	Mr. Carter. I mean, I am trying to understand why this is
	the first hearing, when it is not impacting a single patient at
	this time, it is still in litigation, we don't know how it is
	going to turn out, we don't know how long it is going to take.
	Judging by other court cases that we have seen, it may take a
	long, long time.
	Mr. Miller. Well, to be fair, I used to run hearings in
	Congress on staff.
	Mr. Carter. Well----
	Mr. Miller. The majority can run any kind of hearing it
	wants to.
	Mr. Carter [continuing]. We are not here to be fair. So
	anyway, I am trying to figure out why this is the first
	hearing. I mean, you know, earlier the chairman of the full
	committee berates our Republican leader because he asked for a
	hearing on something that he is opposed to and that I am
	opposed to, and I am just trying to figure it out.
	You know, one of the things that we do agree on is that
	preexisting conditions need to be covered. Isn't it possible
	for us to still be working on preexisting conditions now and
	legislating preexisting conditions while this is under
	litigation?
	Mr. Miller. What you need are majorities who are willing to
	either spend money----
	Mr. Carter. Well----
	Mr. Miller [continuing]. Change rules and move things
	around. But that has been hard for Congress to do.
	Mr. Carter. Well, I think that the record will show that,
	you know, one of the first bills that we proposed in the
	Republican Party, in the Republican conference, was for
	preexisting conditions--Chairman Walden. In fact, I know he did
	because I cosponsored it.
	Mr. Miller. Mm-hmm. Yes. It was one of the more thorough
	ones, actually.
	Mr. Carter. It is something that--we have concentrated on
	that. So thank you for that. I just want to make sure.
	Mr. Roy, I want to ask you, did you testify before the
	Oversight Committee recently?
	Mr. Roy. Last week, yes.
	Mr. Carter. What were they talking about in the Oversight
	Committee? What were you testifying about?
	Mr. Roy. Prescription drug prices. The high cost of
	prescription drugs.
	Mr. Carter. Prescription drugs. Go figure. Here we are in
	the committee and the subcommittee with the most jurisdiction
	over healthcare issues, and Oversight has already addressed
	prescription drug pricing?
	Mr. Roy. Well, you have 2 years in this committee, and I
	look forward to hopefully being invited to talk----
	Mr. Carter. Well, I do too. I am just baffled by the fact
	that, you know, drug pricing is one of the issues--is the issue
	that most citizens when polled identify as being something that
	Congress needs to be active on, and I am just trying to figure
	out. In Oversight they have already addressed it.
	Mr. Roy. You know, one thing I will say about this topic,
	Mr. Carter, is that it is one of the real opportunities for
	bipartisan policy in this Congress. We have a Republican
	administration and a Democratic House where there has been a
	lot of interest in reducing the cost of prescription drugs, and
	I am optimistic that we really have an opportunity here to get
	legislation through Congress.
	Mr. Carter. And I thank you for bringing that up because
	Representative Schrader and I have already cosponsored a bill
	to stop what I think is the gaming of the system of the generic
	manufacturers and the brand-name manufacturers of what they are
	doing in delaying generic products to get onto the market.
	So, Madam Chair, I am just wondering when are we going to
	have----
	Ms. Eshoo. Gentleman yield? Would the gentleman yield?
	Mr. Carter. And if I could ask a question.
	Ms. Eshoo. Mm-hmm.
	Mr. Carter. When are we going to have a hearing on
	prescription drug costs?
	Ms. Eshoo. I can't give you the date. But it is one of the
	top priorities of the majority. It is one of the issues that we
	ran on with the promise to lower prescription drug prices. I
	believe that there is a bipartisan appetite for this, and we
	will have hearings and we will address it and we welcome your
	participation.
	Mr. Carter. Well, reclaiming my time. I appreciate that
	very much, Madam Chair, because it is a pressing issue and it
	is an issue that needs to be addressed now and today, unlike
	what we are discussing here today that is not impacting one
	single person at this point.
	So, you know, with all due respect, Madam Chair, I hope
	that we can get to prescription drug pricing ASAP because it is
	something that we need to be and that we are working on.
	And, Mr. Roy, you could not be more correct. This is a
	bipartisan issue. I practiced pharmacy for over 30 years. Never
	did I once see someone say, ``Oh, this is the price for the
	Democrat, this is the price for the Republican, this is the
	price for this person and that person.'' It was always the
	same. It was always high. That is why we need to be addressing
	this.
	So I thank you for being here. I thank all of you for being
	here and, Madam Chair, I yield back.
	Ms. Eshoo. I thank the gentleman.
	I now would like to recognize a new member of the
	subcommittee, Ms. Barragan from California. Welcome.
	Ms. Barragan. I thank you. Thank you, Ms. Chairwoman.
	My friend from Georgia asked why we are having this as the
	first hearing, and I just have to say something because, you
	know, I am in my second term, and in my first term when the
	Republicans were in the majority they spent all of their time
	trying to take away healthcare coverage for millions of
	Americans.
	They talk about preexisting conditions and talk about
	saving people with preexisting conditions. But this very
	lawsuit is going to put those people at stake.
	So why are we having this hearing? Well, because you guys
	have been working to take away these coverages and we are
	trying to highlight the importance of this lawsuit.
	Now, you had 2 years and, yes, you could have started with
	prescription drug prices and reducing those, and that wasn't
	done. So you are darn right the Democrats are going to take it
	up.
	You are darn right that we are going to have hearings on
	this, and I am proud to say that our chairwoman and our
	chairman have been working hard to make sure we are going to
	work to bring down prescription drug prices. But the hypocrisy
	that I hear on the other side of the aisle can't just go
	completely unanswered in silence.
	So, with that said, I am going to move on to what my
	comments have been. I want to thank you all for your testimony
	here today. It has been really helpful to hear us understand
	the potentially devastating impact of this lawsuit and of the
	district court's decision.
	The court's decision would not only eliminate protections
	for preexisting conditions but would also adversely impact the
	Medicaid program and end the Medicaid expansion.
	Now, the Affordable Care Act's expansion of Medicaid filled
	a major gap in insurance coverage and resulted in 13 million
	more Americans having access to care.
	I represent a district that is a majority minority--about
	88 percent black and brown people of color and, you know, black
	and brown Americans still have some of the highest uninsured
	rates in the country. Both groups have seen their uninsured
	numbers fall dramatically with the ACA. You know, between 2013
	and 2016, more than 4 million Latinos and 1.9 million blacks
	have secured affordable health coverage. Ultimately, black and
	brown Americans have benefitted the most from the ACA's
	Medicaid expansion program.
	Ms. Young, I would like to ask, can you briefly summarize
	the impact of the lawsuit on Medicaid beneficiaries and, in
	particular, the expansion population?
	Ms. Young. Medicaid expansion is, as you note, a very
	important part of the Affordable Care Act's coverage expansion,
	and it is benefitting millions of people in the 37 States that
	have expanded or are in the process of expanding this year.
	Medicaid expansion has been associated with better
	financial security, and failure to expand is associated with
	higher rates of rural hospital closures and other difficult
	impacts in communities.
	If this decision were to be upheld, then the Federal
	funding for Medicaid expansion would no longer be provided and
	States would only be able to receive their normal match rate
	for covering the population that is currently covered through
	expansion. That is an impact of billions of dollars across the
	country and a very large impact in individual States.
	States will have the choice between somehow finding State
	money to make up that gap or ending the expansion and removing
	those people from the Medicaid rolls or potentially cutting
	provider rates or making other changes in the benefit package
	or some combination.
	So you are looking at a potentially loss of--see very
	significant losses of coverage in that group as well as an
	additional squeeze on providers.
	Ms. Barragan. Thank you.
	Ms. Hung, how has Medicaid helped your family afford
	treatment, and why is Medicaid and Medicaid expansion so
	important for children with complex medical needs and their
	families?
	Ms. Hung. Medicaid is a lifesaving program. I say this
	without exaggeration. Medicaid is the difference between life
	and death. It covers what health insurance doesn't cover for a
	lot of children with complex medical needs.
	Notably, it covers long-term services and supports,
	including home and community-based services that enable
	children's independence. For a lot of families who do have
	health insurance like mine, health insurance doesn't really
	cover certain DME--durable medical equipment--certain
	specialists, the ability to go out of State.
	And so that is the difference for a lot of our families.
	Ms. Barragan. Great. Well, thank you all. I yield back.
	Ms. Eshoo. Thank you very much.
	Now, the patient gentleman from Montana, Mr. Gianforte.
	Mr. Gianforte. Thank you, Madam Chair, and thank you to the
	panelists for your testimony today.
	Every day, I hear from Montanans who ask me why their
	healthcare costs keep going up and continue to increase while
	their coverage seems to shrink at the same time.
	While we look for long-term solutions to make healthcare
	costs more affordable and accessible, I remain firmly committed
	to protecting those with preexisting conditions.
	In fact, I don't know anyone on this committee, Republican
	or Democrat, who doesn't want to protect patients with
	preexisting conditions. Insuring Americans with preexisting
	conditions can keep their health insurance and access care is
	not controversial.
	It shouldn't be. We all agree on it. Which brings us to
	today. In the ruling in Texas v. Azar, it has not ended
	Obamacare. It hasn't stripped coverage of preexisting
	conditions, and it hasn't impacted 2019 premiums.
	While we sit here today talking about it, the Speaker has
	moved to intervene in the case and the judge ruling has been
	appealed. The case is working itself through the courts.
	We could have settled this with a legislative solution less
	than a month ago. One of the earliest votes we took in this
	Congress was to lock in protection for patients with
	preexisting conditions.
	Unfortunately, Democrats rejected that measure. And yet,
	here we are in full political theater talking about something
	we all agree on--protecting Americans with preexisting
	conditions.
	We should be focused instead on the rising cost of
	prescription drugs, telehealth, rural access to healthcare, and
	other measures to make healthcare more affordable and
	accessible.
	I hope this committee will hold hearings and take action on
	these issues important to hardworking Montanans. I can
	understand, however, why my friends on the other side of the
	aisle do not want to take that path.
	Some of their party's rising stars and others jockeying for
	Democratic nomination in 2020 have said we should do away with
	private insurance. They advocate for a so-called Medicare for
	All. In reality, Medicare for none.
	Their plan would gut Medicare and the VA as we know it, and
	force 225,000 Montanan seniors who rely on Medicare to the back
	of the line. Montana seniors have earned these benefits, and
	lawmakers shouldn't undermine Medicare and threaten healthcare
	coverage for Montana seniors.
	Since we all agree we should protect patients with
	preexisting conditions, let us discuss our different ideas for
	making healthcare more affordable and accessible.
	We should put forward our ideas: on the one hand, Medicare
	for All, a Government-run single-payer healthcare system that
	ends employer-sponsored health plans; on the other, a health
	insurance system that protects patients with preexisting
	conditions, increases transparency, choice, and preserves rural
	access to care and lowers cost.
	I look forward to a constructive conversation about our
	diverging approaches to fixing our healthcare system. In the
	meantime, I would like to direct a question to Mr. Miller, if I
	could.
	Under Medicare for All, Mr. Miller, do you envision access
	to care would be affected for seniors and those with
	preexisting conditions in rural areas in particular?
	Mr. Miller. Well, that is a particular aspect. I think, in
	general, the world that seniors are currently used to would be
	downgraded. You are taking--spreading the money a little wider
	and thinner in order to help some. This is the story of the
	ACA.
	We can create winners, but we will also create losers. Now,
	the politics as to who you favor sort out differently in
	different folks. It is hard to get a balancing act where
	everybody comes out on top unless you make some harder
	decisions, which is to set priorities and understand where you
	need to subsidize and what you need to do to improve care and
	the health of people before they get sick.
	Mr. Gianforte. So it is your belief that, if this Congress
	were to adopt a Medicare for All approach, seniors would be
	disadvantaged? It will be more difficult to access care?
	Mr. Miller. They would be the first to be disadvantaged, as
	well as those with employer-based coverage because--if you
	swallowed it whole. I mean, there are lots of other problems
	Avik mentioned. It is not just the spending. It is actually the
	inefficiency of the tax extraction costs.
	When you run that much money through the Government, you
	don't get what you think comes out of it.
	Mr. Gianforte. One other topic, quickly, if I could.
	Telehealth is very important in rural areas. It is really vital
	to patients in Montana. How do you foresee telehealth services
	being affected under a single-payer system?
	Mr. Miller. Well, Medicare has probably not been in the
	forefront of promoting telehealth. I think there is a lot more
	buzz about telehealth as a way to break down geographical
	barriers to care, to have more competitive markets.
	And so, if past history is any guide of Medicare fee-for-
	service, it is not as welcoming to telehealth as private
	insurance would be.
	Mr. Gianforte. OK. And I yield back.
	Ms. Eshoo. I thank the gentleman.
	I now would like to recognize the gentleman from Vermont,
	Mr. Welch.
	Mr. Welch. Thank you. I will be brief. Just a few comments.
	I think it is important that we had this hearing. This did
	not come out of thin air. I mean, I was on the committee when
	we wrote the Affordable Care Act. Very contentious. It was a
	party-line vote.
	I was on the committee when we repealed it--this committee
	repealed the Affordable Care Act, and we never saw a bill. We
	never had a hearing.
	And now we have a continuation of this effort by the
	Republican attorneys general to attack it, and we have the
	unusual decision by the administration where, instead of
	defending a Federal law, they are opposing a Federal law.
	So it is why I have been continuing to get so many letters
	from Vermonters who are fearful that this access to healthcare
	that they have is really in jeopardy.
	Loretta Heimbecker from Montgomery has a 21-year-old son
	who is making $11.50 an hour. He has got a medical condition
	from birth, and absent the access to healthcare he wouldn't be
	able to work and the mother would probably be broke.
	I have got a cancer patient, Kathleen Voigt Walsh from
	Jericho, who would not have access to the treatment she needs
	absent this. I mean, Ms. Hung, you really, in your own personal
	presentation, have explained why people who really need it
	would be scared if we lost it.
	And I also served in Congress when the essential agenda on
	the Republican side was to try to repeal it. I mean, it was a
	pretty weird place to be--Congress--when on a Friday afternoon,
	if there is nothing else to do, we would put a bill on the
	floor to repeal healthcare for the sixtieth time. I mean, we
	are just banging our head against the wall.
	So thank you for having this hearing because I see it as a
	reassurance to a lot of people I represent that we mean
	business--that we are going to defend what we have.
	Now, second, on some of the criticisms about this not being
	a hearing on prescription drugs, Mr. Roy, you were in--did a
	great job helping us start the process in Oversight and
	Government Reform.
	But I know our chair of this subcommittee--this is the
	committee where there is actual jurisdiction--is totally
	committed to pursuing this, and I thank our chair.
	And I have been hearing very good things from President
	Trump about the need to do this. So my hope is that we are
	going to get a lot of Republican support to do practical things
	so we are not getting ripped off, as the president has said, by
	us paying the whole cost of research--a lot of it, by the way,
	from taxpayers, not necessarily from the companies--and have to
	pay the highest prices.
	So I am commenting and not asking questions. But I know
	that there has been extensive and excellent testimony. But I
	just want to say to the chair and I want to say to my
	colleagues, Republican and Democrat, if the net effect of this
	hearing is that we are affirming a bipartisan commitment not to
	mess with the Affordable Care Act, then I am going to be able
	to reassure my constituents that their healthcare is safe.
	And if the criticism is essentially we have got to do more,
	we are ready to do more, right?
	Madam Chair, so I thank you for this hearing, and I thank
	the witnesses for their excellent testimony and look forward to
	more down the line.
	Ms. Eshoo. I thank the gentleman for his comments and his
	enrichment of the work at this subcommittee. I think it is
	important to note that, on the very first day of this Congress,
	that House Democrats voted to intervene in this case--the very
	first day of the Congress--as it moves through appeal.
	So we are the ones that are representing the Government,
	and I think that, for my colleagues on the other side of the
	aisle, you may not like my suggestion, but if you are for all
	of these things that you are talking about, write to the
	attorneys general and the Governors that brought the suit and
	say, ``We want it called off. We want to move on and strengthen
	the healthcare system in our country.'' You will find a partner
	in every single person on this side of the aisle.
	With that, I would like to recognize Mr. O'Halleran--what
	State?
	Mr. Burgess. Arizona.
	Ms. Eshoo. Arizona--from the great State of Arizona--who
	is, I believe, waiving on to the subcommittee, and we have a
	wonderful rule in the full committee that, if you are not a
	member of a subcommittee you can still come and participate.
	But you are the last one to be called on. So thank you for your
	patience, and thank you for caring and showing up.
	Mr. O'Halleran. I thank you, Madam Chair. I am also usually
	last in my house also to be called on.
	Thank you, Madam Chair. Although I am not a permanent
	member of the subcommittee, I appreciate your invitation for me
	to join you today to discuss this issue that is so critical to
	families across Arizona, and thank you to the witnesses.
	As some of you know, the district I represent is extremely
	large and diverse--the size of Pennsylvania. Twelve federally
	recognized Tribes are in my district.
	Since I came to Congress 2 years ago, I have been focused
	on working across the aisle to solve healthcare issues. We face
	these issues together because it is one thing that I hear about
	every single corner of my rural district and one of the
	overriding issues in Congress.
	A district where hospitals and the jobs they provide are
	barely hanging on and where decades of toxic legacy of uranium
	mining has left thousands with exposure-related cancers across
	Indian country.
	A district where Medicaid expansion made the difference for
	some veterans getting coverage, some hospitals keeping their
	doors open, where essential health benefits meant some
	struggling with opiate addiction could finally get substance
	abuse treatment.
	I am here because the lawsuit we are discussing today isn't
	about any of those policies and how they save taxpayer dollars
	and protect rural jobs. I am a former Republican State
	legislator. I know that this lawsuit is purely motivated not by
	what is best for the people we are representing but by
	politics.
	Ms. Young, I have three questions for you. The first is,
	the first letter I ever sent as a Member of Congress was a
	bipartisan letter to congressional leadership about dangers of
	ACA repeal on the Indian Health Care Improvement Act, which was
	included in the ACA.
	Madam Chair, I ask unanimous consent to enter my letter
	into the record.
	Ms. Eshoo. So ordered.
	[The information appears at the conclusion of the hearing.]
	Mr. O'Halleran. Ms. Young, can you describe what the fate
	of this law would be if this lawsuit succeeds and what it means
	for Tribal communities?
	Ms. Young. The district court's opinion as written struck
	down the entire Affordable Care Act so it would--even unrelated
	provisions like the Indian Health Care Improvement Act--so, if
	the decision were upheld, then the Indian Health Care
	Improvement Act would no longer have the force of law and the
	improvements included in that law, like better integration with
	the Veterans Health Service and better integration for
	behavioral health and other core benefits for the Indian Health
	Service, would be eliminated.
	Mr. O'Halleran. Thank you, Ms. Young.
	Are cancers caused by uranium exposure considered a
	preexisting condition?
	Ms. Young. I suspect that under most medical underwriting
	screens they would be, yes.
	Mr. O'Halleran. Thank you. And, Ms. Young, over 120 rural
	hospitals have closed since 2005. Right now, 673 additional
	facilities are vulnerable and could close. That is more than a
	third of rural hospitals in the United States.
	If this lawsuit succeeds, do you anticipate rural hospitals
	and the jobs they provide would be endangered as a result of
	fewer people having health coverage?
	Ms. Young. As you know, rural hospitals face a number of
	challenges and a number of difficult pressures. There has been
	research demonstrating that a State's failure to expand
	Medicaid is associated with higher rates of rural hospital
	closures. And so, if the Federal funding for Medicaid expansion
	were removed, then it is likely that that would place
	additional stress on rural hospitals.
	Mr. O'Halleran. Thank you.
	Madam Chair, this is why last year I led the fight to urge
	my State's attorney general to drop this partisan lawsuit. So
	much is at stake in Arizona for veterans, the Tribes, for jobs
	in rural communities like mine.
	I am interested in finding bipartisan solutions to the
	problems we have got, and I will work with anyone here to do
	that. But this lawsuit doesn't take us in that direction. It
	takes us back, and my district can't afford that.
	Thank you, and I yield back.
	Ms. Eshoo. I thank the gentleman for making the time to be
	here and to not only make his statement but ask the excellent
	questions that you have.
	At this time I want to remind members that, pursuant to the
	committee rules, they have 10 business days to submit
	additional information or questions for the record to be
	answered----
	Mr. Burgess. Madam Chair?
	Ms. Eshoo. Yes.
	Mr. Burgess. Could I seek recognition for a unanimous
	consent request?
	Ms. Eshoo. Sure. Just a minute. Let me just finish this,
	all right?
	I want to remind Members that, pursuant to committee rules,
	Members have 10 business days to submit additional questions
	for the record to be answered by the witnesses who have
	appeared, and I ask each of the witnesses to respond promptly
	to any such questions, and I see your heads nodding, so I am
	comforted by that, that these questions that you may receive.
	And I would recognize the ranking member, and I also have a
	list of--to request unanimous consent for the record.
	Mr. Burgess. Oh, I can go after you.
	Ms. Eshoo. OK. The first, a statement for the record from
	the American Cancer Society Cancer Action Network and 33 other
	patient and consumer advocacy organizations; a statement for
	the record from the American Academy of Family Physicians; a
	statement for the record from the American College of
	Physicians; the Wall Street Journal editorial entitled ``Texas
	Obamacare Blunder.'' I think that was referenced by Mr. Lazarus
	earlier today.
	Jonathan Adler and Abbe Gluck, New York Times op-ed
	entitled ``What the Lawless Obamacare Ruling Means''; a brief
	of the amicus curiae from the American Medical Association, the
	American Academy of Family Physicians, the American College of
	Physicians, the American Academy of Pediatrics, and the
	American Academy of Child and Adolescent Psychiatry.
	Isn't it extraordinary what we have in this country? Just
	the listing of these organizations.
	The U.S.A. Community Catalyst, the National Health Law
	Program, Center for Public Policy Priorities, and Center on
	Budget and Policy Priorities; the brief of the amici curiae
	from the American Cancer Society, the Cancer Action Network,
	the American Diabetes Association, the American Heart
	Association, the American Lung Association, and National
	Multiple Sclerosis Society supporting defendants; and a
	statement for the record from America's Health Insurance Plans.
	So I am asking a unanimous consent request to enter the
	following items in the record. I hear no objections, and I will
	call on--recognize the ranking member.
	[The information appears at the conclusion of the
	hearing.]\1\
	---------------------------------------------------------------------------
	\1\ The amici briefs have been retained in committee files and also
	are available at https://docs.house.gov/Committee/Calendar/
	ByEvent.aspx?EventID=108843..
	---------------------------------------------------------------------------
	Mr. Burgess. Thank you. First off, thank you for reminding
	me why I have not yet paid my AMA dues this year.
	[Laughter.]
	Mr. Burgess. I have a unanimous consent request. I would
	ask unanimous consent to place into the record the letter that
	was sent by Mr. Walden and myself regarding the Medicare for
	All hearing.
	Ms. Eshoo. No objection.
	[The information appears at the conclusion of the hearing.]
	Ms. Eshoo. The only request that I would make is that maybe
	on your email mailing list that, when you notify the chairman
	of the full committee, that maybe my office can be notified as
	well.
	Mr. Burgess. Welcome to the world that I inhabited 2 years
	ago.
	Ms. Eshoo. That's why I think you will understand.
	Mr. Burgess. I never found out until after the fact.
	Ms. Eshoo. Right. Right.
	Mr. Burgess. But I would take that up with your full
	committee chair. I am sure they will recognize the importance
	of including you in the email distribution list.
	Ms. Eshoo. I thank the gentleman.
	Let me just thank the witnesses. You have been here for
	almost 3 hours. We thank you for not only traveling to be here
	but for the work that you do that brings you here as witnesses.
	Mr. Lazarus says he is retired, but he brings with him
	decades of experience. We appreciate it. To each witness,
	whether you are a majority or minority witness, we thank you,
	and do get a prompt reply to the questions because Members
	really benefit for that.
	So our collective thanks to you, and to Ms. Hung, what a
	beautiful mother. You brought it all. I am glad that you are
	sitting in the center of the table, because you centered it all
	with your comments.
	So with that, I will adjourn this subcommittee's hearing
	today.
	Thank you.
	[Whereupon, at 1:03 p.m., the committee was adjourned.]
	[Material submitted for inclusion in the record follows:]
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