[Senate Hearing 111-1041]
[From the U.S. Government Publishing Office]



                                                       S. Hrg. 111-1041
 
           WHAT WOMEN WANT: EQUAL BENEFITS FOR EQUAL PREMIUMS

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



                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,

                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                                   ON

   EXAMINING EQUAL HEALTH CARE FOR EQUAL PREMIUMS, FOCUSING ON WOMEN

                               __________

                            OCTOBER 15, 2009

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions


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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                       TOM HARKIN, Iowa, Chairman

CHRISTOPHER J. DODD, Connecticut
BARBARA A. MIKULSKI, Maryland
JEFF BINGAMAN, New Mexico
PATTY MURRAY, Washington
JACK REED, Rhode Island
BERNARD SANDERS (I), Vermont
SHERROD BROWN, Ohio
ROBERT P. CASEY, JR., Pennsylvania
KAY R. HAGAN, North Carolina
JEFF MERKLEY, Oregon
AL FRANKEN, Minnesota
MICHAEL F. BENNET, Colorado

                                     MICHAEL B. ENZI, Wyoming
                                     JUDD GREGG, New Hampshire
                                     LAMAR ALEXANDER, Tennessee
                                     RICHARD BURR, North Carolina
                                     JOHNNY ISAKSON, Georgia
                                     JOHN McCAIN, Arizona
                                     ORRIN G. HATCH, Utah
                                     LISA MURKOWSKI, Alaska
                                     TOM COBURN, M.D., Oklahoma
                                     PAT ROBERTS, Kansas
                                       
                                       

           J. Michael Myers, Staff Director and Chief Counsel

     Frank Macchiarola, Republican Staff Director and Chief Counsel

                                  (ii)




                            C O N T E N T S

                               __________

                               STATEMENTS

                       THURSDAY, OCTOBER 15, 2009

                                                                   Page
Murray, Hon. Patty, a U.S. Senator from the State of Washington, 
  opening statement..............................................     1
    Prepared statement...........................................     2
Burr, Hon. Richard, a U.S. Senator from the State of North 
  Carolina.......................................................     3
Brown, Hon. Sherrod, a U.S. Senator from the State of Ohio.......     4
Casey, Hon. Robert P., Jr., a U.S. Senator from the State of 
  Pennsylvania...................................................     6
Franken, Hon. Al, a U.S. Senator from the State of Minnesota.....     7
    Prepared statement...........................................     8
Mikulski, Hon. Barbara A., a U.S. Senator from the State of 
  Maryland.......................................................    10
Hagan, Hon. Kay R., a U.S. Senator from the State of North 
  Carolina.......................................................    10
    Prepared statement...........................................    11
Guest, James, President and CEO, Consumers Union, Yonkers, NY....    15
    Prepared statement...........................................    17
Furchtgott-Roth, Diana, Senior Fellow, Hudson Institute, and 
  Director, Center for Employment Policy, Washington, DC.........    21
    Prepared statement...........................................    23
Crouse, Janice Shaw, Ph.D., Director and Senior Fellow, Concerned 
  Women for America, Washington, DC..............................    28
    Prepared statement...........................................    29
Greenberger, Marcia F., Founder and Co-President, National 
  Women's Law Center (NWLC), Washington, DC......................    33
    Prepared statement...........................................    35
Buchanan, Amanda, Patient/Health Care Consumer, Weiser, ID.......    45
    Prepared statement...........................................    47
Robertson, Peggy, Patient/Health Care Consumer, Centennial, CO...    48
    Prepared statement...........................................    49
Ignagni, Karen, President and CEO, America's Health Insurance 
  Plans (AHIP), Washington, DC...................................    50
    Prepared statement...........................................    51
Merkley, Hon. Jeff, a U.S. Senator from the State of Oregon......    57
Bennet, Hon. Michael F., a U.S. Senator from the State of 
  Colorado.......................................................    62

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Senator Enzi.................................................    71
    Washington Post article......................................    71
    Letters from:
        North Carolina Department of Insurance to Senator Burr...    72
        Consumers Union to Senator Mikulski......................    73
    Response to Question of Senator Merkley by Jim Guest.........    74

                                 (iii)



           WHAT WOMEN WANT: EQUAL BENEFITS FOR EQUAL PREMIUMS

                              ----------                              


                       THURSDAY, OCTOBER 15, 2009

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:33 a.m. in 
Room SD-430, Dirksen Senate Office Building, Hon. Barbara A. 
Mikulski, presiding.
    Present: Senators Mikulski, Murray, Brown, Casey, Hagan, 
Merkley, Bennet, Franken, and Burr.

                  Opening Statement of Senator Murray

    Senator Murray. This hearing will come to order. Senator 
Mikulski will be chairing this committee, but she is running 
late and asked me to go ahead and get it started, so we could 
get opening statements going. I just want to express my 
appreciation to Senator Mikulski and for all of our colleagues 
who are here today for this hearing, where we are going to be 
talking about a topic that impacts not only women, but families 
and entire communities.
    You know, when the rising cost of health insurance hits 
women, it hurts our Nation. For the millions of women across 
this country who open up the mail every month to see their 
premiums go up, or who cannot get the preventive care like 
mammograms because the co-pays are too high, or who work part-
time or for a small business that doesn't provide insurance, or 
can't get covered for maternity health care, or, worst of all, 
forced to stay in an abusive relationship because if they leave 
they or their children lose coverage, we really have to be the 
voice of those women.
    Today we are having this hearing to ask the questions that 
women and families and businesses across America are asking. 
Some of you in this room have heard me tell the story of a 
young boy I met by the name of Marcellas Owens from my home 
State--I met him back in the spring--who told me that he is 
watching me every day to see what we're going to do with this 
health care bill, because he has a very tragic story. His mom, 
whose name was Tiffany, got sick and, because she was sick, she 
lost days at work and her employer said: ``If you can't come to 
work, we're going to fire you.'' She worked for a fast food 
restaurant. She had three kids and had health coverage through 
that fast food restaurant.
    In September 2006, because she missed so much work, she 
lost her job, and with that she lost her health care coverage. 
When she lost her health care coverage, she could not go to the 
doctor any more, and as a result of that Tiffany lost her life.
    Marcellas, the little boy, told me last spring that he is 
going to be watching me to make sure that no other little boys 
lose their mom. That's what this health care debate is about, 
because our system really is broken. Women like Tiffany, across 
the country who are moms, shouldn't lose their health care 
because they are sick, and we need to make sure that this 
system works for them and for women who are denied coverage or 
charged more because of preexisting conditions, conditions like 
pregnancy or C-sections or domestic violence.
    Our system is broken when insurance companies charge women 
of child-bearing age more than men, but they don't cover the 
maternity care anyway, or only offer it for hefty additional 
premiums. Women and their families and businesses need health 
insurance reform and that's why we're working so hard on this.
    We know that health reform will help women by ending 
discrimination based on gender rating or gender-biased 
preexisting conditions, by covering maternity care, by covering 
preventive care and screenings, including mammograms and well-
baby care, by expanding access to coverage even if an employer 
doesn't offer it, and making family health decisions, which are 
frequently made by women, by setting up a health insurance 
exchange.
    There is a lot in the health care reform that is very 
important to women, and we're having this hearing today to talk 
about those issues in particular as we move forward on this.
    Again, Senator Mikulski will be joining us in just a few 
minutes, but I will turn to our colleagues for their opening 
statements and then, if she's not here, we'll turn to our 
witnesses to begin.
    [The prepared statement of Senator Murray follows:]

                  Prepared Statement of Senator Murray

    Thank you, Senator Mikulski, for holding this hearing.
    And thanks to all of our colleagues for attending to 
discuss a topic that impacts not only women, but families and 
entire communities.
    Because when the rising cost of health insurance hurts 
women, it hurts our Nation.
    And for the millions of women across America--

     who open the mail each month to see premiums go 
up,
     who can't get needed preventative care like 
mammograms because the co-pays are too much,
     who work part time or for a small business that 
doesn't provide insurance,
     who can't get covered for critical maternity care, 
or
     who are forced to stay in abusive relationships 
because if they leave, they or their children will lose health 
care coverage--we are their voice.

    And today we are asking the questions that women and 
families and businesses across America are asking.
    Many of you in this room have heard me tell the story of a 
little boy named Marcellas Owens from my home State of 
Washington whose mom, Tifanny, got sick and lost her life 
because of the high cost of health insurance.
    Tifanny was a single mom who felt strongly about working to 
support her three children. She had health care coverage 
through her job at a fast food restaurant. But, in September 
2006 she got sick and started to miss a lot of work.
    Her employer gave her an ultimatum: make up the lost time 
or lose your jobs. Well, because of her illness, Tifanny 
physically couldn't make up the time and she lost her job and 
with it went her insurance.
    As we have seen time and time again, women are charged 
nearly 50 percent more than men in the insurance market--and 
with a pre-existing condition it would be almost impossible to 
get coverage anyway.
    Without the coverage and care she needed, in June 2007, 
Tifanny lost her life and Marcellas and his sisters lost their 
mom.
    Our health care system is broken.
    It's broken for women and moms like Tifanny who work to 
provide for their families but are charged nearly 50 percent 
more than men for health care in the individual market.
    It's broken for women who are denied coverage or charged 
more for ``Pre-Existing Conditions'' like:

     ``Pregnancy,''
     ``C-Sections,'' or
     ``Domestic violence.''

    It's broken when insurance companies charge women of child-
bearing age more than men but still don't cover maternity care. 
Or only offer it for hefty additional premiums.
    The status quo isn't working.
    Women and their families and businesses need health 
insurance reform now.
    Reform will help women by:

     Ending discrimination based on gender-rating or 
gender-biased ``pre-existing conditions.''
     Covering maternity care.
     Covering preventative care and screenings--
including mammograms and well-baby care.
     Expanding access to coverage even if an employer 
doesn't offer it and making family health decisions--which are 
frequently made by women--easier by setting up a health 
insurance exchange.

    For women across this country, and for their families, our 
businesses, and our Nation's future strength, we have to reform 
our health insurance system this year.
    I want to thank Senator Mikulski again for her dedication 
to this issue and I look forward to hearing from all of today's 
witnesses.

    With that, Senator Burr, if you would like to make an 
opening statement.

                       Statement of Senator Burr

    Senator Burr. Thank you, Senator Murray. I want to thank 
you and Senator Mikulski for chairing this hearing this 
morning. I also want to thank our witnesses for their 
willingness to come in, to travel on a very messy day in 
Washington, DC, probably most of the country. It's a sure sign 
that the season's changing as they call for snow just 60 miles 
away from here.
    In many families women are the primary health care 
decisionmaker for their loved ones. I appreciate having the 
opportunity today to discuss more specifically how health care 
reform would impact women across North Carolina and, more 
importantly, across our country. Today's hearing will help us 
inform our continued work on health care reform.
    As I've told my constituents and colleagues many times in 
recent months and weeks, I agree that we need meaningful, 
meaningful health care reform. I was proud to join my Senate 
colleague Tom Coburn earlier this year when we introduced the 
first comprehensive legislation to fundamentally reform our 
health care system.
    The Patients' Choice Act is based on the principle of 
promoting universal access to quality and affordable health 
care for all. Our bill avoids a one-size-fits-all government-
run program, instead promoting choice for every American 
regardless of their income or employment, so that they can 
access a health plan that meets their income, their health 
needs, their conditions.
    The Patients' Choice Act restores the idea of portability 
to health coverage. If you move or change jobs, you don't lose 
your health insurance. And we create State insurance exchanges 
to give Americans a one-stop marketplace to compare different 
health insurance policies and the ability to select the one 
that meets their unique health needs.
    The Patients' Choice Act also moves our Nation away from 
our current health system that's been plagued by sick care for 
far too long, by promoting prevention, wellness, and chronic 
disease management. For example, we provide incentives for 
States to reduce rates of chronic disease like heart disease, 
the leading cause of death for both women and men in our 
Nation. And our legislation is sustainable for generations to 
come.
    I think another important element that should be part of 
this discussion is medical malpractice reform. If we care about 
making sure women have access to OB-GYNs, we cannot ignore the 
fact that high malpractice insurance is driving doctors out of 
this specialty and, even worse, closing their practices or 
forcing them to migrate to urban areas only.
    I hope this issue is part of the discussion today because 
it is the 800-pound gorilla in the room when it comes to access 
to affordable health care for women. Any serious piece of 
health care reform legislation must include these essential 
principles.
    I look forward to continuing to work with my colleagues on 
health reform to ensure that constituents across North Carolina 
and, more importantly, this country have access to quality and 
affordable health care.
    I thank the chair.
    Senator Murray. Thank you.
    Senator Brown.

                       Statement of Senator Brown

    Senator Brown. Thank you, Senator Murray, and thanks to 
Senator Mikulski for calling this hearing. Thank you all, the 
seven of you, for joining us today.
    There's been a lot of attention this year, as we know, to 
the need for health reform, but there's been too little 
attention focused on how health reform will work to improve the 
health and well-being of more than half our Nation's 
population, America's women. Our Nation's made significant 
progress toward equal treatment of men and women. We've passed 
legislation promoting equitable wages for the same work 
regardless of gender. We've passed legislation to prohibit 
gender discrimination in education and athletics. We've passed 
legislation to end housing discrimination on the basis of sex. 
We've passed legislation to provide compensation for victims of 
sexual harassment. We've passed legislation to end pregnancy 
discrimination in employment.
    However, we've yet to pass legislation to end gender 
discrimination in health insurance coverage and to bridge the 
gender gap that exists so troublingly in our health care 
system. It's simply unacceptable that in a nation which has 
made such great strides with respect to women's rights, 
something we trumpet all over the world, that we allow more 
than 20 million American women and girls to go without health 
insurance each year.
    In 2007, 14 percent of all women in my State of Ohio were 
uninsured. Part of the reason that so many women are uninsured 
stems from the fact that women are less likely to be employed 
full-time, especially full-time in jobs with health care 
benefits, making them less likely to be eligible for employer-
based health benefits.
    Another part of the reason is that important State and 
Federal laws that protect women with employer-sponsored 
coverage don't protect women purchasing health insurance in the 
individual market. For instance, in the private health market, 
insurance companies are allowed to deny care or charge higher 
premiums based on gender, history of domestic violence, or 
preexisting conditions such as pregnancy. As a result, women 
are often charged higher premiums than men.
    In Columbus, the capital of my State, a 30-year-old woman 
pays 49 percent more than a man of the same age for Anthem's 
Blue Access Economy Plan. The woman's monthly payment is 
$92.87; a man pays $62.30. At age 40, women pay 38 percent more 
than men for that policy.
    Compounding this premium hardship is the sad reality that 
women are generally poorer than men. In Ohio, women earn just 
74 cents for every dollar a man earns. Insurers in Ohio and 
most parts of the country are also allowed to exclude coverage 
for preexisting conditions. For example, if a woman previously 
had a C-section, insurers are allowed to refuse to pay for 
future C-sections or reject her application altogether due to a 
supposed preexisting condition. In 2006, close to a third of 
all births in Ohio were by C-section, meaning that tens of 
thousands of women could face coverage exclusions or rejections 
because of these preexisting condition exclusions.
    Health reform will finally put an end to these practices, 
which curtail access to, and undercut the value of, health 
insurance for women. No more gender discrimination in premiums; 
no more coverage denials because of preexisting conditions; no 
more exploitation of a woman's history, particularly a history 
of being victimized by domestic violence--all to inflate 
premiums going forward.
    I would add that a public option is important to ensure 
these rules are indeed enforced. Health reform will then ensure 
coverage of basic health services, including maternity 
benefits. Health reform will place a cap on the costs insurance 
companies charge and, that insurance companies can shift to 
their enrollees.
    One of the industry's smoothest tricks is to market a full 
loaf to get you to purchase coverage to protect against 
unanticipated health spending, but when you get sick what's 
unanticipated is how little your insurance actually covers. We 
all have stories. I go to the Senate floor night after night 
and read letters from people in Lima and Mansfield and Toledo 
and Cincinnati, people who thought they had really good 
insurance until they got really sick and found out their 
insurance wasn't what they thought it was.
    That's why this health insurance legislation is so 
important. That's why the work of all of you on this panel is 
so important, to make sure that these problems that we've had 
in this country for decades are a thing of the past.
    Thanks.
    Senator Murray. Thank you.
    Senator Casey.

                       Statement of Senator Casey

    Senator Casey. First of all, I want to thank Senator Murray 
for chairing our hearing, and Senator Mikulski for her 
leadership.
    I will echo, but not reiterate, a lot of what Senator Brown 
said about so much of the work that's been done this year in 
the Senate, in both the HELP Committee and the Finance 
Committee. I note two provisions among many, but two that we 
worked on in the HELP Committee. One was 2701, prohibiting 
insurance rating based upon gender, which of course leads to 
bad outcomes for women across the board.
    Senator Brown mentioned just the issue of domestic 
violence. The idea that that would be a bar to coverage, that 
that would prevent a woman from getting the kind of health care 
coverage that she should have a right to expect, is really 
horrific. In the case of a victim of domestic violence, it's 
the ultimate betrayal, and then she gets betrayed again because 
the system doesn't give her the kind of coverage and/or 
treatment that she should have a right to expect.
    The Office of Women's Health was also part of the HELP 
bill. Obviously, in the Finance Committee more work was done as 
well. I was on the HELP Committee, so I tend to favor that 
bill. I voted for it.
    But I think between the two committees we can make 
tremendous progress on a whole host of issues that relate to 
women, but in particular those issues that center on the kind 
of coverage that all of us should have a right to expect. But 
the idea that we're still allowing gender discrimination to go 
on when we have the power to fix it at long last is 
particularly disturbing.
    This is the year that we will not only vote on a health 
care bill, but it's the year at long last that we correct that 
continuing problem for women as it relates to the kind of 
coverage they get.
    There's a lot more to talk about. I know that many of us 
have worked on--as I was a co-sponsor of the Women's Hospital--
Women's Hospitals, plural, Education Equity Act, which among 
other things would create a $12 million funding pool for 
graduate medical education for small women's hospitals, it also 
requires hospitals to report annually on the status of the 
residency training programs. Senator Whitehouse has led on this 
and others have helped as well.
    We have to continually look for opportunities to make 
progress, but the most important thing we can do this year, I 
believe, is to make sure that no more gender discrimination 
occurs in our health insurance policies.
    With that, Senator Murray, thank you for chairing the 
hearing.
    Senator Murray. Thank you.
    Senator Franken.

                      Statement of Senator Franken

    Senator Franken. Thank you, Senator Murray. And I want to 
thank Chairwoman Mikulski for holding today's hearing on this 
crucial topic of how health reform will improve the lives of 
American women. I believe that women's health is fundamental to 
our country's health because women are the small business 
owners and entrepreneurs, they are the educators, doctors, and 
CEOs. As mothers and grandmothers, women are often also the 
health care decisionmakers for our families.
    It is of utmost importance that the national health reform 
legislation makes a real difference in the lives of American 
women across their entire lifespan. As others on the committee 
have mentioned, women are among those most severely 
disadvantaged in our current health system. Right now, health 
insurance companies discriminate against women solely on the 
basis of their gender. Right now it is legal in many States for 
health insurance companies to charge women higher premiums or 
deny coverage altogether if they are, for example, survivors of 
domestic violence, as Senators Brown and Casey have spoken to.
    Instead of providing the care and support that victims need 
in order to get out of abusive situations and stay healthy, 
health insurance companies actually punish these women. This is 
simply amoral and unacceptable.
    It is also unbelievable to me that in this day and age we 
allow insurance companies to charge women more for health 
insurance simply because of the fact that they may become 
pregnant. I heard recently from a woman named Jessica in 
Minneapolis. Jessica is 35 years old and works as an 
independent contractor. When she started her business she knew 
that it was important to have health insurance, of course, and 
she wanted to do the responsible thing, so she looked into 
buying an individual health plan.
    She found two main options, both of which had the same 
benefits except for one thing: maternity care. The plan that 
included maternity services cost about twice as much and was 
unaffordable for her. Right now she doesn't have any children, 
but she thinks she might like to become pregnant some time in 
the next few years. But as she was considering these individual 
health coverage options, Jessica found out that to get the 
pregnancy coverage she would also need to be enrolled in the 
maternity coverage for 18 months before becoming pregnant. 
Otherwise her pregnancy would be considered a preexisting 
condition and would not be covered.
    Health insurance companies consider pregnancy a preexisting 
condition, and as far as I know it's only one that women can 
have. We permit this discrimination under current law.
    Now, Jessica is a young entrepreneur, exactly the type of 
smart and innovative business person that we want to encourage 
in Minnesota. But this ridiculous practice of charging women 
more for health insurance sends a message that we don't want 
women to receive prenatal services and high quality maternity 
care, as if we don't all benefit from healthy mothers and 
healthy babies.
    The reality is that if my wife or your sister doesn't have 
access to high quality affordable health care, that's bad for 
all of us, bad for our economy, our country, and our future.
    Fortunately, when we pass national health reform we will 
begin a new era in women's health. For the first time, women 
will have access to comprehensive health benefits, including 
maternity care, without having to pay more than their male 
counterparts. This is a huge step forward for justice in our 
country and it's one of the main reasons why we must pass 
health reform this year.
    It's also a top priority for me that health reform includes 
a crucial women's health service, access to affordable family 
planning services. These services enable women and families to 
make informed decisions about when and how they become parents. 
Access to contraception is a fundamental right of adult 
Americans, and when we fulfil this right we're able to 
accomplish a goal that we all share on both sides of the aisle, 
to reduce the number of unintended pregnancies.
    I believe that affordable family planning services must be 
a part of the final implementation of health reform 
legislation. I look forward to working with all of my 
colleagues here to ensure that we make this a reality for all 
women in America.
    Senator Murray and Senator Mikulski, I appreciate the 
opportunity to participate in today's discussion and look 
forward to hearing from all of our witnesses. Thank you all for 
being here today.
    Madam Chairwoman.
    [The prepared statement of Senator Franken follows:]

                 Prepared Statement of Senator Franken

    Thank you, Madam Chairwoman. And thank you for holding 
today's hearing on this crucial topic of how health reform will 
improve the lives of American women. I believe that women's 
health is fundamental to our country's health because women are 
small business owners and entrepreneurs; they are educators and 
doctors and CEOs. And as mothers and grandmothers, women are 
often also the health care decisionmakers for our families. It 
is of utmost importance that national health reform legislation 
makes a real difference in the lives of American women, across 
their lifespan.
    As others on the committee have mentioned, women are among 
those most severely disadvantaged in our current health system. 
Right now, health insurance companies discriminate against 
women solely on the basis of their gender. And right now, it's 
legal in many States for health insurance companies to charge 
women higher premiums--or deny coverage all together--if they 
have a history of domestic violence. Instead of providing the 
care and support that victims need in order to get out of 
abusive situations and stay healthy, health insurance companies 
punish them. This is simply immoral and unacceptable.
    It is also unbelievable to me that, in this day and age, we 
allow insurance companies to charge women more for health 
insurance simply because of the fact that they may become 
pregnant. I heard recently from a woman named Jessica in 
Minneapolis. Jessica's 35 years old and works as an independent 
contractor.
    When she started up her business, she knew that it was 
important to have health insurance. She wanted to do the 
responsible thing so she looked into buying an individual 
health plan. She found two main options, both of which had all 
of the same benefits except for one thing: maternity care. And 
the plan that included maternity services cost about twice as 
much and was unaffordable.
    Right now, she doesn't have any children but she thinks she 
might like to become pregnant sometime in the next few years. 
But as she was considering these individual health coverage 
options, Jessica also found out that to get the pregnancy 
coverage, she would also need to be enrolled in the maternity 
coverage for 18-months before becoming pregnant. Otherwise, her 
pregnancy would be considered a preexisting condition and would 
not be covered. Health insurance companies consider pregnancy a 
preexisting condition. And we permit this discrimination under 
current law.
    Jessica is a young entrepreneur--exactly the type of smart 
and innovative businessperson that we want to encourage in 
Minnesota. But this ridiculous practice of charging women more 
for health insurance sends the message that we don't want women 
to receive prenatal services and high-quality maternity care. 
As if we don't all benefit from healthy mothers and babies. The 
reality is that if my wife or your sister doesn't have access 
to high-quality, affordable health care, that's bad for all of 
us--bad for our economy, our country and our future.
    Fortunately, when we pass national health reform, we will 
begin a new era in women's health. For the first time ever, 
women will have access to comprehensive health benefits, 
including maternity care--without having to pay more than their 
male counterparts. This is a huge step forward for justice in 
our country, and it's one of the main reasons why we must pass 
health reform this year.
    It is also a top priority for me that health reform 
includes a crucial women's health service--access to affordable 
family planning services. These services enable women and 
families to make informed decisions about when and how they 
become parents. Access to contraception is a fundamental right 
of adult Americans. And when we fulfill this right, we are able 
to accomplish a goal that we all share, on both sides of the 
aisle--to reduce the number of unintended pregnancies. And so I 
believe that affordable family planning services must be part 
of the final implementation of health reform legislation. I 
look forward to working with all of my colleagues here to 
ensure that we make this a reality for all women in America.
    Madam Chairwoman, I appreciate the opportunity to 
participate in today's discussion and look forward to hearing 
from all of our witnesses.

                     Statement of Senator Mikulski

    Senator Mikulski. Well, good morning, everybody.
    I'll kind of be the wrap-up speaker. The vagaries of the 
Baltimore-Washington Parkway delayed my arrival. But I will now 
turn to Senator Hagan and then I'll say a few words, and then 
we look forward to hearing from our excellent panel.

                       Statement of Senator Hagan

    Senator Hagan. Thank you, Madam Chairwoman. Thanks so much 
for holding this hearing today. I think that it's critical that 
we highlight the disparities in affordable health insurance 
options between men and women.
    Recently I received communications from several women in 
North Carolina. One woman in particular, when she was 27 years 
old she was diagnosed with breast cancer. She had a 16-month-
old son and this woman was in an extremely abusive 
relationship. It was interesting, too: Her husband knew that 
she could not leave him because of her breast cancer and that 
she had to have his employer-provided health insurance.
    She looked into individual insurance plans, but her breast 
cancer obviously was considered a preexisting condition. For 7 
years this woman stayed in this abusive relationship.
    Another woman called me about her sister, and the sister, 
who was uninsured, had waited years between mammograms because 
she couldn't afford to pay for the out-of-pocket screenings. 
She found a lump in her breast. What happened, the lump became 
a mass, she finally got a mammogram, and she paid for that with 
cash. The mammogram confirmed what she had suspected, that she 
did have breast cancer. Once she had that diagnosis, she still 
was unable to get the treatment she needed.
    She ended up passing away last March. Her sister obviously 
feels that had she had preventive care, early detection, that 
perhaps she could still be with us today.
    Unfortunately, we hear about these cases far too often. I 
think the inefficiencies and discriminatory practices in our 
health care system disproportionately affect women. In all but 
12 States, insurance companies are allowed to charge women more 
than they charge men for coverage. I think some other people 
have already said it, that the great irony is that so many 
people who are being obviously cared for by women and mothers, 
these women are penalized under our current system.
    I have two children in their early 20s, one male, one 
female. Guess what, the female is paying lots more for private 
health insurance than her brother. I had a 23-year-old staff 
member look up--she's from Fayetteville--look for health 
insurance on the open market. The best-selling plan with the 
$2,700 deductible that she could find would cost her $235 a 
month. For men of the same age, it was $88 a month, more than 
2\1/2\ times as expensive.
    We looked up in Maryland, too, Senator Mikulski, you might 
be interested, one of the few States that prohibits gender 
rating. A basic health plan there costs as low as $37 a month 
both for men and women.
    After overcoming some of the cost and preexisting 
qualifying hurdles, many women who have health insurance are 
still stuck because some of the preventive screenings--
mammograms, Pap smears--are not covered as preventive care, and 
often the co-pays for these extremely critical services are 
extremely high. In many cases, the difference between life and 
death is early detection. I think we all know that. I think 
everything we can do to give preventive screenings will pay 
off.
    I also heard from a hospital in North Carolina that 
recently implemented a wellness program. A few years ago this 
CEO was meeting with about 20 to 30 of the nursing assistants, 
who were earning at the lower wage of the hospital. The CEO 
asked the group of those who were there who were old enough to 
require a mammogram how many had had one. Only 20 percent of 
these women said that they'd had one and the rest said, due to 
the out-of-pocket cost and the other financial items that they 
were juggling, food for their children, paying rent, et cetera.
    After that meeting, the CEO said that the hospital decided 
to remove that cost-sharing barrier for those preventive 
services, which I think is a plus.
    The bill that we put forward in this committee, the 
Affordable Health Choices Act, makes preventive care possible 
for women across America, and it eliminates the co-pays and the 
deductibles for these recommended preventive screenings.
    I also think that we need to really look at the fact that 
so many places around our country, insurance companies are 
charging women more than men, whether it's just for basic 
coverage, and then obviously a separate item on maternity 
coverage; and that using these preexisting conditions as a 
reason to deny anyone health insurance is unacceptable.
    Madam Chairman, thanks for holding this committee meeting 
and I look forward to hearing from our witnesses today.
    [The prepared statement of Senator Hagan follows:]

                  Prepared Statement of Senator Hagan

    Madame Chairwoman, thank you for holding this hearing 
today.
    I think it is critical that we highlight the disparities in 
affordable health insurance options among men and women.
    Recently, I received two e-mails highlighting the real word 
ramifications of health insurance inequities between men and 
women.
    A few weeks ago, I received a heartbreaking e-mail from a 
young woman from North Carolina. When this woman was 27, she 
was diagnosed with breast cancer. She had a 16-month-old son, 
and was in an extremely abusive relationship.
    Her husband knew she wouldn't leave him because she 
couldn't afford her medical treatment without his employer-
provided health insurance.
    This woman looked into individual insurance plans, but her 
breast cancer was considered by insurance companies to be a 
preexisting condition. For 7 years, her husband kept her in 
this abusive relationship by threatening to take her off his 
insurance plan.
    I also received an e-mail from a woman in Raleigh, NC about 
her sister, who was uninsured and waited years between 
mammograms because she couldn't afford to pay for out-of-pocket 
screenings. She found a lump in her breast.
    By the time the lump became a mass, Julie's sister finally 
got a mammogram--and had to pay for it with cash. The mammogram 
confirmed what she suspected--that she had breast cancer. But 
now that she had a diagnosis, she had no way to pay for the 
treatment.
    Julie's sister lost her battle with breast cancer this 
March. Like thousands of women across America, Julie's sister 
probably could have beaten this cancer if she had access to 
affordable preventive care and, after her diagnosis, access to 
insurance to cover her cancer treatment.
    In this heartbreaking situation, Julie's sister was sick 
and stuck.
    Unfortunately, I hear about cases like these far too often. 
Inefficiencies and discriminatory practices in our health care 
system disproportionately affect women.
    In all but 12 States, insurance companies are allowed to 
charge women more than they charge men for coverage. The great 
irony here is that mothers, the people who care for us when we 
are sick, are penalized under our current system.
    My daughter Carrie recently graduated from college and had 
to purchase her own insurance. For no other reason than her 
gender, insurance policies cost more for Carrie than they do 
for my son, Tilden.
    For a 23-year-old, healthy female from Fayetteville, NC 
shopping for health insurance on the individual market, the 
most basic, best selling plan, would cost her $235 a month. For 
a man of the same age, it would cost $88 a month. That's more 
than 2\1/2\ times more expensive.
    While some argue that females cost the health care system 
more in medical costs, these discrepancies are steep. 
Especially if you consider in Maryland, one of the few States 
that prohibit gender rating, a basic health plan costs as low 
as $37 per month for both men and women.
    After overcoming some of the cost and preexisting 
qualifying hurdles, many women who have health insurance are 
still stuck. Insurance companies often don't cover key 
preventive care services--ranging from mammograms to pap 
smears. And often the co-pays for these critical services are 
extremely high.
    One in five women over the age of 50 has not received a 
mammogram in the past 2 years. More than half of all women, 
like Julie's sister, have reported delaying preventive 
screenings because of the exorbitant cost.
    In many cases, the difference between life and death is 
early detection.
    I heard from one of the hospitals in North Carolina which 
recently implemented a wellness program. A few years ago, the 
CEO of this hospital was meeting with about 20 to 30 nursing 
assistants who were earning relatively low wages. The CEO asked 
the group of those who were old enough to require a mammogram, 
how many had. Only 20 percent said they had and the rest said 
they could not afford the out-of-pocket costs with all the 
other financial items that they were juggling, like food for 
their children, paying rent, etc. After that meeting, the 
hospital decided to remove the cost sharing barriers for 
preventive services.
    The Affordable Health Choices Act, which came out of this 
committee, makes preventive care possible for women across 
America. It eliminates all co-pays and deductibles for 
recommended preventive services.
    We also are stopping insurance companies from charging 
women more than men--or using preexisting conditions as a 
reason to deny anyone health insurance.
    I look forward to hearing from our witnesses today.

    Senator Mikulski. Well, good morning to everybody. I 
apologize for being late. It was not only the traffic, but, as 
you can see, I'm now looking at the health care system from the 
wheelchair up. A couple of months ago, coming out of mass, I 
took a fall on some steps and broke my ankle in three places, 
and have required extensive surgery and extensive 
rehabilitation. I have seen health care from a patient's 
perspective more up close and personal than I wanted; I also 
have spent a lot of time talking to very talented providers, 
from gifted surgeons to the physical therapists and GNAs; and I 
also have been in the rooms with others who've had to seek 
assistance, from knee replacements to amputations.
    We know that health care is truly an American issue, where 
we need to be able to guarantee access. Health reform is how we 
achieve universal access in a way that meets quality standards 
and also cost standards.
    Along our way, as we've looked at this, we see that there 
are other issues related to what appears to be discrimination 
or redlining, and this is why we're holding our hearing today, 
called Equal Benefits for Equal Premiums. I want to thank my 
colleagues for their opening statements because they set the 
tone that I was going to call for if I kicked it off, which is: 
one, to welcome everyone, acknowledging that when coming to the 
table we will have diverse views, just as they are among 
ourselves here on the committee, and also at our witness table.
    We welcome diverse views. That's how we arrive at what we 
hope will be the sensible center in which we can achieve health 
care reform that will provide the greatest range of access, but 
at the same time recognizing the mandate for prudence when it 
comes to cost to both our government, to insurance companies, 
but most of all to American families.
    We have here a representation on a bipartisan panel. We've 
worked with Senator Burr, who is my ranking member on the 
subcommittee, and we thank you for being here. We really 
welcome your views and we want to hear them. What I will 
guarantee is that this hearing from our side of the table will 
be conducted with the utmost of civility. I believe that, in 
order to arrive at that sensible center, we really need to 
listen to each other and have a dialogue with each other.
    In preparation for turning to our witness table, I just 
wanted to note that every single panelist will be treated with 
the utmost respect, dignity, and civility, because the issue is 
too big, it's too serious, to get into petty, prickly disputes.
    For me, health care definitely is a woman's issue. My 
history goes back to my early days on this panel, when women 
were excluded from the protocols at NIH. The famous study, take 
an aspirin a day to keep a heart attack away, was done on 
10,000 male residents, doctor residents, and not one woman was 
included.
    Thanks to working on a bipartisan basis, Senator Kennedy, 
Senator Harkin, myself in the House, Senators then-
Congresswomen Snowe and Connie Morella, and working with a very 
brilliant physician named Bernadine Healy, we were able to 
change the paradigm and I believe have improved quality care 
for women.
    For us, health care as a woman's issue has been an 
important part of this panel. Health care reform, we believe, 
is a must-do woman's issue because so many women are affected 
by health care and they also often drive the decisions that 
families make about health care. And health insurance reform is 
a must-change issue.
    We've heard many of the facts presented by colleagues in 
their opening statements, how we're concerned that women are 
discriminated against, No. 1, in paying higher premiums; also 
that often our life processes, like pregnancy, are treated as 
preexisting conditions; and also the issue of prevention and 
wellness often, because we want those much-needed screenings, 
are high-cost or have other barriers.
    My colleagues have given an excellent set of facts and I am 
not going to repeat them. I think we can turn right to the 
witnesses. But I can tell you where I'm heading, which is I 
want to be able to listen to ideas and recommendations and 
experiences, but one of the largest consumers of health care 
are older women and, quite frankly, older Americans. At the end 
of the day, when we conclude our deliberations and votes on 
this, we want to save and strengthen Medicare.
    No. 2, we want to eliminate those barriers to health 
insurance. Particularly the issue of gender rating is of great 
concern, where simply being a woman means you pay more.
    No. 3, the very controversial issue of what is a 
preexisting condition that could be a barrier to getting health 
care. I was very concerned that simply being pregnant or having 
a C-section often can result in paying far more, far more for 
care.
    Again, my colleagues have given the other facts and 
statistics, which I won't repeat. But the fact remains that 
women often pay more than their male counterparts: a 25-year-
old male in roughly the same condition often pays less than a 
25-year-old female; and the fact of the matter is that 
preexisting conditions like pregnancy or having had a C-section 
could be a barrier to health insurance.
    And No. 4, often those vagaries of life, like being a 
battered woman, in eight States also means you can have a 
harder time affording or obtaining health insurance.
    What we want to be able to do, because this committee and 
many at this table have fought for equal pay for equal or 
comparable work, we want to be able to have equal or comparable 
benefits for equal premiums.
    I've said enough for now, and I want to turn to our 
panelists. I thought maybe, rather than saying should we go in 
alphabetical order or whatever, maybe we'll just start with Mr. 
Guest and go all the way down and, Ms. Ignagni, wrap up with 
you, and then we can go to our questions. What I'd like to do 
is welcome Mr. Guest, the President and CEO of Consumers Union, 
with a distinguished career in public service. We want to turn 
to Diane Furchtgott-Roth of the Hudson Institute, Senior Fellow 
on Employment Policy and also Lead Economist, who comes to us 
having actually served as a staff member in President Reagan's 
Council of Economic Advisers, and we look forward to her 
testimony.
    Janice Shaw Crouse of the Concerned Women of America, who's 
also a Senior Fellow at the Beverly LaHaye Institute, and 
worked for Dr. Lou Sullivan, the wonderful Secretary of HHS. We 
miss seeing him as much as we used to. We welcome her and her 
expertise.
    Marcia Greenberger, the Founder and Co-President of the 
National Women's Law Center, that has helped us, giving us many 
of the ideas that helped us with the Lilly Ledbetter Fair Pay 
Act and the Pregnancy Discrimination Act and so on.
    Amanda Buchanan, who is a real live mother who has had to 
face the significant issues of family and responsibility both 
for herself and for her children.
    Peggy Robertson, who also was someone who thought she had 
health insurance, then had a C-section, which I know she'll 
tell us about, and then what happened as she came up against 
the insurance bureaucracies.
    Then Karen Ignagni, President and CEO of the American 
Health Insurance Plans. She herself was a professional staffer 
here to a beloved member, Claiborne Pell, and actually worked 
for the HELP Committee. Some might say, well, she's kind of a 
proxy staffer now, the way we see her so much. But she comes 
with a tremendous background in really the human service field 
and now is representing the insurance company and is viewed as 
one of the three trade associations.
    Again, we welcome all views and we want everyone to really 
lay it out, because what we're here to do is not debate, but to 
discuss, to listen, to learn and to see how we can find that 
sensible center the American people want us to.
    We look forward to hearing from you all.
    Mr. Guest.

 STATEMENT OF JAMES GUEST, PRESIDENT AND CEO, CONSUMERS UNION, 
                          YONKERS, NY

    Mr. Guest. Well, Madam Chairwoman, thank you very much, and 
members of the committee. I'm Jim Guest, President of Consumers 
Union, publisher of Consumer Reports. Thank you for the chance 
to be heard on this crucial issue.
    Clearly, one of the most important pocketbook issues for 
American families today is health care. For the last few years, 
Consumer Reports has both done extensive surveys about the 
health care crisis and we've also collected personal stories, 
thousands of personal stories, many from women, about the 
country's broken health care system.
    Women are the chief purchasing officers in most households, 
as you know, making health care decisions, buying decisions, 
and managing the care of family members, as well as themselves. 
But there is another reason that we hear from women so often 
today and that's because the system makes accessing and 
affording high quality care uniquely difficult and burdensome 
for women. The reasons why--lower incomes, more part-time work, 
more small businesses, more periods of unemployment to care for 
children or aging parents, higher use of medical devices, and 
so forth.
    In September, just last month, Consumer Reports conducted 
the latest of our nationally representative surveys and it 
shows significant differences between men and women in the 
impact of the health care crisis. Just to give a few numbers, 
51 percent of all respondents said in the past year they had to 
put off a doctor's visit, not fill a prescription, skip a 
treatment, not pay a bill because of cost. But notably, women 
were much more likely than men--55 percent for women compared 
to 47 percent for men--to have faced those choices and given up 
needed medical care.
    Sixty-seven percent of women, compared to 59 percent of 
men, fear they'll be denied coverage because of preexisting 
conditions and other circumstances; and 78 percent of women, 
versus 68 of men, fear they'll be unable to afford health care 
in the future.
    Behind those numbers, of course, are real people. From the 
thousands of personal stories that we have gathered over the 
years, it's clear that women far too often are not adequately 
covered under current insurance practices. You members of the 
committee have given many examples of that.
    We have also heard from numerous women who found themselves 
with coverage delayed or denied for some of the same causes 
that were described here earlier. You can see some of the 
stories, by the way, that we've collected in my written 
testimony and in a reprint from Consumer Reports I'm happy to 
make available.
    The surveys and the personal stories highlight areas that 
urgently need attention in the health care crisis. I just want 
to flag three of them especially as they affect women. First is 
the question of affordability, which is a major concern, 
obviously, for everyone, for middle and lower income Americans, 
and disproportionately for women. We support proposals 
mentioned earlier that prohibit higher premiums due to gender 
and we support limiting age rating to two to one.
    We support expansion of Medicaid to the 133 percent poverty 
level to provide a stable source of coverage for low-income 
working women. We support the employer mandate to cover lower 
wage workers, many of whom are women. And we support the 
highest feasible--this is really important--the highest 
feasible premium and cost-sharing assistance. On this, by the 
way, we believe that the HELP bill is better, significantly 
better, than the Finance version. And we support having a 
public insurance plan option, which will expand consumer 
choices, men and women, and hold down costs through greater 
competition.
    Second, on transparency, more complete, easy to use 
information about medical providers and systems will enable 
women, as the primary health shoppers, to make informed 
choices. We like the HELP Committee scenarios, by the way, of 
what it would cost to be treated for certain common conditions. 
We support mandatory public disclosure of hospital-acquired 
infections and other adverse events.
    When it comes to insurance plans, it's most useful to give 
not just what the premium's going to be, but the total cost of 
a plan, rather than just the premium. That allows more informed 
choices.
    Then finally, I want to talk about the real importance of 
the investment in comparative effectiveness research, which 
will be a huge gain for women. It will help end the historic 
underrepresentation of women in medical research that the 
chairwoman referred to, and it holds the promise of medical 
care that's more effectively tailored to subpopulations, 
including subpopulations of women.
    Finally, we vigorously support the HELP approach in terms 
of comparative effectiveness research in a public agency, not a 
private body. We think the advisory and oversight panels for 
CERs should include a substantial number of consumer and 
patient representatives, including women, as well as 
independent experts, and we urge that there be a requirement 
that all members of such panels be completely free of conflicts 
of interest whatsoever.
    Bottom line, Madam Chairwoman and members of the committee, 
for women the health care crisis is very real, very personal, 
and very scary. The time for action is now.
    Thank you very much.
    [The prepared statement of Mr. Guest follows:]
                   Prepared Statement of James Guest
    Senator Mikulski and members of the committee, I'm Jim Guest, 
President and CEO of Consumers Union, publisher of Consumer Reports, 
and I thank you for the opportunity to testify on the subject of equal 
treatment for women in our health care system. Consumers Union is a 
non-profit, non-partisan, independent testing, research and public 
policy organization whose mission is to work for a fair, safe and just 
marketplace for all consumers. We have over 4 million subscribers to 
our print magazine and more than 3.2 million on-line subscribers. We 
have tested, reported and spoken out on health care matters since our 
very first issue in February 1936.
    For more than 70 years, we have been dedicated to helping consumers 
make informed choices that affect their pocketbooks. And today, one of 
the most important pocketbook issues for American families is health 
care. For the past 2 years we have done extensive national surveys and 
research which we have used in Consumer Reports articles to educate 
consumers about what is happening in the health sector and the 
underlying causes of today's health care crisis. In addition, we have 
been collecting many thousands of personal stories from around the 
country that illustrate the realities Americans are facing in our 
broken health care system.
    Several thousands of those who have shared their experiences with 
us are women. Women are the ``chief purchasing officers'' in most 
households--making most of the health-care buying decisions and 
managing the health care of family members as well as their own. But 
there is another reason we hear from so many women, and that is because 
the system today makes accessing and affording high-quality health care 
uniquely difficult and burdensome for women.
    The reasons women are disproportionately impacted in the current 
health care system are well documented: lower incomes, more part-time 
work, more small businesses, more periods of unemployment to care for 
children or aging parents, more bankruptcies, higher use of medical 
services and so forth. The other experts on this panel can speak in 
depth about these factors.
    In September, the Consumer Reports National Research Center 
conducted the latest of our nationally representative polls on health 
care. Two sets of questions, in particular, showed significant 
differences between men and women that are relevant to this panel's 
focus today.
    First, regarding cost and its impact on access to care, we asked 
respondents if they were rationing their own care--that is, were they 
restricting their use of health care due to cost. The results were 
striking: 51 percent of all respondents said that in the past year they 
had put off a doctor's visit, or not filled a prescription, or skipped 
a treatment or procedure, or not been able to pay their medical bills 
due to cost. Women were much more likely than men to face such 
choices--55 percent to 47 percent.
    Specifically, women are more likely to have:

     Skipped filling a prescription (23 percent versus 16 
percent).
     Taken an expired medication (18 percent versus 11 
percent).
     Shared a prescription with someone else (12 percent versus 
6 percent).

    Second, we asked respondents about their main concerns regarding 
health care. Women have greater concerns than men on most health care 
issues, including significantly greater concern that they would:

     Suffer a major financial loss or setback from medical cost 
due to an illness or accident (77 percent versus 70 percent).
     Face rising costs forcing a choice between healthcare and 
other necessities (69 percent versus 59 percent).
     Not be able to afford health care in the future (78 
percent versus 68 percent).
     Be denied health coverage because of preexisting 
conditions or other circumstances (67 percent versus 59 percent).

    And, by a difference of 75 to 70 percent, women are more concerned 
that needed care will be rationed or denied by their insurance company.
    In the thousands of stories we gathered in recent years of people's 
experiences and concerns with the health care system, the reality is 
clear: Common health needs specific to women too often are not covered 
under current health insurance practices. We heard from numerous women 
who found themselves with coverage delayed or denied because of very 
common health needs such as benign fibroids, previous fertility 
treatments, pregnancies and the like.
    Attached are some truly moving stories that illustrate the types of 
everyday problems women experience because of their unique health 
needs.
    These survey results and personal stories highlight policy areas 
that need to be changed for all consumers of health care, but 
especially for women. I want to highlight four such areas.
                            1. affordability
    We support proposals that prohibit higher premiums due to gender. 
These proposals will greatly help women, particularly in their young 
adulthood.
    We support limiting age-rating differentials. Doing so will help 
women at an especially vulnerable time--the years leading up to 
Medicare eligibility--when they often find themselves without their 
husband's coverage due to divorce or death of their spouse. We 
recommend the lowest age rating of 2:1, as in the House bills and the 
Senate HELP Committee bill.
    We support expansion of Medicaid to 133 percent of poverty ($24,400 
for a family of 3) in order to provide a stable source of coverage for 
low-income working women. We urge Congress to ensure that this 
expansion be coupled with improvements in Medicaid provider rates so 
that it increases real access to care, not just insurance.
    Even with these important improvements, affordability remains a 
major concern for middle- and lower-income people who are, 
disproportionately, women. Because the costs of insurance are so high 
relative to their families' take-home pay, all of the current bills 
include sliding-scale subsidies to help them afford the insurance they 
will be required to get under all of the proposals. We strongly believe 
that more must be done to ensure affordability. We support the highest 
possible premium subsidies that waive mandatory premiums for those on 
Medicaid (those below 133 percent to 150 percent, or $24,400 to 
$27,500, for a family of three) and charge families at 400 percent of 
poverty ($73,240 for a family of three) no more than 10 percent of 
their income. While this will increase costs, insurance reform will not 
work effectively if it requires Americans to buy policies that are 
unaffordable. Additional savings and progressive finances are needed to 
ensure affordability.
    Another problem is that in recent years consumers have seen more 
and more of the costs of health care shifted to them in the form of 
higher out-of-pocket cost-sharing, often at levels they cannot afford. 
Therefore, we urge that you also limit out-of-pocket spending to no 
more than 5 percent of income for people with incomes below 200 percent 
of FPL and--using a graduated sliding scale--a limit between 5 percent 
to 10 percent of income for people between 201 percent and 400 percent 
of FPL. Finally, we support the approach taken by the HELP Committee to 
increase the actuarial value of plans that are offered in order to 
ensure that the coverage people will be required to carry will truly 
protect against health care costs.
    Finally, we strongly support giving American families the choice of 
a Public Insurance Plan option, which will hold down costs by ensuring 
competition and holding private insurers accountable.
                              2. coverage
    All of the proposals under consideration make necessary and 
important improvements in coverage for conditions that only women 
experience--maternity and preventive services like mammograms and other 
screenings. In addition, ending exclusions due to preexisting 
conditions will help everyone, but as our stories show, this will 
especially help increase women's access to affordable care without 
penalty for common female conditions like fibroid tumors, C-sections 
and other child-bearing-related experiences.
                        3. consumer information
    Finally, I want to mention a third key reform that will help women 
as the primary decisionmakers about health care in most families, and 
that will greatly improve competition based on cost and quality, 
helping reduce the growth of health costs over time.
    Health care experts like to talk about the ``marketplace'' and 
``competition.'' But today's health care marketplace lacks an essential 
element necessary for consumers to be able to choose the insurance or 
health care services that best meet their needs. People are forced to 
make high-cost decisions without being able to know the full costs or 
the relative quality and effectiveness of different insurance products, 
procedures or providers. This has to change.
    First, we all know about the fine print, loopholes, and ``got cha'' 
aspects of health insurance policies. It is vital that the final law 
retains the HELP Committee provisions that define medical and insurance 
terms so consumers can compare apples-to-apples. We particularly like 
the HELP Committee's ``scenarios'' of what it would cost to be treated 
for certain common conditions.
    Second, in whatever ``exchange'' or ``connector'' marketplace that 
is established to help people shop, make sure that the consumer is told 
not just the premium cost, but also the estimated annual total cost, 
based on past medical history or on one's own estimate of one's health 
condition--for example, ``good health, fair health, poor health.'' 
Consumers Union has some data that shows that when consumers can see an 
estimate of their likely total cost, they make much better choices than 
if they only have premium information available. And if they make 
better insurance choices, they will need less subsidy help with 
premiums, deductibles, and co-pays. Total estimated cost data will help 
everyone win.
    Third, make available to consumers comparable information about the 
quality and effectiveness of providers and different services. For 
example, we support the Senate Finance provision that requires the 
development of a rating system for plans based on relative quality and 
price compared to other plans offering products in the same benefit 
level. Consumers need this kind of help on the exchange Web sites to 
deal with what is likely to be a confusing, busy new market (similar to 
the 40-60 plans that faced seniors in Part C and D). As another 
example, we also support Senator Reed's amendment in the HELP bill, 
requiring clearer fact-based labeling of pharmaceuticals.
              4. comparative effectiveness research (cer)
    The CER provisions in the three bills will be a huge gain for women 
in the decades to come. Women, and minorities, historically have been 
badly under-represented in clinical trials and pharmaceutical and 
medical device research. The new CER Trust Funds will provide a robust 
level of funding that is mandated to give better, more balanced 
attention to research on what works for women. CER holds the promise of 
personalized medicine in the future, where, for example, the best 
treatment for breast and other cancers can be determined by an 
understanding of gene markers. We think it is crucial, however, that 
CER research is housed in a public agency, as proposed by the HELP 
Committee. Turning CER over to a private foundation means that the 
process is likely to be captured by the medical industries, and instead 
of delivering scientific research, it will become just another part of 
the drug and device sales juggernaut. Further, members of the CER body 
should be free of any personal or financial conflicts of interest, and 
membership should include a substantial number of consumer and patient 
representatives.
                               conclusion
    The disproportionate burdens of the current system are unfair to 
women. But in the end, the disparities have long-lasting effects on us 
all, men as well as women. For men, these are our wives, our mothers, 
our daughters, our sisters who are being denied the insurance coverage 
and access to care that they deserve. When a mother or wife or daughter 
or sister faces a serious health challenge, so does everyone in her 
family. It is in the interests of all consumers that our health 
insurance system must be improved. The time for action is now.
                                 ______
                                 
         Examples of Why American Women Need Health Care Reform
                          dee k. from florida
    During her first pregnancy, Dee suffered a miscarriage, a 
devastating loss for her and her husband.
    Sometime after that, Dee considered switching from her health plan 
(purchased through the American Veterinary Medicine Association) to her 
husband's non-group plan as the switch would save the family almost 
$300 per month. Much to her surprise, and even the surprise of their 
insurance agent, carriers in Florida refused to cover Dee due to her 
miscarriage. In fact, they were told that Dee was considered 
uninsurable for 5 years.
    Dee was incredulous and angry: ``I am not a cancer patient. I am 
healthy, don't smoke, and exercise. I do have back issues and dry eyes, 
which I thought may cause more of a problem, but miscarriage is not a 
constant state. At least 20 percent of women suffer miscarriage, and 
probably many more go unreported.''
    Unfortunately, Dee regrets obtaining medical care for her 
miscarriage because now she must stay with her current policy which 
features a $1,500 deductible and is not accepted by many physicians in 
her area.
                      nanci l. from north carolina
    During 1998, Nanci had a hysterectomy. Most of the surgery was paid 
for by her non-group insurance policy. However, a year later her 
insurers reversed their decision to cover Nanci's surgery. Why? Prior 
to her surgery, Nanci's ob/gyn had written on her chart that her uterus 
was fibrous, and the surgeon also found fibroids on her uterus during 
the hysterectomy.
    Her insurance carriers asserted these fibroids were a ``preexisting 
condition'' and, hence, not covered under her policy. The carrier asked 
the hospital and surgeon to return their payment and Nanci was 
unexpectedly stuck with the bill for the hysterectomy--about $12,000. 
The hospital that performed the surgery told Nanci, that if they didn't 
return the payment, they would have trouble getting other claims paid.
    This reversal is an industry practice called ``rescission.'' 
Exactly what is permitted will vary from State to State. In North 
Carolina, a fibrous uterus can be considered a basis for denying 
coverage, despite the fact that the condition is quite common among 
women. As happened in Nanci's case, this denial can be made 
retroactively leaving consumers vulnerable to large medical bills, 
despite paying for insurance coverage.
                       tina g. from pennsylvania
    Anticipating that she and her new husband would soon start a 
family, Tina called her health insurance company to make sure she was 
covered for maternity care. A customer service rep assured her that she 
had maternity coverage and that she would only be responsible to pay 
for 20 percent of all costs after the birth of the child. Four months 
into her pregnancy, Tina started getting huge bills from the insurance 
company.
    Repeated phone calls finally revealed that she did not have 
maternity coverage and that Tina would be responsible to pay for 
everything. As Tina puts it ``[b]eing pregnant was stressful enough, 
then to find out half way through the pregnancy that I didn't have the 
proper coverage was even worse.'' Tina believes that the added stress 
of huge, daunting medical bills contributed to high blood pressure 
during her pregnancy and gestational diabetes--increasing the risk to 
Tina's health and that of her unborn baby.
    Tina contacted an attorney who suggested that she first try 
contacting her local news channel's consumer reporter. This reporter 
empathized with her plight and made some phone calls. As a result, the 
reporter got insurers to admit that they incorrectly represented the 
coverage during Tina's initial inquiries and convinced them to pay 
Tina's maternity bills.
    Tina, a registered nurse, advised people who interact with their 
insurance company to document everything and to persist, using any 
method available, if your health insurer appears to have made a 
mistake.
                        stephanie h. from texas
    Stephanie left the work force to care for her young child and left 
behind the family's group health insurance policy she had through her 
employer. Her husband is a self-employed professional without access to 
group coverage. At the time, Stephanie was unconcerned because her 
family (then ages 33, 35 and 2) was very healthy and not currently 
taking any prescriptions.
    When she applied for non-group family coverage she was shocked to 
be turned down based on her usage of a drug called Clomiphene Citrate 
over a 5-day period approximately 1 year earlier. Clomiphene Citrate is 
a commonly used drug that stimulates ovulation. Stephanie notes it is 
``the mildest fertility drug available'' and has a ``risk'' of less 
than 10 percent of having twins. Stephanie complained and, with her 
doctor, attempted to appeal the denial, but to no avail.
    The stated reason for denial was that if she ever had another baby, 
the insurer would be forced to cover the newborn even if it wasn't 
healthy. Stephanie notes that rationale could be used to deny woman of 
childbearing years. She also notes that she was not applying for 
maternity health coverage and that her husband was also turned down for 
this reason. Further, she already had one healthy child with no medical 
complications. Stephanie contacted the Texas Department of Insurance as 
well as Texas representatives about her plight, but also to no avail. 
She was told that there was no remedy available within the current laws 
and regulations.

    Senator Mikulski. Well, thank you, and you even had 9 
seconds to spare. That was great.

   STATEMENT OF DIANA FURCHTGOTT-ROTH, SENIOR FELLOW, HUDSON 
    INSTITUTE, AND DIRECTOR, CENTER FOR EMPLOYMENT POLICY, 
                         WASHINGTON, DC

    Ms. Furchtgott-Roth. Madam Chairwoman, as a resident of the 
State of Maryland, it's a great honor to testify in front of 
you in this committee. Thank you very much for giving me the 
opportunity.
    I would like to say that our health insurance system is in 
terrible shape. We never hear anybody say: ``Oh my goodness, 
I'm losing my job, I'm losing my auto insurance.'' We never 
hear anyone say: ``I'm losing my job, I'm losing my home 
insurance.'' But we do hear: ``Oh my goodness, I'm losing my 
job, I'm losing my health insurance.'' This is because of the 
links between employment and health insurance.
    We know how to do insurance. We don't have problems with 
life insurance, auto insurance, home insurance. What we need to 
do is give people a choice of health insurance plans, just as 
the way we have for auto, home, and life insurance, just like 
the Patients' Choice Act of Senator Burr and Senator Coburn, 
who is a physician, that would give everyone the opportunity to 
choose their own plans and have people, insurance companies, 
competing for people's business, just like we see ads from 
GEICO: Call us for a 15-minute quote and we'll give you a lower 
rate. That's what we need to do with the health insurance 
market.
    Unfortunately, the bills in front of Congress right now, 
the House Democrats' bill, the two bills in the Senate, are 
anti-woman, anti-man, and anti-American. They would provide 
worse care to all Americans. They would hurt our economy by 
raising taxes, increasing our national debt, raising the 
deficit. This would lower job creation and stop women from 
progressing. Women progress when they are employed and right 
now their unemployment rates are 2 percentage points lower than 
men's. Women are doing well in this economy. But if they don't 
have any jobs, they're not going to be doing well any more.
    This bill would only help one group, foreign workers. They 
would benefit from the outsourcing that American firms would do 
to plants and firms by shipping jobs overseas. Foreign workers 
are not the people we want to help. We want to help Americans.
    There are four major things wrong with these bills. First 
of all, everyone would pay more for health insurance because 
the mandated plan that one would purchase under the health 
exchange is so large that it would be very, very expensive. A 
catastrophic bare-bones insurance plan, where you pay for 
routine care, is not permitted under the health exchanges. You 
would have to have no payments for routine care. A large array 
of things would be covered, such as mental health, substance 
abuse, that you might not need.
    It's as though auto insurance paid for changing your 
windscreen wiper blades and changing your oil. They're routine 
expenditures that you can pay on your own. You don't need 
insurance for that. Your auto insurance would be really 
expensive if it paid for all those little things. But people 
should be allowed to buy a plan that just has insurance against 
major things, maybe having a baby, breaking a leg, getting hit 
while you're on your bicycle, that kind of thing. But this plan 
doesn't do it.
    The higher cost of the premiums for this expensive plan 
would lower cash wages, so lower income and minorities would be 
more likely to lose their job. Say you have a job at minimum 
wage, $7.25 right now. Your employer is required to cover you, 
so in fact your wage couldn't go any lower. You would be 
covered, but what would happen is the employer would have an 
incentive not to hire you, just as when we raised the minimum 
wage this summer the teen unemployment rate hit 26 percent 
because these groups just were not hired any more.
    Another problem with these bills is that those on Medicare 
would receive worse care. As Senator Mikulski pointed out, 
women are disproportionately large consumers of Medicare. But 
these bills--the Baucus bill, for example, would cut $404 
billion off Medicare with cuts in Medicare of 10 to 15 percent 
every year. We're going to be covering more people, lower cost, 
cuts in Medicare--no one can really believe that women are 
going to continue to get the care, and men, that they get now 
with these different cuts in Medicare, with such substantial 
cuts.
    In fact, Congress has overridden its own laws and not 
allowed the 10 percent cuts in reimbursement rates for Medicare 
physicians that have been in the law right now. It's overridden 
those, but the bill mandates 25 percent cut in Medicare 
reimbursement rates for physicians. Women aren't going to be 
able to get to see their doctors.
    Finally, health reform would discourage job creation and 
incentive to work by raising taxes. House Democrats' bill, the 
top rate would go to 45 percent, penalizing the most productive 
small businesses, the most productive workers. They wouldn't 
have an incentive to expand and create jobs.
    It's also true at the low end. The Joint Tax Committee has 
estimated that the effective tax rate for people at 150 percent 
of the poverty line is 59 percent. They would face a tax of 59 
percent because of the phaseout of the benefits. Those at 250 
percent of the poverty line would face a tax rate of 49 
percent. This is not something that we want to have. This bill, 
we need health reform, but this is not the reform we have. We 
need to take a serious look at Senator Burr's bill that would 
give everyone tax credits to go out and buy their own plan, 
just like we use our own money to go out and buy auto 
insurance, life insurance, and home insurance.
    Thank you very much.
    [The prepared statement of Ms. Furchtgott-Roth follows:]
              Prepared Statement of Diana Furchtgott-Roth
    Senator Mikulski, Mr. Chairman, members of the committee, I am 
honored to be invited to testify before your committee today on the 
subject of the effects of the health reform bills on men and women. I 
have followed and written about this and related issues for many years. 
I am the coauthor of two books on women in the labor force, Women's 
Figures: An Illustrated Guide to the Economic Progress of Women in 
America, and The Feminist Dilemma: When Success Is Not Enough. I am 
currently working on a sequel to Women's Figures, entitled Better 
Women's Figures.
    Currently I am a senior fellow at the Hudson Institute. From 
February 2003 until April 2005 I was chief economist at the U.S. 
Department of Labor. From 2001 until 2003 I served at the Council of 
Economic Advisers as chief of staff and special adviser. Previously, I 
was a resident fellow at the American Enterprise Institute.
    Women are doing better than men in many measurable areas. Women 
live on average 5.1 years longer than men.\1\ In September 2009, men's 
unemployment rate was 11 percent and women's was 8.4 percent.\2\ Last 
year women received 58 percent of all BA degrees awarded, and 61 
percent of all MA degrees.\3\ Women have made tremendous progress in 
labor force participation over the past 50 years: last year their labor 
force participation was 14 percentage points lower than men's, compared 
with 46 percentage points lower than men's in 1960.\4\ When 
demographics, education, work experience, workplace and occupational 
characteristics, and child-
related factors are taken into account, women earn practically the same 
as men. In order to continue this progress, it is vital that American 
employers be given the maximum opportunities to create jobs.
---------------------------------------------------------------------------
    \1\ Jiaquan Xu, Kenneth D. Kochanek, and Betzaida Tejada-Vera, 
``Deaths: Preliminary Data for 2007.'' Division of Vital Statistics, 
National Vital Statistics Reports, Volt. 58, No. 1, August 19, 2009. 
Available at http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_01.pdf.
    \2\ Bureau of Labor Statistics, ``The Employment Situation--
September 2009,'' October 2009. Available at: http://www.bls.gov/
news.release/pdf/empsit.pdf.
    \3\ U.S. Department of Education, National Center for Education 
Statistics, ``Digest of Education Statistics: 2008,'' March 2009.
    \4\ Bureau of Labor Statistics and Haver Analytics.
---------------------------------------------------------------------------
    Although the leading Democratic healthcare reform bills in 
Congress--the Senate HELP Committee's Affordable Health Choices Act,\5\ 
the Senate Finance Committee's America's Healthy Future Act of 2009,\6\ 
and the House Education and Labor Committee's America's Affordable 
Health Choices Act of 2009 \7\--intend to help women, they would leave 
all Americans, including women, worse off than they are at present. 
First, everyone, including women, would pay more for health insurance. 
Second, the higher cost of health insurance premiums would lower cash 
wages for Americans. Third, those on government plans, such as Medicare 
and Medicaid, predominantly women, would receive worse care. Fourth, 
the economy-wide effects of health care reform mandates would 
discourage job creation and incentives to work by raising taxes.
---------------------------------------------------------------------------
    \5\ U.S. Senate ``Affordable Health Choices Act.'' 111th Congress, 
1st session. S. 1679. Washington: GPO, September 2009. Available at: 
http://frwebgate.access.gpo.gov/cgi-bin/getdoc
.cgi?dbname=111_cong_bills&docid=-f:s1679pcs.txt.pdf.
    \6\ U.S. Senate Committee on Finance, ``America's Healthy Future 
Act of 2009.'' Available at: http://www.finance.senate.gov/sitepages/
leg/LEGpercent202009/100209_Americas_Healthy_
Future_Act_AMENDED.pdf.
    \7\ U.S. House ``America's Affordable Health Choices Act of 2009.'' 
111th Congress, 1st session. H.R. 3200. Washington: GPO, July 2009. 
Available at: http://frwebgate.access.gpo.gov/cgi-bin/
getdoc.cgi?dbname=111_cong_bills&docid=f:h3200ih.txt.pdf.
---------------------------------------------------------------------------
    Everyone, including women would pay more for health insurance. 
Young women would have to pay substantially more for health insurance 
than they do at present because premium differentials for health 
insurance would be capped. All women would have to pay more due to the 
government's definition of a qualified plan.
    One feature of the health reform bills is that variation in 
premiums would be limited. Under the House Democrats' bill, for 
example, the most expensive premium could not be more than twice as 
much as the cheapest for the same plan, and variation would only be 
allowed on the basis of age. This means that younger women would have 
to pay far more in premiums than they would otherwise.
    The Baucus bill would require everyone to purchase health insurance 
or face penalties. Americans with incomes up to 400 percent of the 
poverty line (currently $90,100 for a family of four) who are not 
covered by an employer plan would receive tax credits to purchase 
health insurance plans in an ``exchange.''
    Plans purchased in the exchange would be Cadillac plans, with 
generous coverage and no lifetime or annual limits on any benefits. 
Only Americans under 25 and those who spend more than 8 percent of 
their income on health insurance premiums would be allowed to purchase 
``young invincible'' plans, catastrophic insurance against major 
accidents. American men and women would have to pay a far higher cost 
for health insurance, since plans would have to accept everyone, 
regardless of health or pre-existing conditions.
    It's easy to see from the Baucus bill why the cost of health 
insurance is going to skyrocket. According to the Senate Finance 
Committee, ``All plans would be required to provide primary care and 
first-dollar coverage for preventive services, emergency services, 
medical and surgical care, physician services, hospitalization, 
outpatient services, day surgery and related anesthesia, diagnostic 
imaging and screenings, including x-rays, maternity and newborn care, 
pediatric services (including dental and vision care), prescription 
drugs, radiation and chemotherapy, and mental health and substance 
abuse services. Plans would not be allowed to set lifetime limits on 
coverage or annual limits on any benefits.'' \8\
---------------------------------------------------------------------------
    \8\ U.S. Senate Committee on Finance, ``Baucus Introduces Landmark 
Plan to Lower Health Care Costs, Provide Quality, Affordable Coverage'' 
(News Release) September 16, 2009. Available at: http://
finance.senate.gov/press/Bpress/2009press/prb091609h.pdf.
---------------------------------------------------------------------------
    Half of the Baucus plan would be funded through an excise tax on 
expensive plans of 40 percent on premiums above $8,000 for singles and 
$21,000 for families, bringing in $201 billion from 2013 through 2019. 
Today health insurance premiums cost on average $4,824 for singles and 
$13,375 for families.\9\ CBO's calculates that in 2019, in addition to 
$46 billion in excise taxes, Americans would be paving over $100 
billion in higher premiums.\10\ Since CBO forecasts increases in excise 
tax revenues of 10 percent to 15 percent annually after 2019, health 
insurance premiums must also rise by the same percent annually. This 
government mandate will amount to a steady drain on American men and 
women. A memo dated October 13, 2009, from Thomas Barthold, chief of 
staff of the Joint Committee on Taxation, said ``Generally, we expect 
the insurer to pass along the cost of the excise tax to consumers by 
increasing the price of health coverage.'' \11\
---------------------------------------------------------------------------
    \9\ The Kaiser Family Foundation and Health Research and 
Educational Trust, ``Employer Health Benefits 2009 Annual Survey'' 
September 15, 2009. Available at: http://egbs.kff.org/pdf/2009/
7936.pdf.
    \10\ Congressional Budget Office. ``Letter to the Honorable Max 
Baucus on the Preliminary Analysis of the Chairman's Mark for the 
America's Healthy Future Act, as Amended,'' October 7, 2009. Available 
at: http://www.cbo.gov/ftpdocs/106xx/doc10642/10-7-Baucus_letter.pdf.
    \11\ Joint Committee on Taxation. ``Memo from Thomas A. Barthold to 
Cathy Koch and Mark Prater,'' October 13, 2009.
---------------------------------------------------------------------------
    The higher cost of health insurance premiums would lower cash wages 
for everyone, in particular women. A government mandate for employers 
to provide health insurance would cause wages to decline, because the 
costs of the insurance would be passed on to workers, who would see a 
decline in wages. Alternatively, discussed in the following section, 
employers would reduce employment, especially for low-wage workers.
    Harvard University economics professor Katherine Baicker and 
University of Michigan economics professor Helen Levy concluded that 
low-income, minority workers would be the most affected by a government 
mandate: \12\ ``We find that 33 percent of uninsured workers earn 
within $3 of the minimum wage, putting them at risk of unemployment if 
their employers were required to offer insurance. . . . Workers who 
would lose their jobs are disproportionately likely to be high school 
dropouts, minority, and female. Thus, among the uninsured, those with 
the least education face the highest risk of losing their jobs under 
employer mandates.''
---------------------------------------------------------------------------
    \12\ Katherine Baicker and Helen Levy, ``Employer Health Insurance 
Mandates and the Risk of Unemployment,'' NBER Working Paper No. 13528, 
October 2007. Available at: http://www.nber.org/papers/W13528.pdf.
---------------------------------------------------------------------------
    Employers are likely to respond to the higher costs resulting from 
mandated provision of health insurance by employing fewer workers, or 
outsourcing jobs overseas. This would be especially harmful for small 
businesses which employ low-income wage workers at or near the minimum 
wage since employers cannot reduce these wages to absorb the increased 
cost. It is no coincidence that this summer's increase in the minimum 
wage to $7.25 hourly \13\ was followed by record teen unemployment 
rates, the latest almost 26 percent in September.\14\ Employers laid 
off the less-skilled workers rather than paying them more than they 
were worth.
---------------------------------------------------------------------------
    \13\ U.S. Department of Labor Wage and Hour Division, ``Employee 
Rights under the Fair Labor Standards Act,'' July 2009. Available at: 
http://www.dol.gov/esa/whd/regs/compliance/posters/minwagep.pdf.
    \14\ Bureau of Labor Statistics, `` The Employment Situation--
September 2009.''
---------------------------------------------------------------------------
    CBO concluded that a requirement for employers to provide health 
insurance would encourage employers to hire more part-time workers and 
fewer full-time workers. According to CBO, the creation of different 
penalties for full- and part-time workers ``would increase incentives 
for firms to replace full-time employees with more part-time or 
temporary workers.'' \15\
---------------------------------------------------------------------------
    \15\ Congressional Budget Office, ``Effects of Changes to the 
Health Insurance System on Labor Markets,'' July 13, 2009. Available 
at: http://www.cbo.gov/ftpdocs/104xx/doc10435/07-13-
HealthCareAndLaborMarkets.pdf.
---------------------------------------------------------------------------
    According to Ezekiel Emanuel and Victor Fuchs in the Journal of the 
American Medical Association,

          ``It is essential for Americans to understand that while it 
        looks like they can have a free lunch--having someone else pay 
        for health insurance --they cannot. The money comes from their 
        own pockets. Understanding this is essential for any 
        sustainable health care reform.'' \16\
---------------------------------------------------------------------------
    \16\ Ezekiel J. Emanuel and Victor R. Fuchs, ``Who Really Pays for 
Health Care Costs,'' Journal of the American Medical Association, March 
5, 2008. Similarly, Harvard economist Katherine Baicker wrote, 
``Employees ultimately pay for the health insurance they get through 
their employer, no matter who writes the check to the insurance 
company. The view that we can get employers to shoulder the cost of 
providing health insurance stems from the misconception that employers 
pay for benefits out of a reservoir of profits. Regardless of a firm's 
profits, valued benefits are paid for primarily out of workers' 
wages.'' Katherine Baicker and Amitabh Chandra, ``Myths and 
Misconceptions about U.S. Health Insurance,'' Health Affairs, 2008.

---------------------------------------------------------------------------
    Peter Orszag reiterated this as CBO director, saying that,

          ``The economic evidence is overwhelming, the theory is 
        overwhelming, that when your firm pays for your health 
        insurance you actually pay through reduced take-home pay. The 
        firm is not giving that to you for free. Your other wages or 
        what have you are reduced as a result. I don't think most 
        workers realize that.'' \17\
---------------------------------------------------------------------------
    \17\ CBO Director Peter Orszag Testimony before the Senate Finance 
Committee, June 17, 2008.
---------------------------------------------------------------------------
    Those on government plans, such as Medicare and Medicaid, 
predominantly women, would receive worse care. Medicare recipients, who 
are primarily women,\18\ would receive a lower standard of care than 
they do at present due to cuts in the program. Putting more low-income 
women into the Medicaid program would give them a lower standard of 
care.
---------------------------------------------------------------------------
    \18\ The Kaiser Family Foundation, ``Medicare's Role for Women,'' 
June 2009. Available at: http://www.kfforg/womenshealth/upload/
7913.pdf.
---------------------------------------------------------------------------
    Nearly 90 percent of the $404 billion Medicare and Medicaid savings 
would be from Medicare in the period 2013 to 2019 in the Baucus bill. 
Thereafter, savings would be expected to continue at the rate of 10 
percent to 15 percent. Of all demographic groups in America, elderly 
women would be the biggest losers under the Baucus plan. CBO estimates 
that Medicare Advantage plans, popular bundled health maintenance 
organizations serving 20 percent of Medicare patients, primarily women, 
would be cut by $117 billion.\19\ Under the heading ``Ensuring Medicare 
Sustainability,'' more than $200 billion would be cut from payments to 
hospitals, elder care, doctors, and hospices. Payments to Medicare 
doctors would be cut by 25 percent in 2011. A Medicare Commission would 
propose further cuts.
---------------------------------------------------------------------------
    \19\ Congressional Budget Office. ``Letter to the Honorable Max 
Baucus on the Preliminary Analysis of the Chairman's Mark for the 
America's Healthy Future Act, as Amended.''
---------------------------------------------------------------------------
    The government would persuade doctors to cut Medicare costs by 
associating more tests with lower reimbursements. Ranked in order of 
spending per patient, every year the top 10 percent of physicians would 
have their reimbursements cut. Since by definition there would always 
be 10 percent of physicians in the top 10 percent, they would have an 
incentive to avoid the sickest patients or the specialties with the 
most tests. Since women are disproportionate users of Medicare, they 
would be the most affected.
    According to the Kaiser Family Foundation, women comprise 69 
percent of Medicaid recipients.\20\ The House Democrats bill plans to 
expand the Medicaid program to 133 percent of the poverty line in order 
to cover low-income uninsured workers. Not only would this cause a 
financial drain on already-strained budgets, but Medicaid does not 
provide as high a level of care as with many other private plans. Women 
would be disadvantaged by being put on Medicaid rather than being given 
a refundable tax credit to purchase a private plan, as has been 
suggested by Congressman Tom Price.
---------------------------------------------------------------------------
    \20\ The Kaiser Family Foundation, ``Medicaid's Role for Women,'' 
October 2007. Available at: http://www.kff.org/womenshealth/upload/
7213_03.pdf.
---------------------------------------------------------------------------
    Many Medicaid patients cannot find doctors who will see them. In 
California, 49 percent of family physicians do not participate in 
Medicaid \21\ while in Michigan the number of doctors who do not see 
Medicaid patients has risen from 12 percent in 1999 to 36 percent in 
2005.\22\ Physicians don't want to take Medicaid patients because of 
low reimbursement and substantial paperwork. A 2009 Health Affairs 
report indicated that Medicaid physician fees increased 15.1 percent, 
on average, between 2003 and 2008.\23\ This was below the general rate 
of inflation of 20.3 percent, resulting in a reduction in real fees.
---------------------------------------------------------------------------
    \21\ Lisa Backus et al., ``Specialists' and Primary Care 
Physicians' Participation in Medicaid Managed Care,'' Journal of 
General Internal Medicine, Volt. 16, No. 12. December 2001.
    \22\ Jay Greene, ``Committee looks at taxing Michigan doctors to 
help avert 12 percent Medicaid cuts,'' Michigan State Medical Society, 
September 22, 2009. Available at: http://www.msms.org/AM/
Template.cfm?Section = Advocacy &TEMPLATE =/CM/
ContentDisplay.cfm&CONTENTID=
12302.
    \23\ Stephen Zuckerman, Aimee F. Williams, and Karen E. Stockley, 
``Trends in Medicaid Physician Fees, 2003-2008,'' Health Affairs, Volt. 
28, No. 3, 2009.
---------------------------------------------------------------------------
    The economy-wide effects of health care reform mandates would 
discourage job creation and incentives to work by raising taxes. The 
tax increases in the House bill would disproportionately fall on women, 
discourage job creation, and reduce the incentives for married women to 
work.
    According to Dr. Jonathan Javitt, adjunct professor of public 
health at Johns Hopkins University,

          ``Many more women are single parent heads of households than 
        are men. If families are taxed for not having health insurance, 
        this tax is certain to disproportionately penalize single-
        parent families who are barely making ends meet.''

    Health reform is expensive, and some of the bills pay for it 
through increased taxes. For instance, the House bill relies on income 
tax surcharges on the most productive workers, bringing the top tax 
rate to 45 percent, as well as an 8 percent payroll tax on employers 
who do not offer the right kind of health insurance to their employees. 
Moreover, anyone who does not sign up for health insurance would face 
an additional 2.5 percent income tax. Taxes discourage work and 
investment, thereby reducing employment.
    Such tax increases would adversely affect married women because 
their incomes are frequently secondary. It would not only discourage 
marriage, but also discourage married women from working.
    By raising taxes on upper-income Americans to 45 percent, Congress 
would worsen our tax system's marriage penalty on two-earner married 
couples, and women would pay even more tax married than single. Unless, 
of course, women left the workforce, lowering a couple's Federal tax 
rate. Federal taxes are not the whole story. State taxes would take 
another 9 percent of incomes in States such as Oregon, Vermont and 
Iowa; Medicare would take another 1.45 percent; and Social Security 
taxes would add another 6.2 percent up to $107,000.
    The tax penalty for working is even more substantial at the low end 
of the income spectrum. The staff of the Joint Tax Committee estimated 
that combined effective income and premium marginal tax rates, 
including payroll taxes, for poor families of four under the Baucus 
bill would be substantial, dwarfing rates for upper-income individuals. 
They would reach 59 percent at 150 percent of the poverty line; 49 
percent at 250 percent of the poverty line; 39 percent at 350 percent 
of the poverty line; and 40 percent at 450 percent of the poverty 
line.\24\
---------------------------------------------------------------------------
    \24\ Joint Committee on Taxation. ``Memo from Thomas A. Barthold to 
Mark Prater, Tony Coughlan, Nick Wyatt, and Chris Conlin'' October 13, 
2009.
---------------------------------------------------------------------------
    When mothers take jobs, earnings are reduced by taxes, in addition 
to costs for childcare and transportation. This discourages women not 
just from working, but also from striving for promotions, from pursuing 
upwardly-mobile careers. Mothers are more affected by the marriage 
penalty than other women because they are more likely to move out of 
the labor force to look after newborn children and toddlers, and then 
to return to work when their children are in school.
    Our tax system should not make it harder for women to work. The 
penalty falls both on women struggling to escape from poverty, and on 
married women who have invested in education, hoping to shatter glass 
ceilings and compete with men for managerial jobs. Throughout the 
income spectrum, higher taxes would exacerbate the penalty for working.
    Our health insurance system needs to change, but not in the way 
envisaged by Congress. Rather than mandating one expensive plan, 
Congress would do better to change the current health insurance tax 
credit from employers to individuals and allow people to pick their own 
portable plans, as they do with other forms of insurance. That would 
help women, and men too. It is vital that women's progress in the labor 
force continue, and the main route to this progress is an abundant 
supply of job opportunities. As configured, the three plans under 
consideration today would impede such job creation.
    Thank you for allowing me to appear before you today. I would be 
glad to answer any questions.
                               Reference
Bureau of Labor Statistics, ``The Employment Situation--September 
    2009,'' October 2009. Available at: http://www.bls.gov/
    news.release/pdf/empsit.pdf.
Congressional Budget Office, ``Effects of Changes to the Health 
    Insurance System on Labor Markets,'' July 13, 2009. Available at: 
    http:/www.cbo.gov/ftpdocs/104xxdoc10435/07-13-
    HealthCareAndLaborMarkets.pdf.
Congressional Budget Office. ``Letter to the Honorable Max Baucus on 
    the Preliminary Analysis of the Chairman's Mark for the America's 
    Healthy Future Act, as Amended,'' October 7, 2009. Available at: 
    http://www.cbo.gov/ftpdocs/106xx/doc10642/10-7-Baucus_letter.pdf.
CBO Director Peter Orszag, Testimony before the Senate Finance 
    Committee, June 17, 2008.
Ezekiel J. Emanuel, MD, PhD and Victor R. Fuchs, PhD, ``Who Really Pays 
    for Health Care Costs,'' Journal of the American Medical 
    Association, March 5, 2008.
Jay Greene, ``Committee looks at taxing Michigan doctors to help avert 
    12 percent Medicaid cuts,'' Michigan State Medical Society, 
    September 22, 2009. Available at: http:/www.msms.org/AM/
    Template.cfm?Section=Advocacy&TEMPLATE=/CM/
    ContentDisplay.cfm&CONTENTID=12302.
Jiaquan Xu, Kenneth D. Kochanek, and Betzaida Tejada-Vera, ``Deaths: 
    Preliminary Data for 2007.'' Division of Vital Statistics, National 
    Vital Statistics Reports, Volt. 58, No. 1, August 19, 2009. 
    Available at http://www.cdc.gov/nchs/data/nvsr/nvsr58/
    nvsr58_01.pdf.
Katherine Baicker and Amitabh Chandra, ``Myths and Misconceptions about 
    U.S. Health Insurance,'' Health Affairs, 2008).
Katherine Baicker and Helen Levy, ``Employer Health Insurance Mandates 
    and the Risk of Unemployment,'' NBER Working Paper No. 13528, 
    October 2007. Available at: http://www.nber.org/papers/w13528.pdf.
Lisa Backus, et al., ``Specialists' and Primary Care Physicians' 
    Participation in Medicaid Managed Care,'' Journal of General 
    Internal Medicine, Volt. 16, No. 12. December 2001.
Stephen Zuckerman, Aimee F. Williams, and Karen E. Stockley, ``Trends 
    in Medicaid Physician Fees, 2003-2008'', Health Affairs, Volt. 28, 
    No. 3, 2009.
The Kaiser Family Foundation, ``Medicaid's Role for Women,'' October 
    2007. Available at: http://www.kff.org/womenshealth/upload/
    7213_03.pdf.
The Kaiser Family Foundation, ``Medicare's Role for Women,'' June 2009. 
    Available at: http://www.kff.org/womenshealth/upload/7913.pdf.
The Kaiser Family Foundation and Health Research and Educational Trust, 
    ``Employer Health Benefits 2009 Annual Survey'' September 15, 2009. 
    Available at: http://ehbs.kff.org/pdf/2009/7936.pdf.
U.S. Department of Education, National Center for Education Statistics, 
    ``Digest of Education Statistics: 2008,'' March 2009.
U.S. Department of Labor Wage and Hour Division, ``Employee Rights 
    under the Fair Labor Standards Act,'' July 2009. Available at: 
    http:/www.dol.gov/esa/whd/regs/compliance/posters/minwagep.pdf.
U.S. Senate ``Affordable Health Choices Act.'' 111th Congress, 1st 
    session. S. 1679. Washington: GPO, September 2009. Available at: 
    http://frwebgate.access.gpo.gov/cgi-bin/
    getdoc.cgi?dbname=111_cong_bills&docid=f:s1679pcs.txt.pdf.
U.S. Senate Committee on Finance, ``America's Healthy Future Act of 
    2009.'' Available at: http:/www.finance.senate.gov/sitepages/leg/
    LEGpercent202009/100209_
    Americas_Healthy_Future_ActAMENDED.pdf.
U.S. Senate Committee on Finance, ``Baucus Introduces Landmark Plan to 
    Lower Health Care Costs, Provide Quality, Affordable Coverage'' 
    (News Release) September 16, 2009. Available at: http://
    finance.senate.gov/press/Bpress/2009press/prb091609h.pdf.
U.S. House ``America's Affordable Health Choices Act of 2009.'' 111th 
    Congress, 1st session. H.R. 3200. Washington: GPO, July 2009. 
    Available at: http://frwebgate
    .access.gpo.gov/cgi-bin/
    getdoc.cgi?dbname=111_cong_bills&docid=f:h3200ih.txt
    .pdf.

    Senator Mikulski. Ms. Crouse.

  STATEMENT OF JANICE SHAW CROUSE, Ph.D. DIRECTOR AND SENIOR 
      FELLOW, CONCERNED WOMEN FOR AMERICA, WASHINGTON, DC

    Ms. Crouse. Thank you. I'm from Maryland, too, Senator 
Mikulski. It's a privilege to present testimony before this 
august group on such an important topic and to participate in a 
debate on an issue that is so important to the future of this 
Nation.
    Let me assure you that I agree with the wonderful arguments 
that have been put forth about the importance of the equality 
of care--health care--for women. I represent Concerned Women 
for America, the Nation's largest public policy women's 
organization. We are a membership group with over 600,000 
members from all across the United States. Our grassroots 
members are women on the Main Streets of small town America and 
big city America. We are the women who will be most affected by 
health care reform provisions, those things that are being 
discussed.
    You can read my formal testimony. Copies are on the table 
and all of the members have received copies. But in my verbal 
remarks this morning I want to focus on two issues that are 
vitally concerning to the women that I represent. Those two 
issues are the elephant in the room this morning when it comes 
to women's concerns, and that is abortion and end of life 
women's issues.
    In the Old Testament, the Fifth Commandment is given with a 
promise. We are told that we should honor our father and 
mother, and if we do we will live long lives. No Nation can 
hope to prosper if it does not act in accordance with this 
mandate. To claim that cutting Medicare by half a trillion 
dollars will have no impact on senior citizen benefits mocks 
voters and insults our intelligence. No amount of smoke and 
mirrors can conceal this fact from our Nation's senior 
citizens, and most of our senior citizens are women. Many of 
them, if not most of them, have been mothers.
    These mothers are the backbone of our Nation. They are the 
very DNA. The DNA of a mother is a mandate to answer the call 
to sit in vigil with a sick child or any loved one who is sick. 
Mothers generally do not begrudge that labor and service to 
those that they love.
    It's an outrage when we hear politicians say to these 
mothers that as old women their years of service are ended and 
it's time for them to quit consuming resources. In a democratic 
representative democracy, elected officials are honor-bound to 
represent those whom they serve.
    A November 2008 Zogby poll revealed 71 percent of Americans 
oppose government-funded abortion. Those of us who give 
testimony and represent the public are free citizens, very 
grateful for the opportunity to give feedback and opinion on 
the issues before this great body of legislators. But in a 
representative democracy we are not summoned by masters and we 
are not intimidated by power. Instead, we are here representing 
the views of thousands, if not millions, just like us, who do 
not intend for our voices to be unheard or our choices limited 
or for our hard-fought liberties to be taken away by those who 
would obfuscate, distort, or hide the truth.
    No one today here should forget that the citizenry of this 
Nation has a history of overthrowing tyranny, and nothing is a 
clearer act of tyranny than for Congress to legislate change 
that abrogates our God-given right to choose life.
    It is clear that the current health care reform legislation 
would classify abortion as an essential benefit and make it 
illegal for health care workers to deny abortion to anyone who 
seeks it, regardless of their personal convictions or their 
beliefs. Further, it is clear that the legislation would 
overrule State laws that require limitations, such as mandatory 
parental notification or even waiting periods.
    It is also clear that the current bills would force 
American citizens, whether they want to or not, to subsidize 
abortion on demand with their tax dollars. Even those with 
incomes up to 400 percent of poverty would receive subsidies to 
pay for abortions.
    Many things are negotiable and amendable to finding some 
middle ground, but human life is sacred. Its defense is not 
open to negotiation or to compromise. Defending life is our 
sacred duty.
    The 6,000 women of CWA and the millions of like-minded 
women in this country count it a privilege to stand for those 
who are too vulnerable to stand for themselves.
    Thank you for this opportunity.
    [The prepared statement of Ms. Crouse follows:]
            Prepared Statement of Janice Shaw Crouse, Ph.D.
                                summary
    While the cost is a major concern, health care reform must respect 
all life, at the beginning and end of life.
                       issues related to abortion
    We have two primary concerns about health care reform relating to 
abortion--whether it funds and covers abortion and whether it allows 
health care workers freedom of conscience.
    Funding and Covering Abortion: Without explicit wording prohibiting 
abortion funding and coverage, health care reform will involve all 
American taxpayers in explicit financial support for abortion-on-
demand. In addition, Planned Parenthood is a ``community provider'' 
under health care reform bills.
    Freedom of Conscience for Health Care Workers: Any health care 
reform provisions must provide protection for the rights of conscience 
for health care workers and medical providers. Those whose faith or 
conscience prevent them from performing abortions must have the ability 
to object and refrain from participating in actions that are contrary 
to their beliefs.
                     issues related to end-of-life
    Life Sustaining Treatment: Pro-lifers are, rightly, concerned about 
the possibility of limitations on life-sustaining treatment of the 
elderly, permanently disabled, terminally ill, or those with long-term 
chronic illnesses. No one should suggest the least expensive treatment 
or no treatment for those who are at or near the end of life or those 
whose conditions are irreversible.
    Care at the End-of-Life: One of the most troubling aspects of 
health care reform legislation concerns end-of-life issues. Any health 
care reform must provide effective treatment for the Nation's older 
people--without curtailment, withdrawal or denial of life-sustaining 
care for the terminally ill, the chronically ill, or the permanently 
disabled. Further, those provisions that address end-of-life issues 
must clearly leave no room for an interpretation that would pressure 
healthcare providers to make decisions based on cost rather than the 
best medical care.
                               conclusion
    Concerned Women for America believes that for any health care 
legislation to pass Congress it must protect life from conception to 
death. Therefore, we recommend:

    1. First and foremost, abortion must be explicitly prohibited both 
in funding and coverage, with the Hyde Amendment permanently codified 
in law.
    2. Second, the right to free exercise of their conscience must be 
granted to all health care workers without penalty or intimidation.
    3. Third, life-sustaining treatment must be available to all 
citizens, including the elderly, terminally or chronically ill or those 
who are permanently disabled.
    4. Fourth, we categorically reject end-of-life counseling based on 
cost considerations and government formulas generated by Comparative 
Effectiveness Research. And, we reject all assisted suicide measures.
                                 ______
                                 
    It is a pleasure to address this distinguished committee and to be 
a part of this distinguished panel. We are part of one of the most 
important debates to face this Nation--especially for women and 
children. Ironically, as this debate rages, my book, Children at Risk, 
is being printed by the publisher. That book details all the ways that 
we are failing our children--primarily because of fatherless families 
leaving both women and children to face the vicissitudes of life 
without the support, protection and comfort that they need to thrive. 
With the additional costs and the problems associated with the health 
care reform bills currently in Congress, the burdens on women and 
children will escalate.
    There is ample evidence (including a just-released report from 
Pricewater-
houseCoopers) that health care reform measures will be prohibitively 
expensive--more than twice the expected growth in the Consumer Price 
Index with the increased cost of health insurance premiums being borne 
by individuals and families.\1\
---------------------------------------------------------------------------
    \1\ ``Potential Impact of Health Reform on the Cost of Private 
Health Insurance Coverage,'' PricewaterhouseCoopers, October, 2009.
---------------------------------------------------------------------------
    While the cost is a major concern, I would like to focus this 
morning on health care concerns at the beginning and end of life. 
Health care reform must respect all life, but human beings are 
especially vulnerable at the beginning and end of their lives. 
Provisions of a satisfactory plan must protect the baby in the womb and 
provide effective care for citizens at the end of life. At both these 
stages of life, females are more vulnerable than males.
                       issues related to abortion
    We have two primary concerns about health care reform relating to 
abortion--whether it funds and covers abortion and whether it allows 
health care workers freedom of conscience.
    Funding and Covering Abortion: In spite of all the rhetoric to the 
contrary, all the health care reform bills currently before Congress 
mandate abortion funding and coverage. As pointed out so effectively by 
Americans United for Life (AUL), all of the pro-life amendments that 
came before the various committees were rejected. It is very clear that 
any health care reform bill must contain express language prohibiting 
abortion funding and coverage. Otherwise, ``courts and administrative 
agencies will interpret health care reform to include it, based on 
prior interpretations of Medicaid's `Mandatory Categories of Care.' In 
addition, the Hyde Amendment, as added yearly to HHS Appropriations, is 
insufficient to prevent abortion funding and coverage under the health 
care bills.'' \2\ In short, without explicit wording prohibiting 
abortion funding and coverage, health care reform will involve all 
American taxpayers in explicit financial support for abortion-on-
demand.
---------------------------------------------------------------------------
    \2\ Mary Harned, ``A Pro-Life Look at the Health Care Reform Bills 
Currently in Congress,'' Americans United for Life, October 12, 2009, 
p. 1. http://blog.aul.org/2009/10/10/a-pro-life-look-at-the-health-
care-reform-bills-currently-in-congress/.
---------------------------------------------------------------------------
    For instance, the Senate HELP bill provides for a ``Medical 
Advisory Committee'' (Sec. 3103) to determine the specific benefits 
that are offered by the private and public health care plans. The 
members of this committee (to be appointed by President Obama's 
administration rather than be elected or result from a Senate-
appointed bipartisan effort) will make decisions regarding whether 
abortion will be mandatory in the health care plans that are offered. 
President Obama has made it clear that he supports such coverage. 
Indeed, in July 2007 speech he promised Planned Parenthood that his 
Administration would provide mandatory abortion coverage.
    In addition, Planned Parenthood is a ``community provider'' that 
would be included in the health insurance networks under health care 
reform bills. Under Sen. Mikulski's (D-MD) amendment, accepted by the 
Senate HELP committee, community providers ``that serve predominantly 
low-income, medically under-served individuals'' would be covered to 
provide ``any service deemed medically necessary or medically 
appropriate.'' At the time that her amendment passed, Sen. Mikulski 
pointedly refused Senator Hatch's request to specifically exclude 
``abortion services.''
    In the Senate HELP Committee, four separate pro-life amendments 
were defeated along party lines, with the notable exception of Sen. Bob 
Casey (D-PA) who consistently votes pro-life. The amendments would have 
prevented taxpayer funding for abortion, excluded abortion clinics from 
Federal grants and would have kept health care plans from including 
provisions to invalidate State laws regulating abortion. Obviously, the 
defeat of these amendments indicates the intent to implement by stealth 
what cannot be openly passed by vote. Lest anyone think such statements 
are an exaggeration, the lawyers at Americans United for Life have 
itemized cases where the courts have interpreted ``Mandatory 
Categories'' of care to include abortion.\3\ AUL notes that though 
abortion is not explicitly named as a service, the courts have 
concluded that abortion is included in ``family planning,'' 
``outpatient services,'' ``inpatient services'' and ``physician 
services.''
---------------------------------------------------------------------------
    \3\ http://www.aul.org/.
---------------------------------------------------------------------------
    In seeking to reassure pro-life citizens, supporters of health care 
reform measures always refer to the Hyde Amendment as protecting the 
pro-life cause. Sadly, the Hyde Amendment, which prohibits taxpayer 
money for abortion through the Medicaid program, is not permanent law, 
instead, it is a pro-life rider that must be re-introduced and passed 
annually. Further, the proposed health care reform measures include 
funding mechanisms that enable Congress to circumvent the Hyde 
Amendment. This ``back door spending authority'' completely bypasses 
the Appropriations Committee. In addition, the tax credit provisions of 
the Baucus bill are not dependent upon the annual appropriations 
process so Hyde doesn't apply there, either.
    Freedom of Conscience for Health Care Workers: Any health care 
reform provisions must provide protection for the rights of conscience 
for health care workers and medical providers. Those whose faith or 
conscience prevent them from performing abortions must have the ability 
to object and refrain from participating in actions that are contrary 
to their beliefs. The Kennedy amendment [the late Sen. Ted Kennedy (D-
MA)--(amdt. 205) is often invoked to reassure pro-lifers that health 
care workers will continue to be free to object to participate in 
performing abortions. The Kennedy amendment, however, has limited 
scope: it does not cover those who refuse to pay for or to refer 
patients for abortion services. Further, the Kennedy amendment has a 
provision for an exception in ``cases of emergency''--an undefined 
phrase allowing for broad interpretation.\4\ Again, an amendment--
(amdt. 246) to specifically allow health care providers to refuse to 
participate in an abortion or to be discriminated against when they do 
so--failed, clear evidence of the intent of those who are pushing for 
health care reform measures with vague references and back door 
mechanisms. The American people deserve--and demand--clarity on any 
measures that are brought to vote and passed into law.
---------------------------------------------------------------------------
    \4\ The Congressional Budget Office sent a devastating analysis of 
the provisions to Senator Kennedy in a letter dated July 2, 2009 with 
two attachments. Their analysis indicated ``a net increase in Federal 
budget deficits of $597 billion over the 2010-2019 period--reflecting 
net costs of $645 billion for the coverage provisions which would be 
partially offset by net savings of $48 billion from other provisions in 
title I. (CBO has also estimated the budgetary impact of provisions in 
titles III and VI of an earlier draft of the legislation, which would 
add another $14 billion to the net cost of the proposal.'' They 
estimated very little change in the number of people covered by 
insurance.
---------------------------------------------------------------------------
                     issues related to end-of-life
    Life Sustaining Treatment: Pro-lifers are, rightly, concerned about 
the possibility of limitations on life-sustaining treatment of the 
elderly, permanently disabled, terminally ill, or those with long-term 
chronic illnesses. All the health care reform measures currently under 
consideration utilize the CER, Comparative Effective Research, a 
technique that compares and measures the benefits and harms of 
treatments, including prevention, diagnosis, treatment, and monitoring 
of health care delivery services. There are legitimate concerns that 
the CER will be used to determine whether to come to the aid of those 
who are elderly, terminally or chronically ill or those who are 
permanently disabled. Certainly, high profile politicians have made 
comments that would indicate they believe the least expensive treatment 
or no treatment at all is appropriate for those who are at or near the 
end of life or those whose conditions are irreversible.
    Currently, the Senate HELP bill contains a comparative 
effectiveness provision--the Center for Health Outcomes Research and 
Evaluation (CHORE)--but the CHORE is charged to ``report and 
recommend'' rather than to ``mandate.'' Nothing in the bill, however, 
keeps it from being used to deny treatment. Further, the bill provides 
incentives for health care providers to use cost-effective measures. 
(See Sec. 2707 (1)(C)). Most troubling, the bill establishes a Medical 
Advisory Council, reporting to the Secretary of Health and Human 
Services, to establish a minimum set of required ``health care 
benefits.''
    It must be noted that, as is true with the other pro-life 
amendments, all amendments (amdts. 278 and 280) to prohibit cost-driven 
``curtailment, withdrawal or denial'' of care and those that would 
prevent rationing or forcing taxpayers to fund assisted suicide (amdts. 
232, 233, 228) were rejected along party line votes. Amazingly, 
amendments ensuring that everyone have access to essential health 
benefits regardless of their age, expected length of life or disability 
(amdts. 209, 210, and 211)--even amendments preventing private health 
insurers from being prevented from covering treatments--were defeated 
along party lines.
    Care at the End-of-Life: One of the most troubling aspects of 
health care reform legislation concerns end-of-life issues. In the 
House bill (H.R. 3200, section 1233) it is unclear whether patients 
could choose physician-assisted suicide in cases of terminal illness. 
Amendments prevent ``promotion'' of assisted suicide, but not the 
practice of it. And, there are potential conflicts in various sections 
of the bill which preclude advance directives with a suicide or 
assisted suicide option and those that have State exceptions (see 
section 1233 and section 138).The Senate Finance Committee added a 
modification prohibiting Federal funding for assisted suicide and a 
conscience protection clause for those refusing to participate in 
assisted suicide. (#C12, Page 17).
    It is no secret that senior citizens require far more health care 
than younger people. Any health care reform must provide effective 
treatment for the Nation's older people--without curtailment, 
withdrawal or denial of life-sustaining care for the terminally ill, 
the chronically ill, or the permanently disabled. Further, those 
provisions that address end-of-life issues must clearly leave no room 
for an interpretation that would pressure healthcare providers to make 
decisions based on cost rather than the best medical care.
                               conclusion
    In conclusion, Concerned Women for America is concerned about some 
key issues regarding abortion in the health care reform provisions. The 
current bill contains required benefits that the courts can interpret 
as covering abortion. The current bill precludes the Hyde Amendment 
from applying to new funds. Current language requires health plans to 
contract with abortion providers, like Planned Parenthood, and allows 
abortion providers to receive identical non-discrimination protections. 
Further, the bill could pre-empt some State anti-abortion laws.
    CWA believes that for any health care legislation to pass Congress 
it must protect life from conception to death. Therefore, we recommend:

    1. First and foremost, abortion must be explicitly prohibited both 
in funding and coverage, with the Hyde Amendment permanently codified 
in law. The Enzi Amendment #276 ensures that taxpayer's dollars will 
not be used to fund procedures that are ethically and morally 
objectionable to a vast majority of Americans.
    2. Second, the right to free exercise of their conscience must be 
granted to all health care workers without penalty or intimidation. We 
recommend the language of the Pitts/Stupak amendment to H.R. 3200 
rather than the Kennedy Amendment to the Senate HELP bill.
    3. Third, life-sustaining treatment must be available to all 
citizens, including the elderly, terminally or chronically ill or those 
who are permanently disabled.
    4. Fourth, we categorically reject end-of-life counseling based on 
cost considerations and government formulas generated by Comparative 
Effectiveness Research. And, we reject all assisted suicide measures.

    In the Old Testament, the very first commandment [the 5th 
commandment--Exodus 20:12] given with a promise [that those who follow 
the commandment will live long lives] is to honor your father and 
mother. No nation can hope to prosper if it does not act in accordance 
with this mandate. To claim that cutting Medicare by half a trillion 
dollars will have no impact on senior citizen's benefits, mocks voters 
and insults our intelligence. No amount of smoke and mirrors will 
conceal the facts from the Nation's senior citizens.
    Most of our senior citizens are women--most of whom have been 
mothers. Those mothers are the backbone of the Nation; there is in the 
very DNA of a mother the mandate to answer the call to sit in vigil 
when a child or loved one is sick. Mothers generally do not begrudge 
that labor in service to those that they love. It is an outrage to hear 
politicians say to those mothers, in effect, that as old women whose 
years of service are ended, it is time for you to quit consuming 
resources . . . now roll over and die.
    In a representative democracy, elected officials are honor bound to 
represent those whom they serve. A November 2008 Zogby poll revealed 71 
percent of Americans oppose government-funded abortion. Those of us who 
come to give testimony and represent the public are free citizens, 
grateful for the opportunity to give feedback and opinion on the issues 
before this great body of legislators. We are not here summoned by 
masters. We are not here intimidated by power. Instead, we are here 
representing the views of thousands just like us who do not intend for 
our choices to be limited or for our hard-fought liberties to be taken 
away by those who would obfuscate, distort and hide the truth. No one 
here today should forget that the citizenry of this great Nation has a 
history of overthrowing tyranny. And nothing is a clearer act of 
tyranny than for Congress to legislate change that abrogates our God-
given right to choose life.
    It is clear that the current health care reform legislation would 
classify abortion as an ``essential benefit'' and make it illegal for 
health care workers to deny abortion to anyone who seeks it (regardless 
of their personal convictions or beliefs). Further, it is clear that 
the legislation will overrule State laws that require limitations such 
as mandatory parental notification or waiting periods. It is also clear 
that the current bills would force American citizens, whether they want 
to or not, to subsidize abortion-on-demand with their tax dollars. Even 
those with incomes up to 400 percent of poverty would receive subsidies 
to pay for abortion.
    Many things are negotiable and amenable to finding some middle 
ground. But human life is sacred; thus, its defense is not open to 
negotiation or compromise. Defending life is our sacred duty. It is 
also a privilege to stand for those who are too vulnerable to stand for 
themselves.

    Senator Mikulski. Ms. Greenberger.

 STATEMENT OF MARCIA D. GREENBERGER, FOUNDER AND CO-PRESIDENT, 
          NATIONAL WOMEN'S LAW CENTER, WASHINGTON, DC

    Ms. Greenberger. Madam Chairwoman and members of the HELP 
Committee, thank you very much for this opportunity to testify 
on behalf of the National Women's Law Center. The center has 
long advocated for national health care reform that meets 
women's needs and we are, unfortunately, all too familiar with 
the challenges that characterize women's everyday experiences 
in the current health care system and, as has been described in 
very graphic and moving terms by a number of the Senators on 
this committee, subcommittee, among the most damaging are the 
unfair and discriminatory practices of the health insurance 
industry, including gender rating, the exclusion of health care 
services that only women need, and preexisting condition 
denials.
    I would appreciate my full statement being made a part of 
the record, and appended to it is a report that the National 
Women's Law Center issued, ``Nowhere To Turn: How the 
Individual Health Insurance''----
    Senator Mikulski. I'm going to ask unanimous consent your 
full statement be in the record, that Ms. Crouse's full 
statement be in the record. All of you I know have a more 
amplified one, and so let's just ask one unanimous consent. And 
I appreciate everybody staying in the time line. Yours will be, 
Ms. Crouse, and all others, who have a rather extensive one.
    Ms. Greenberger. The report that the National Women's Law 
Center prepared, which focused on the individual market in 
particular, would be the subject of my brief remarks just now. 
But I would hope in the questions to be able to address some of 
the other issues that have been brought up with the members of 
the panel this morning.
    In 2008 the center study documented women's experiences 
that have been described and showed what a difficult and unfair 
place the individual market can be for women in particular. 
Since then, we've also begun to speak out about the problems of 
gender rating in insurance that affect the group market. The 
very fact that employers also have to pay different rates for 
their women employees versus their male employees serves as a 
major disincentive for those employers who have a large number 
of women employees in their workforce to be able to provide 
adequate health care. Gender rating is not only a problem in 
the individual market; it affects the entire health care 
system, and we have found it in group association plans as 
well.
    With respect to gender rating, just a few additional 
statistics to elucidate the unfairness. As much as 45 percent 
more is what is charged for women at age 25 than men at age 25; 
at age 40, as much as 48 percent more; and, as has been 
described, those are figures excluding maternity care coverage.
    Sixty-percent of plans that we surveyed did not offer even 
a rider to cover maternity coverage. As has been described, if 
you are reduced to having to buy that rider, it is 
extraordinarily expensive and there are many limitations that 
make the coverage inadequate.
    A second issue. Some have said that, well, women just cost 
more than men to insure. Well, that is not an answer that's 
acceptable as a matter of common fairness and justice. But 
let's look at some of the numbers as well. In looking at some 
of the best-selling plans, we saw ranges where, for example, in 
Arizona a 40-year-old woman was charged anywhere from 2 percent 
to 51 percent more than a man; in Lincoln, NE, between 11 
percent and 60 percent more than a man. Well, the idea that 11 
percent is actuarially based and yet 60 percent could be 
actuarially based strains credulity, to say the least, and we 
have many other wild variations in the charges that are 
imposed, because there isn't the protection in the law that 
health care reform would provide to eliminate gender rating.
    With respect to the group market, what we have been told 
repeatedly is of employers with large percentages of women in 
their workplace who have been told by their insurance companies 
that what we see in rates can also reflect the gender 
composition of that workplace. We have heard the statistics of 
the difficulty women have in getting insurance, including that 
they are often working for employers that don't provide health 
care at all. Well, when those employers are charged more it's 
hardly any wonder why that would be the case.
    I want to skip now, with just a few seconds actually that I 
have remaining, to make some specific recommendations with 
respect to the differences in the plans. The HELP Committee 
eliminates gender rating in all plans, in groups of all sizes. 
That's a very important protection to be sure exists when these 
bills are merged. That across the board protection is not in 
the Finance Committee version right now.
    Also, it's very important to be sure that the cost and the 
affordability considerations are closer to the HELP plan for 
all the reasons that have been described, of the difficulties 
of women, who earn less than men, who have these greater out-
of-pocket costs, and who also end up often right now not only 
going into bankruptcy, which we know is a major cause--caused 
by health care costs, unfortunately, with loss of homes and 
foreclosures and all of those things this country does not 
need, but women in particular are vulnerable for that.
    Also with respect to coverage, it's very important that 
that coverage be comprehensive in nature. I want to say just a 
few quick words about the idea that older women would end up 
losing coverage.
    Senator Mikulski. We don't want to muzzle or gag rule 
anybody, but you've gone 2 minutes over.
    Ms. Greenberger. Oh, OK. Well then, I'll wait for questions 
and answers. But we don't agree with that.
    Senator Mikulski. We certainly want to hear about those 
older women.
    Ms. Greenberger. And I could describe why we----
    Senator Mikulski. Perhaps you could elaborate on that in 
the Q and A's.
    Ms. Greenberger. OK, yes, and with respect to reproductive 
health care coverage I also disagree with some of those 
comments that were made as well.
    [The prepared statement of Ms. Greenberger follows:]
              Prepared Statement of Marcia D. Greenberger
    Madame Chairwoman and members of the committee on Health, 
Education, Labor and Pensions, thank you for this opportunity to 
testify on behalf of the National Women's Law Center. The Center is a 
non-profit organization that has worked to expand the possibilities for 
women and girls in this country since 1972. Since its founding, the 
Center has confronted the health care coverage problems that women 
face, which have extracted a high toll on women and their families. The 
health care reform legislation now under debate can provide the major 
improvements in health care quality and affordability that women and 
their families so desperately need.
                              introduction
    In particular, I want to focus on the results of the Center's 
research for a report we published in 2008 called Nowhere to Turn: How 
the Individual Health Insurance Market Fails Women, supplemented by the 
stories of many individual women who have told us about the challenges 
they encounter in the health system every day. A copy of the report* is 
attached as an appendix to my testimony. Among the most deplorable of 
these obstacles are the harmful and discriminatory practices of 
insurance companies, including gender rating and coverage exclusions of 
health care services that only women need. Regardless of whether they 
receive their coverage from an employer via the group health insurance 
market or are left to purchase health insurance directly from insurers 
through the individual market, health insurance practices can hinder a 
woman's ability to obtain affordable and comprehensive health care 
coverage.
---------------------------------------------------------------------------
    * The Report referred to may be found at: http://action.nwlc.org/
site/DocServer/Nowhere
toTurn.pdf.
---------------------------------------------------------------------------
    The majority of American women have health insurance either through 
an employer or through a public program such as Medicaid. In 2008, 
nearly two-thirds of all women aged 18 to 64 had insurance through an 
employer, and another 16 percent had insurance through a public 
program.\1\ In addition, about 7 percent of nonelderly women purchase 
health coverage directly from insurance companies in what is known as 
the ``individual market.'' \2\ For the 18 percent of women who are 
currently uninsured \3\--largely those who lack access to employer 
coverage and who do not qualify for public programs--the individual 
insurance market is often the last resort for coverage.
    While women who get health insurance from their employer are 
partially protected by both Federal and State employment discrimination 
laws, States are left to regulate the sale of health insurance in the 
individual market with no minimum Federal standards. In the vast 
majority of States, few if any such protections exist for women who 
purchase individual health coverage. Furthermore, those seeking health 
coverage in the individual market are often less able to afford 
insurance without the benefit of an employer to share the cost of the 
premium.
    The individual health insurance market presents numerous problems 
for women, but even those who obtain group health insurance from their 
employer are adversely affected by some of the same harmful practices 
that impede access to affordable coverage in the individual market.
     women face many challenges in the individual insurance market
    To learn more about the experiences of women seeking coverage in 
the individual insurance market, between July and September 2008, the 
National Women's Law Center (``NWLC'' or ``the Center'') gathered and 
analyzed information on over 3,500 individual health insurance plans 
available through the leading online source of health insurance for 
individuals, families and small businesses.\4\ The Center investigated 
two phenomena: the ``gender gap''--the difference in premiums charged 
to female and male applicants of the same age and health status--in 
plans sampled from each State and the District of Columbia (DC), and 
the availability and affordability of coverage for maternity care 
across the country.\5\ NWLC examined State statutes and regulations 
relating to the individual insurance market to determine whether the 
States and Washington, DC have protections against premium rating based 
on gender, age, or health status in the individual market, and to 
determine whether States have any maternity coverage mandates requiring 
insurers in the individual market to cover comprehensive maternity care 
(defined as coverage for prenatal and postnatal care as well as labor 
and delivery for both routine and complicated pregnancies).
    Based on this research, NWLC found that the individual insurance 
market is a very difficult place for women to buy health coverage. 
Insurance companies can refuse to sell women coverage altogether due to 
a history of any health problems whatsoever, or charge women higher 
premiums based on factors that include gender, age and health status. 
This coverage is often very costly and limited in scope, and it fails 
to meet women's needs. In short, women face too many obstacles 
obtaining comprehensive, affordable health coverage in the individual 
market--simply because they are women.

     Women often face higher premiums than men. Under a 
practice known as gender rating, insurance companies are permitted in 
most States to charge men and women different premiums. This costly 
practice often results in wide variations in rates charged to women and 
men for the same coverage. The Center's 2008 research on gender rating 
in the individual market found that among insurers who gender rate, the 
majority charge women significantly more than men until they reach 
around age 55, and then some (though not all) charge men only somewhat 
more.\6\ The Center also found huge and arbitrary variations in each 
State and across the country in the difference in premiums charged to 
women and men. For example, insurers who practice gender rating charged 
40-year-old women from 4 percent to 48 percent more than 40-year-old 
men.\7\ The huge variations in premiums charged to women and men for 
identical health plans highlight the arbitrariness of gender rating, 
and the financial impact of gender rating is compounded when insurers 
also omit coverage for services that women need (like maternity care) 
or charge a higher premium because a woman has a preexisting condition.
     Insurance companies can deny applicants health coverage 
for a variety of reasons that are particularly harmful to women. In the 
vast majority of States, individual market insurers can use evidence of 
a ``preexisting'' condition to deny coverage or exclude important 
health benefits. Simply being pregnant or having had a Cesarean section 
is grounds enough for insurance companies to reject a woman's 
application.\8\ And in eight States and the District of Columbia, 
insurers are allowed to use a woman's status as a survivor of domestic 
violence to deny her health insurance coverage.\9\
     It is difficult and costly for women to find health 
insurance that covers maternity care. After reviewing over 3,500 
policies available to women across the Nation in 2008, NWLC found that 
the vast majority of individual market health insurance policies do not 
cover maternity care at all. Just 12 percent included comprehensive 
maternity coverage (i.e. coverage for pre- and post-natal visits as 
well as labor and delivery, for both routine pregnancies and in case of 
complications) within the insurance policy.
    While women in some States may be able to purchase optional 
maternity coverage (called a ``rider'') for an additional premium, the 
extra cost can be prohibitively expensive; NWLC identified maternity 
riders that cost over $1,000 per month, in addition to a woman's 
regular insurance premium. Riders may also involve a waiting period (1 
or 2 years, for example) and benefits are often limited in scope.\10\ 
Moreover, insurers that sell maternity riders typically offer just a 
single rider option. Typically, a woman cannot select a more or less 
comprehensive rider policy--her only option is to purchase the limited 
rider or go without maternity coverage altogether.\11\
    Other research confirms the dearth of maternity coverage in the 
individual health insurance market. In California, for example, the 
California Health Benefits Review Program found that only 22 percent of 
the estimated 1,038,000 people in the individual market in California 
in 2009 had maternity benefits--a dramatic decrease from the 82 percent 
of people with individual policies that covered maternity in 2004.\12\
     Both women and men face problems in the individual 
insurance market that gender rating compounds. Insurance companies also 
engage in premium rating practices that, while not unique to women, 
compound the affordability issues caused by gender rating. These 
include setting premiums based on age and health status.\13\
      women face similar challenges in the group insurance market
    The practice of gender rating also occurs in the group health 
insurance market, most notably when employers obtain coverage for their 
employees.\14\ Insurance companies in most States are allowed to use 
the gender make-up of an insured group as a rating factor when 
determining how much to charge the group for health coverage. From the 
employee's perspective, this disparity may not be apparent, since 
employment discrimination laws prohibit an employer from charging male 
and female employees different rates for coverage, and employers 
themselves often do not know the factors that determine the rates they 
are charged. Yet gender rating in the group insurance market can 
present a serious obstacle to affordable health coverage for an 
employer and all of its employees. If the overall premium is not 
affordable, a business may forgo offering coverage to workers 
altogether, or shift a greater share of health insurance costs to 
employees.

     Gender rating may affect health premium costs for 
employers of varying sizes. As a result of State and Federal employment 
discrimination protections that apply to employer-provided fringe 
benefit plans including health insurance, gender rating--while still 
present in the group market--manifests itself differently than in the 
individual market. Under Federal and most State laws, employers 
unlawfully discriminate if they charge female employees more than male 
employees for the same health coverage.
    Nonetheless, when a business applies for health insurance, the 
majority of States allow insurance companies to determine the premium 
that will be charged using a process known as ``medical underwriting.'' 
As part of this process, an insurer considers various criteria--such as 
gender, age, health status, claims experience, or occupation--and 
decides how much to charge an applicant for health coverage. In the 
large group market, insurers underwrite the group as a whole rather 
than considering the health-related factors of each employee--but this 
limitation provides little relief for employers with a high proportion 
of female workers.\15\ Under the premise that women have, on average, 
higher hospital and physicians' costs than men, insurance companies 
that gender rate may charge employers more for health insurance if they 
have a predominantly female workforce. This can raise premiums for all 
employees and potentially move the employer to forgo providing health 
coverage all together.
    In the wide range of industries in which women dominate the 
workforce, gender rating makes group health plan premiums harder to 
afford. The fields of home health care and child care, for instance, 
are majority-female (90 percent and 95 percent, respectively).\16\ More 
than three-quarters of people employed by hospitals and physician's 
offices are women, as are an estimated 82 percent of the employees in 
dentists' offices.\17\ Women dominate the workforces of pharmacies and 
drug stores (63 percent), retail florists (70 percent), and community 
service organizations (69 percent).\18\ Over two-thirds of employees in 
the nonprofit industry are women.\19\
 discriminatory insurance industry practices contribute significantly 
                  to women's affordability challenges
    Unfair insurance industry practices--including gender rating, 
denials based on preexisting conditions and exclusion of coverage for 
essential needs like maternity care--exacerbate the affordability 
problems that women are especially likely to face. Greater health care 
needs,\20\ combined with a disadvantaged economic status and 
discriminatory industry practices, make it difficult for many women to 
afford necessary care.
    Regardless of whether they have health insurance, women face more 
cost-related challenges to securing access to health care than men.\21\ 
They generally have less income, earning only 77 cents, on average, for 
every dollar that men earn.\22\ Roughly 57 percent of the adults living 
in poverty (i.e. with incomes below 100 percent of the Federal poverty 
level) are women.\23\ In 2008, the median earnings of female workers 
working full time, year round, were $35,745, compared to $46,367 for 
men.\24\
    Women spend a greater share of their income on out-of-pocket 
medical costs than men, and are more likely to avoid needed health care 
because of cost. In 2007, for example, 52 percent of all nonelderly 
women reported a cost-related access barrier--including not filling a 
prescription, skipping a recommended test or treatment, or not getting 
needed basic or specialist care because of cost--compared to 39 percent 
of all nonelderly men.\25\
    Women are also more likely than men to experience significant 
financial hardship as a result of medical bills. In 2007, one-third of 
women, compared to one-quarter of men, were either unable to pay for 
food, heat or rent; had used up all of their savings; had taken out a 
mortgage or loan against their home; or had taken on credit card debt 
because of medical bills.\26\ Overall, 7 in 10 women are either 
uninsured or underinsured, struggling to pay a medical bill, or 
experiencing another cost-related problem in accessing needed care.\27\
 some states have taken action to protect consumers in the individual 
                        and small group markets
    Some States have taken action to address the challenges that women, 
and employers with female employees, face in the individual and group 
markets.

     Protections against gender rating: Because the regulation 
of insurance has been largely left to the States,\28\ no Federal law 
provides protections against gender rating in the individual and group 
markets. Overall, 39 States and Washington, DC allow gender rating in 
the individual market, with two of these States limiting the amount 
premiums can vary based on gender through ``rate bands.'' \29\ However, 
even States that ban gender rating allow some plans to use this 
practice, such as the bare-bones basic and essential plans offered in 
New Jersey.\30\ There are three basic approaches to prohibit or limit 
gender rating in the individual market:

          Explicit Protections against Gender Rating: Five 
        States in the individual market have passed laws prohibiting 
        insurers from considering gender when setting health insurance 
        rates: California,\31\ Minnesota,\32\ Montana,\33\ New 
        Hampshire,\34\ and North Dakota.\35\ California became the most 
        recent State to ban gender rating, through a bill that Governor 
        Schwarzenegger signed into law on October 11, 2009.
          Community Rating: Currently, six States prohibit the 
        use of gender as a rating factor under community rating 
        statutes: New York imposes pure community rating \36\; while 
        Maine,\37\ Massachusetts,\38\ New Jersey,\39\ Oregon,\40\ and 
        Washington \41\ impose modified community rating that, in 
        addition to prohibiting rating based on health status, also 
        bans rating based on gender.
          Gender Rate Bands: Some States have passed laws 
        limiting insurers' ability to base premiums on gender by 
        establishing a ``rate band,'' which sets limits between the 
        lowest and highest premium that a health insurer may charge for 
        the same coverage based on gender. In the individual market, 
        two States--New Mexico \42\ and Vermont \43\--use rate bands to 
        limit insurers' ability to vary rates based on gender.

    In the group market, 12 States have banned gender rating 
altogether. Three States have applied gender ``rate bands,'' and one 
State prohibits gender rating unless the carrier receives prior 
approval from the State insurance commissioner.

          Explicit Protections against Gender Rating: Only one 
        State--Montana--prohibits insurers from using gender as a 
        rating factor in any type of insurance policy issued within the 
        State. Montana's distinctive ``unisex insurance law'' considers 
        gender rating to be discrimination against women, and bans the 
        practice among insurers issuing all types of insurance, 
        including health coverage, to individuals and groups of all 
        sizes.\44\
           In addition, California,\45\ Colorado,\46\ Michigan,\47\ and 
        Minnesota,\48\ specifically prohibit insurers from considering 
        gender when setting health insurance rates in the small group 
        market.
          Community Rating: New York \49\ imposes pure 
        community rating in its small group market, while Maine,\50\ 
        Maryland,\51\ Massachusetts,\52\ New Hampshire,\53\ Oregon,\54\ 
        and Washington,\55\ ban gender-based rating under modified 
        community rating.
          Gender Rate Bands: Three States--Delaware,\56\ New 
        Jersey,\57\ and Vermont,\58\ limit the extent to which insurers 
        may vary premium rates based on gender through a rate band.
          Other: One State, Iowa,\59\ prohibits gender rating 
        unless a small group insurance carrier secures prior approval 
        from the State insurance commissioner.

    It is important to note that with the exception of Montana, the 
States' group market gender rating regulations apply only to health 
insurance sold to small groups. Most States use an upper size limit of 
50 members/employees to define a small group, though a few have 
established limits as low as 25 members.\60\ In nearly all of the 
States with group market protections against gender rating, therefore, 
employers that exceed the State-defined size limit--including those 
with as few as 51 employees--are still subject to this discriminatory 
practice.

     Maternity mandates: The Federal Pregnancy Discrimination 
Act protects women in covered employer-provided health plans against 
the exclusion of maternity benefits,\61\ but no similar Federal 
protection exists for women in the individual market. A handful of 
States have recognized the importance of ensuring that maternity 
coverage--including prenatal, birth, and postpartum care--is a part of 
basic health care by establishing a ``benefit mandate'' law that 
requires insurers to include coverage for maternity services in all 
individual health insurance policies sold in their State. Currently, 
just five States have enacted mandate laws that require all insurers in 
the individual market to cover the cost of maternity care. These States 
are: Massachusetts,\62\ Montana,\63\ New Jersey,\64\ Oregon,\65\ and 
Washington.\66\ In New Jersey and Washington, individual insurance 
providers are allowed to offer bare-bones plans that are exempt from 
the mandate and exclude maternity coverage.\67\
    Beyond this short list of five, other States have adopted limited-
scope mandate laws for the individual market that require maternity 
coverage only for certain types of health plan carriers, certain types 
of maternity care, or for specific categories of individuals. Limited-
scope mandate laws address the provision of maternity care but may fall 
short of providing women with full coverage for the care they need. In 
California,\68\ Illinois,\69\ and Georgia,\70\ for example, only Health 
Maintenance Organizations (HMOs) are subject to State laws that mandate 
maternity benefits in the individual insurance market.
    With regard to the group market, some States have taken an 
additional step to guarantee that women who work for small businesses 
have access to employer-
sponsored insurance that includes maternity benefits, since employers 
with fewer than 15 workers are not subject to the Federal Pregnancy 
Discrimination Act law requiring businesses to provide the same level 
of coverage for pregnancy as is provided for other medical conditions. 
By adopting laws that mandate the inclusion of maternity benefits in 
policies sold through the State's group health insurance market, States 
ensure that all women with group health plans have access to these 
important benefits, no matter how small the employer. Fifteen States 
have enacted such laws, though they may apply only to certain types of 
health plans such as managed care plans.\71\ Therefore, it is possible 
that in some States women who obtain ESI through a small business do 
not receive maternity benefits as part of that coverage.
     State maternity coverage programs: In a few instances, 
State governments have stepped in (at taxpayer expense) to fill gaps in 
private health insurance by establishing programs to assist pregnant 
women who have private coverage that does not meet their maternity care 
needs. At least two States have such programs: California's Access for 
Infants and Mothers (AIM) program is a low-cost coverage program for 
pregnant women who are uninsured and ineligible for Medi-Cal (the 
State's Medicaid program).\72\ New Mexico's Premium Assistance for 
Maternity (PAM) program is a State-sponsored initiative that provides 
maternity coverage for pregnant citizens who are ineligible for 
Medicaid.\73\ According to program officials in New Mexico, PAM was 
established expressly because of the gaps that existed in private 
market maternity coverage. If maternity care was included as a basic 
benefit in comprehensive and affordable health insurance policies, such 
programs would be unnecessary.
                 recommendations for health care reform
    Health reform holds the promise of making affordable care available 
to millions of women who need it. As the legislation progresses in the 
coming weeks, however, it is essential that robust insurance market 
reforms are included, as well as other provisions to ensure that health 
care is truly affordable. If these key pieces are absent from the final 
legislation, health reform will provide inferior coverage and 
protection to the millions of women who are currently struggling to get 
the care they need. Specifically, to protect women and their families 
health care reform must:

     Include insurance market reforms that protect ALL women, 
whether they obtain coverage on their own, get health benefits from an 
employer, or secure coverage from other types of plans. Health reform 
must eliminate unfair and discriminatory practices, such as gender 
rating and preexisting condition exclusions, by applying reforms 
broadly across the individual market and for all groups of all sizes. 
It must ensure that reforms protect women from unfair practices 
regardless of whether they obtain coverage through the new Health 
Insurance Exchanges, from an employer of any size (not just a small 
business), or an association health plan. Limiting reforms to a subset 
of the health insurance market--such as for individuals and small 
groups only--creates a loophole for insurance companies and squanders 
an opportunity to ensure uniform and fair rules for all women with 
health insurance. It allows moderate-sized and large groups to continue 
facing unfair and costly insurance practices related to the sex, age, 
or health claims history of their employees.
    Eliminating gender rating and other discriminatory practices for 
individuals and groups of all sizes is especially important given other 
potential health reform provisions, such as the proposed excise tax on 
so-called ``high-cost'' health plans. Plans--and ultimately 
individuals--may be subject to the tax due to the gender, age, or 
health status of the enrolled individual or group if unfair premium 
rating practices are allowed to continue.
     Ensure affordable coverage. Affordability in health reform 
is especially important for women. There are more than 14 million 
uninsured women (ages 18-64) with incomes below 400 percent of the 
Federal poverty level.\74\ Without sufficient subsidies to help with 
the cost of health insurance, women in this income range would struggle 
to afford newly-available coverage and could even join the ranks of the 
underinsured. For a single mom with two children at 400 percent of 
poverty, the average premium cost for a Blue Cross standard policy 
alone would be almost 18 percent of her income.
      Accordingly, there must be adequate sliding scale subsidies for 
premiums and out-of-pocket costs--as well as reasonable limits on total 
out-of-pocket costs--so that women can obtain health coverage that they 
can realistically afford. The legislation reported by the Health, 
Education, Labor, and Pensions Committee (S. 1679) provides stronger 
affordability protections than the legislation reported by the Finance 
Committee.
     Prohibit any annual or lifetime benefit caps for all 
individual and group health insurance plans. Even benefit limits that 
appear to be high can be used up quickly if a woman faces a serious 
condition, leaving little or no coverage for a woman's other basic 
health care needs. For example, a woman suffering from coronary artery 
disease, the leading killer of women in the United States, could spend 
over $1 million over the course of her lifetime on related treatment 
alone,\75\ and a condition such as multiple sclerosis--which affects 
twice as many women as men \76\--costs an estimated $2.2 million over 
the course of an individual's lifetime.\77\ This critically important 
protection will help women afford health care when they need it most, 
as well as avoid medical debt and bankruptcy.
                               conclusion
    Women's relationship with the health system is characterized by 
many disadvantages, including continued discrimination by health 
insurance companies and increasing proportions who report cost-related 
problems with access to care. Quite simply, there is an urgent need for 
health reform now, to make affordable, high-quality health care a 
reality for women across the country.
    The country is closer than ever been before to realizing this goal, 
but the debate over the scope of insurance market reforms and various 
other provisions to ensure affordable coverage is far from over. The 
protections that are of fundamental importance for women are essential 
components of health reform. For women and their families, health 
reform that assures affordability and fairness will mean the difference 
between securing access to quality health care, and going without.
                               References
    1. National Women's Law Center analysis of 2008 data on health 
coverage from the Current Population Survey's Annual Social and 
Economic Supplement (U.S. Census Bureau, 2009) using CPS Table Creator, 
http://www.census.gov/hhes/www/cpstc/cps_table_creator.html.
    2. Id.
    3. Id.
    4. This source is eHealthInsurance, available at http://
www.ehealthinsurance
.com/. Notably, eHealthInsurance may not represent all insurance 
companies 
licensed to sell individual health insurance policies in every State. 
However, the company bills itself as the leading online source of 
health insurance for individuals, families, and small businesses, 
partnering with over 160 health insurance companies in 50 States and 
Washington, DC and offering more than 7,000 health insurance products 
online. NWLC chose to use eHealthInsurance for this study because it 
presents the clearest available picture of the individual market across 
the country, and because it is the most readily available tool for 
individuals seeking private insurance who do not wish, or cannot 
afford, to employ the services of an insurance agent. Any limitations 
in eHealthInsurance's scope--in tandem with the basic fact that its 
services are only available online and therefore may not be accessible 
to individuals without a computer or Internet access or who are not web 
savvy--simply underscores the challenges women (and men) face seeking 
coverage in the individual market without a government-sponsored system 
to help facilitate their search.
    5. While NWLC's review of health insurance plans examined coverage 
for maternity-related care, it was much more difficult to determine 
whether other pregnancy-related benefits, such as contraception or 
pregnancy termination, are covered under a plan; accordingly, our 
review did not include these important reproductive health benefits. 
For example, in many plan brochures, if information about either of the 
above benefits is available at all, it is visible only as part of a 
long list of exclusions. This obfuscation reflects another challenge 
women face in assessing the adequacy of a plan's coverage.
    6. Lisa Codispoti, Brigette Courtot and Jen Swedish, Nat'l Women's 
Law Ctr, Nowhere to Turn: How the Individual Market Fails Women (Sept. 
2008), http://action.nwlc.org/site/PageServer?pagename=nowheretoturn.
    7. Id.
    8. Denise Grady, After Caesareans, Some See Higher Insurance Cost, 
N.Y. Times, June 1, 2008, at A26, available at http://www.nytimes.com/
2008/06/01/health/01insure.html.
    9. Women's Law Project & Pennsylvania Coalition Against Domestic 
Violence, FYI: Insurance Discrimination Against Victims of Domestic 
Violence, 2002 Supplement 2 (2002), http://www.womenslawproject.org/
brochures/InsuranceSup_DV
2002.pdf. In the early 1990s, advocates discovered that insurers had 
denied applications for coverage submitted by women who had experienced 
domestic violence. See, e.g., 142 Cong. Rec. E1013-03, at E1013-14 
(June 5, 1996) (statement of Rep. Pomeroy) (``the Pennsylvania State 
Insurance Commissioner surveyed company practices in Pennsylvania and 
found that 26 percent of the respondents acknowledged that they 
considered domestic violence a factor in issuing health, life and 
accident insurance''). Since 1994, the majority of States have adopted 
legislation prohibiting health insurers from denying coverage based on 
domestic violence, but nine States and Washington, DC offer no such 
protection to survivors of domestic violence. Even though Vermont lacks 
legislation specifically prohibiting discrimination against domestic 
violence survivors, the State requires guaranteed issue of all 
individual insurance plans. See infra note 94 and accompanying text. 
Though the report identifies nine States, as well as the District of 
Columbia, which do not prohibit this practice, Arkansas Gov. Beebe 
recently signed into law ACT 619, which amends Arkansas Code  23-66-
206(14)(G), to add ``status as a victim of domestic abuse'' to the list 
of attributes that insurers may not use as the sole justification for 
denying an individual health insurance coverage.
    10. It is quite common for a rider to limit the total maximum 
benefit to amounts such as $3,000 (available only after a 10-month 
waiting period for a rider option identified in the District of 
Columbia) or $5,000 (available only after a 12-month waiting period for 
an Arkansas rider option).
    11. Id.
    12. California Health Benefits Review Program, Executive Summary: 
Analysis of Assembly Bill 98: Maternity Services, A Report to the 2009-
2010 California Legislature (Mar. 16, 2009), http://www.chbrp.org/
documents/ab_98_fnlsumm.pdf.
    13. Nowhere to Turn, supra note 6.
    14. There are also non-employer based group plans that provide 
insurance, commonly referred to as association health plans.
    15. Id.; Henry J. Kaiser Family Foundation, How Private Health 
Coverage Works: A Primer, 2008 Update (Apr. 2008), http://www.kff.org/
insurance/upload/7766.pdf.
    16. U.S. Bureau of Labor Statistics, Women in the Labor Force: A 
Data Book, 2008 Edition (2008), ``Table 14: Employed Persons by 
Detailed Industry and Sex, 2007 Annual Averages,'' http://www.bls.gov/
cps/wlf-databook-2008.pdf.
    17. Id.
    18. Id.
    19. Jasmine McGinnis, Georgia State University and Georgia 
Institute of Technology, The Young and Restless: Generation Y in the 
Nonprofit Workforce (Working Paper, 2009), http://www.utexas.edu/lbj/
rgk/fellowship/2009papers/McGinnis.pdf.
    20. Women are more likely than men to require health care 
throughout their lives, including regular visits to reproductive health 
care providers. They are more likely to have chronic conditions that 
necessitate continuous health care treatment. They also use more 
prescription drugs on average, and certain mental health problems 
affect twice as many women as men. See: Elizabeth Patchias and Judy 
Waxman, Women and Health Coverage: The Affordability Gap (2007), 
National Women's Law Center. An issue brief prepared for the 
Commonwealth Fund, available at http://www.nwlc.org/pdf/
NWLCCommonwealthHealthInsuranceIssueBrief2007.pdf (last visited May, 12 
2008).
    21. Sheila D. Rustgi, Michelle M. Doty, and Sara R. Collins, Women 
at Risk: Why Many Women are Forgoing Needed Health Care (New York: The 
Commonwealth Fund, May 2009).
    22. U.S. Census Bureau (Sept 2009), Men's and Women's Earnings by 
State: 2008 American Community Survey, http://www.census.gov/prod/
2009pubs/acsbr08-3.pdf.
    23. National Women's Law Center calculations based on U.S. Census 
Bureau, ``Table POV01: Age and Sex of All People, Family Members and 
Unrelated Individuals Iterated by Income-to-Poverty Ratio and Race: 
2005, Below 100 percent of Poverty--All Races.'' Current Population 
Survey Annual Demographic Survey March Supplement, (2006), available 
at: http://pubdb3.census.gov/macro/032006/pov/new01_100_01.htm. (last 
visited May 12, 2008).
    24. National Women's Law Center, Women's Private Health Coverage, 
Incomes Decline While Poverty Increases, Census Data Show (September 
2009 Press Release), http://www.nwlc.org/
details.cfm?id=3711&section=newsroom.
    25. Women at Risk, supra note 21.
    26. Id.
    27. Id.
    28. McCarran-Ferguson Act, 15 U.S.C.  1011-1015 (2008).
    29. Nowhere to Turn, supra note 6.
    30. N.J. Dept. of Banking & Ins., N.J. Individual Health Coverage 
Program Buyer's Guide: How To Select a Health Plan--2006 Ed. (2006), 
http://www.state.nj.us/dobi/division_insurance/ihcseh/ihcbuygd.html 
(``carriers may vary the rates for the B&E plan based on age, gender 
and geographic location'').
    31. On October 11, 2009, California governor Arnold Schwarzenegger 
signed Assembly Bill 119, which prohibits gender rating in the State's 
insurance markets, into law. The law affects insurance policies issued 
or renewed on or after January 1, 2011.
    32. MN. Stat.  62A.65(4) (2008) (``No individual health plan 
offered, sold, issued, or renewed to a Minnesota resident may determine 
the premium rate or any other underwriting decision, including initial 
issuance, through a method that is in any way based upon the gender of 
any person covered or to be covered under the health plan.'').
    33. MT. Code Ann.  49-2-309(1) (2008) (``It is an unlawful 
discriminatory practice for a financial institution or person to 
discriminate solely on the basis of sex or marital status in the 
issuance or operation of any type of insurance policy, plan, or 
coverage or in any pension or retirement plan, program, or coverage, 
including discrimination in regard to rates or premiums and payments or 
benefits.''). Montana's ``unisex insurance law'' is not limited to 
health insurance; it prohibits insurers from using gender as a rating 
factor in any type of insurance policy issued within the State. See 
Mont. Code Ann.  49-2-309(1) (2008) (``It is an unlawful 
discriminatory practice for a financial institution or person to 
discriminate solely on the basis of sex or marital status in the 
issuance or operation of any type of insurance policy, plan, or 
coverage or in any pension or retirement plan, program, or coverage, 
including discrimination in regard to rates or premiums and payments or 
benefits'').
    34. N.H. Rev. Stat. Ann.  420-G:4(I)(d) (2008) (allowing insurers 
to base rates in the individual market solely on age, health status, 
and tobacco use).
    35. N.D. Cent. Code  26.1-36.4-06(1) (2008) (imposing a rate band 
under which age, industry, gender, and duration of coverage may not 
vary by a ratio of more than 5 to 1, but providing that ``[g]ender and 
duration of coverage may not be used as a rating factor for policies 
issued after January 1, 1997''). Despite the statutory prohibition on 
gender rating in North Dakota, the only company offering individual 
policies through www.eHealthInsurance.com does use gender as a rating 
factor. In an attempt to understand this seeming inconsistency, NWLC 
contacted the North Dakota Insurance Department, which indicated that 
this company is a ``hybrid situation'' and thus permitted to rate its 
individual policies as if they were sold on the group market; gender 
rating is allowed within limit for groups in North Dakota. Telephone 
Interview with North Dakota Insurance Department (Sept. 12, 2008).
    36. N.Y. Ins. Law  3231(a) (McKinney 2008) (defining community 
rating as ``a rating methodology in which the premium for all persons 
covered by a policy or contract form is the same based on the 
experience of the entire pool of risks covered by that policy or 
contract form without regard to age, sex, health status or 
occupation'').
    37. ME. Rev. Stat. Ann. tit. 24-A,  2736-(2)(B) (2008) 
(prohibiting insurance carriers from varying the community rate due to 
gender or health status). ME. Rev. Stat. Ann. tit. 24-A,  2736-
C(2)(D)(3) (2008) (imposing a rate band under which insurance carriers 
may only vary the community rate due to age by plus or minus 20 percent 
for policies issued after July 1, 1995).
    38. MA. Gen. Laws ch. 176M,  1 (2008) (defining ``modified 
community rate'' as ``a rate resulting from a rating methodology in 
which the premium for all persons within the same rate basis type who 
are covered under a guaranteed issue health plan is the same without 
regard to health status; provided, however, that premiums may vary due 
to age, geographic area, or benefit level for each rate basis type as 
permitted by this chapter''). Mass. Gen. Laws ch. 176M,  4(a)(2) 
(2008) (imposing a rate band under which the ``premium rate adjustment 
based upon the age of an insured individual'' may range from 0.67 to 
1.33).
    39. 2008 N.J. Sess. Law Serv. Ch. 38, page nos. 12, 15 (Senate 
1557) (West) (amending N.J. Stat. Ann.  17B:27A-2 (West 2008) to 
define ``modified community rating'' as ``a rating system in which the 
premium for all persons under a policy or a contract for a specific 
health benefits plan and a specific date of issue of that plan is the 
same without regard to sex, health status, occupation, geographic 
location or any other factor or characteristic of covered persons, 
other than age,'' and amending N.J. Stat. Ann.  17B:27A-4 (West 2008) 
to require individual health benefits plans to ``be offered on an open 
enrollment, modified community-rated basis''). New Jersey law excludes 
bare-bones basic and essential plans from the modified community-
rating requirement.
    40. OR. Rev. Stat.  743.767(2) (2008) (``The premium rates charged 
during a rating period for individual health benefit plans issued to 
individuals shall not vary from the individual geographic average rate, 
except that the premium rate may be adjusted to reflect differences in 
benefit design, family composition and age.'').
    41. WA. Rev. Code  48.43.005(1) (2008) (defining ``adjusted 
community rate'' as ``the rating method used to establish the premium 
for health plans adjusted to reflect actuarially demonstrated 
differences in utilization or cost attributable to geographic region, 
age, family size, and use of wellness activities''); Wash. Rev. Code  
48.44.022(1)(a) (2008) (allowing insurers to only vary the adjusted 
community rate based on geographic area, family size, age, tenure 
discounts, and wellness activities).
    42. N.M. Stat.  59A-18-13.1(A) (2008) (allowing gender rating); 
N.M. Stat.  59A-18-13.1(B) (2008) (providing that ``the difference in 
rates in any one age group that may be charged on the basis of a 
person's gender shall not exceed another person's rates in the age 
group by more than 20 percent of the lower rate'').
    43. VT. Stat. Ann. tit. 8,  4080b(h)(1) (2008) (prohibiting the 
use of the following rating factors when establishing the community 
rate: demographics including age and gender, geographic area, industry, 
medical underwriting and screening, experience, tier, or duration); VT. 
Stat. Ann. tit. 8,  4080b(h)(1) (2008), 21-020-034 VT. Code R.  93-
5(11)(G), (13)(B)(6) (2008) (providing that upon approval by the 
insurance commissioner, insurers may adjust the community rate by a 
maximum of 20 percent for demographic rating including age and gender 
rating, geographic area rating, industry rating, experience rating, 
tier rating, and durational rating).
    44. MT. Code Ann.  49-2-309(1) (2008).
    45. CA. Ins. Code  10714(a)(2), 10700(t)--(v) (West 2008) 
(prohibiting small employer insurance carriers from setting premium 
rates based on characteristics other than age, geographic region, and 
family size, in addition to the benefit plan selected by the employee).
    46. CO. Rev. Stat.  10-16-105(8)(a), 10-16-102(10)(b) (2008) 
(prohibiting small employer insurance carriers from setting premium 
rates based on characteristics other than age, geographic region, 
family size, smoking status, claims experience, and health status).
    47. MI. Comp. Laws  500.3705(2)(a) (2008) (prohibiting commercial 
small employer insurance carriers from setting premium rates based on 
characteristics of the small employer other than industry, age, group 
size, and health status).
    48. MN. Stat.  62L.08(5) (2008) (prohibiting the use of gender as 
a rating factor for small employer insurance carriers).
    49. N.Y. Ins. Law  3231(a) (McKinney 2008) (requiring all small 
employer insurance plans to be community rated and defining ``community 
rating'' as ``a rating methodology in which the premium for all persons 
covered by a policy or contract form is the same based on the 
experience of the entire pool of risks covered by that policy or 
contract form without regard to age, sex, health status or 
occupation'').
    50. ME. Rev. Stat. Ann. tit. 24-A,  2808-B(2)(B) (2008) 
(prohibiting small employer insurance carriers from varying the 
community rate based on gender, health status, claims experience or 
policy duration of the group or group members).
    51. MD. Code Ann., Ins.  15-1205(a)(1)-(3) (West 2008) (allowing 
small employer insurance carriers to adjust the community rate only for 
age and geography).
    52. MA. Gen. Laws ch. 176J,  3(a)(1), (2) (2008) (allowing small 
employer insurance carriers to adjust the community rate only for age, 
industry, participation-rate, wellness program, and tobacco use).
    53. N.H. Rev. Stat. Ann.  420-G:4(1)(e)(1) (2008) (prohibiting 
small employer insurance carriers from setting premium rates based on 
characteristics of the small employer other than age, group size, and 
industry classification).
    54. OR. Rev. Stat.  743.737(8)(b)(B) (2008) (providing that small 
employer insurance carriers may only vary the community rate based on 
age, employer contribution level, employee participation level, the 
level of employee engagement in wellness programs, the length of time 
during which the small employer retains uninterrupted coverage with the 
same carrier, and adjustments based on level of benefits). Overall Rate 
Band: 50 percent
    55. WA. Rev. Code  48.21.045(3)(a) (2008) (providing that small 
employer insurance carriers may only vary the community rate based on 
geographic area, family size, age, and wellness activities).
    56. DE. Code Ann. tit. 18,  7205(2)(a) (2008) (allowing small 
employer insurance carriers to vary premium rates based on gender and 
geography combined by up to 10 percent). Age: DE. Code Ann. tit. 18,  
7202(9), 7205 (2008) (allowing the use of age as a rating factor if 
actuarially justified).
    57. N.J. Stat. Ann.  17B:27A-25(a)(3) (West 2008) (providing that 
the premium rate charged by a small employer insurance carrier to the 
highest rated small group shall not be greater than 200 percent of the 
premium rate charged to the lowest rated small group purchasing the 
same plan, ``provided, however, that the only factors upon which the 
rate differential may be based are age, gender and geography''). Rate 
Band for Age, Gender & Geography: 200 percent.
    58. VT. Stat. Ann. tit. 8,  4080a(h)(1) (2008) (prohibiting the 
use of the following rating factors when establishing the community 
rate: demographics including age and gender, geographic area, industry, 
medical underwriting and screening, experience, tier, or duration); VT. 
Stat. Ann. tit. 8,  4080a(h)(2) (2008) (providing that upon approval 
by the insurance commissioner, insurers may adjust the community rate 
by a maximum of 20 percent for demographic rating including age and 
gender rating, geographic area rating, industry rating, experience 
rating, tier rating, and durational rating). Overall Rate Band: 20 
percent.
    59. IA Code  513B.4(2) (2008) (prohibiting the use of rating 
factors other than age, geographic area, family composition, and group 
size without prior approval of the insurance commissioner).
    60. In Louisiana, for instance, a small group has 35 or fewer 
members; Arkansas and Tennessee define a small group as one that has 25 
or fewer members. (Unpublished research conducted by the National 
Women's Law Center, 2009).
    61. Pub. L. No. 95-555, 92 Stat. 2076 (1978).
    62. MA. Gen. Laws ch. 176G,  4(c), 4I (2008) (requiring health 
maintenance organizations to include maternity coverage); MA. Gen. Laws 
ch. 176B,  4H (2008) (requiring medical service corporations to 
include maternity coverage); MA. Gen. Laws ch. 176A,  8H (2008) 
(requiring non-profit hospital service corporations to include 
maternity coverage).
    63. MT. Ins. Or. (Feb. 16, 1994); Bankers Life & Casualty Co. v. 
Peterson, 866 P.2d 241 (Mont. 1993). Mandated maternity coverage is not 
always imposed by State legislation or via administrative regulations. 
Montana's mandate is the result of a 1993 State Supreme Court decision 
which held that a health plan excluding maternity coverage 
unconstitutionally discriminated based on gender.\74\ In response to 
this court decision, the Montana Insurance Commissioner issued an order 
that all insurers in the State must include maternity benefits.\75\
    64. N.J. Stat. Ann.  17B:26-2.1b (West 2008) (requiring all 
individual plans, except the bare-bones basic and essential plans, to 
include maternity coverage). N.J. Dept. of Banking & Ins., N.J. 
Individual Health Coverage Program Buyer's Guide: How To Select a 
Health Plan--2006 Ed. (2006), http://www.state.nj.us/dobi/
division_insurance/ihcseh/ihcbuygd.html (``carriers may vary the rates 
for the B&E plan based on age, gender and geographic location'').
    65. OR. Rev. Stat.  743A.080 (2008).
    66. WA. Rev. Code  48.43.041(1)(a) (2008) (requiring all 
individual plans, except the bare-bones catastrophic plans, to include 
maternity coverage).
    67. Id.; N.J. Dept. of Banking & Ins., supra note 8 (``B&E Plans do 
not provide comprehensive benefits like the standard plans described 
above,'' which include prenatal and maternity care).
    68. CA. Health & Safety Code  1367(i) (requiring health care 
service plans to provide basic health care services); A.B. 1962, 2007-
2008 Sess.  1 (Cal. 2008) (recognizing that, in practice, health care 
service plans are required to provide maternity services as a basic 
health care benefit).
    69. IL. Admin. Code tit. 50,  5421.130(e) (2008).
    70. GA. Comp. R. & Regs. 290-5-37-.03(4) (2008).
    71. HI, MD, MA, MI, MN, MT, NJ, NY, OR, VT, and WA have enacted 
laws requiring maternity benefits in all policies for employers in the 
small group market. ID requires that maternity benefits be covered for 
employers with five or more employees, and CA, GA, and ME have laws 
require that maternity be covered by managed care organizations in the 
small group market. See: Ed Neuschler, Institute for Health Policy 
Solutions, Policy Brief on Tax Credits for the Uninsured and Maternity 
Care 3 (March of Dimes 2004), http://www.marchofdimes.com/Tax
CreditsJan2004.pdf.
    72. Managed Risk Medical Insurance Board, Access for Infants and 
Mothers, http://www.aim.ca.gov/english/AIMHome.asp (last visited Sept. 
17, 2008).
    73. Insure New Mexico, Premium Assistance for Maternity (PAM) 
Frequently Asked Questions, http://www.insurenewmexico.state.nm.us/
PAMFaqs.htm (last visited Sept. 17, 2008).
    74. National Women's Law Center calculations based on health 
insurance data for women ages 18-64 from the Current Population 
Survey's 2008 Annual Social and Economic Supplement, using CPS Table 
Creator, http://www.census.gov/hhes/www/cpstc/cps_table_creator.html.
    75. Leslee J. Shaw; C. Noel Bairey Merz; Carl J. Pepine, et al., 
The Economic
Burden of Angina in Women With Suspected Ischemic Heart Disease, 
Circulation
114 (2006):894-904, http://circ.agajournals.org/cgi/content/abstract/
114/9/894?
maxtoshow =&HITS =10&hits=10&RESULTFORMAT=&fulltext=cardiovascular&
searchid=1&FIRSTINDEX=20&resourcetype=HWFIG.
    76. Brigham and Women's Hospital, ``Focus on Multiple Sclerosis'' 
(April 2008), http://www.brighamandwomens.org/patient/healthmatters/
multiplesclerosis.aspx.
    77. Kathryn Whetten-Goldstein, Frank A. Sloan, Larry B. Goldstein, 
et al., A Comprehensive Assessment of the Cost of Multiple Sclerosis in 
the United States, Multiple Sclerosis 4, no. 5 (1998):419-425, http://
msj.sagepub.com/cgi/content/abstract/4/5/419.

    Senator Mikulski. Ms. Buchanan.

  STATEMENT OF AMANDA BUCHANAN, PATIENT/HEALTH CARE CONSUMER, 
                           WEISER, ID

    Ms. Buchanan. Madam Chair, members of the committee, I 
would like to thank you for giving me the opportunity to 
testify before this committee today. My name is Amanda Buchanan 
and I live in Weiser, ID. I am the wife of a public school 
teacher and a mother to two young sons.
    My husband transferred from a large school district to a 
small rural one shortly after my first son was born. The 
decrease in income this change created was a compromise for our 
desire to raise a family in a small town. We have always been 
great at living simply and frugally, which came in especially 
handy as I had decided to become a stay-at-home mom.
    However, what we weren't prepared for was the astronomical 
cost of putting myself and my infant son on my husband's group 
insurance policy--$760 a month on a $33,000 a year gross 
income. For the first time I decided to get individual market 
coverage for the baby and me. I quickly learned that in Idaho 
as an individual searching for coverage I had two options, 
Regents Blue Shield of Idaho and Blue Cross of Idaho, and the 
limited options available between these two companies were 
remarkably similar. In fact, every single policy available, 
despite the premium and deductible level, came with an 
additional maternity deductible of $5,000 plus 20 percent of 
all remaining costs.
    At the time, my focus was on being responsible, which to me 
meant having insurance. I wasn't planning on getting pregnant 
for some time and I really had no other choice. Several months 
later, my husband and I found ourselves answering the 
possibility of a second child. Instead of an intimate 
conversation between the two of us about goals and family, I 
felt like there were actually three of us at the table: myself, 
my husband, and our insurance policy.
    We had to decide if we could even afford to have a second 
child, and not ``afford'' in the sense of clothing, food, et 
cetera, but could we afford to pay a hospital bill. There I 
was, paying a $280 premium every month for the best individual 
market policy Regents offered, and I was having to debate if I 
could afford the medical bills from a routine pregnancy and 
delivery.
    I was very angry that an insurance company could set up a 
policy in a way that would either discourage women from getting 
pregnant altogether or, if they did become pregnant, force them 
to pay for basically the entire cost of a typical delivery.
    My husband and I came up with a plan. I would have a baby, 
then take myself off of insurance and use the money I'd save to 
pay down our medical debt, and this is exactly what we did. In 
the end, health care premiums, deductibles, and the medical 
costs from the pregnancy and delivery ate up 28 percent of our 
net income in 2008, and this is even after the hospital wrote 
off our bill.
    As it stands, our medical debts are paid. I remain 
uninsured. You could argue that I'm being irresponsible and 
creating a potentially disastrous situation for my family, and 
I would agree with you. But it would be impossible for us to 
come up with $300 a month to cover me. We would be sacrificing 
any ability to save money for emergencies and would most 
definitely be cutting into our grocery budget.
    As a mother, my responsibility is to my children and 
family. My sons remain well-fed and insured. I also have the 
responsibility of taking care of myself. Fortunately, I am a 
healthy woman. Even so, my lack of insurance is a constant 
source of stress.
    I am tired of the tactics insurance companies use to make 
quality coverage unaffordable, tactics that include outrageous 
separate deductibles for the common condition of pregnancy. I 
do not trust these companies and certainly do not believe that 
they will ever have the best interests of patients at heart. I 
want an affordable public option that will provide quality 
coverage and the assurance that out-of-pocket costs will be 
reasonable and fair. Health insurance premiums should be a part 
of every family's budget. However, they should not be a 
crippling part.
    My family could live comfortably on my husband's salary if 
our insurance premiums were reasonably proportionate to our 
income. We have made many minor sacrifices in order for me to 
remain at home with our children. However, in this day and age 
and in this great country I should not have to sacrifice basic 
health care coverage as well.
    Thank you for your time.
    [The prepared statement of Ms. Buchanan follows:]
                 Prepared Statement of Amanda Buchanan
    Mr. Chair, members of the committee, I would like to thank you for 
giving me the opportunity to testify before this committee today. My 
name is Amanda Buchanan, and I live in Weiser, ID. I am the wife of a 
public school teacher and a mother to two young sons.
    My husband transferred from a large school district to a small, 
rural one shortly after my first son was born. The decrease in income 
this change created was a compromise for our desire to raise a family 
in a small town. We have always been great at living simply and 
frugally--which came in especially handy as I had decided to become a 
stay-at-home mom. However what we weren't prepared for was the 
astronomical cost of putting myself and my infant son on my husband's 
group insurance policy. ($760 a month on a $33,000 a year gross 
income.) For the first time, I decided to get individual market 
coverage for the baby and me.
    I quickly learned that in Idaho, as an individual searching for 
coverage, I had two options: Regence Blue Shield of Idaho and Blue 
Cross of Idaho. And the limited options available between these two 
companies were remarkably similar. In fact every single policy 
available, despite the premium and deductible level, came with an 
additional maternity deductible of $5,000 (plus 20 percent of all 
remaining costs). At the time, my focus was on being responsible, which 
to me meant having insurance. I wasn't planning on getting pregnant for 
some time and I really had no other choice.
    Several months later, my husband and I found ourselves discussing 
the possibility of a second child. Instead of an intimate conversation 
between the two of us about goals and family, I felt like there were 
actually three of us at the table--myself, my husband and our insurance 
policy. We had to decide if we could even afford to have a second 
child. And not ``afford'' in the sense of clothing, food, et cetera; 
but could we afford to pay a hospital bill? There I was paying a $280 
premium every month for the best individual market policy Regence 
offered, and I was having to debate if I could afford the medical bills 
from a routine pregnancy and delivery. I was very angry that an 
insurance company could set up a policy in a way that would either 
discourage women from getting pregnant altogether, or if they did 
become pregnant, force them to pay for basically the entire cost of a 
typical delivery.
    My husband and I came up with a plan: I would have a baby, then 
take myself off of insurance and use the money I'd save to pay down our 
medical debt. And this is exactly what we did. In the end, health care 
premiums, deductibles and the medical costs from the pregnancy and 
delivery ate up 28 percent of our net income in 2008. And this is even 
after the hospital wrote off our bill.
    As it stands, our medical debts are paid. I remain uninsured. You 
could argue that I'm being irresponsible and creating a potentially 
disastrous situation for my family, and I would agree with you. But it 
would be impossible for us to come up with $300 a month to cover me. We 
would be sacrificing any ability to save money for emergencies, and 
would most definitely be cutting into our grocery budget. As a mother, 
my responsibility is to my children and family. My sons remain well fed 
and insured. I also have the responsibility of taking care of myself. 
Fortunately, I am a healthy woman. Even so, my lack of insurance is a 
constant source of stress.
    I am tired of the tactics insurance companies use to make quality 
coverage unaffordable. Tactics that include outrageous separate 
deductibles for the common condition of pregnancy. I do not trust these 
companies, and certainly do not believe that they will ever have the 
best interests of patients at heart. I want an affordable public option 
that will provide quality coverage and the assurance that out-of-pocket 
costs will be reasonable and fair. Health insurance premiums should be 
a part of every family's budget; however they should not be a crippling 
part.
    My family could live comfortably on my husband's salary if our 
insurance premiums were reasonably proportionate to our income. We have 
made many minor sacrifices in order for me to remain at home with our 
children, however in this day and age, and in this great country I 
should not have to sacrifice basic health care coverage as well.
    Thank you for your time.
    For the record, I would like to submit a few additional points.
    As I said, affordability is a key. As the Congress works to merge 
the House, HELP, and Senate Finance Committee bills, I hope you will 
put yourself in the shoes of families like mine. We need a good health 
insurance policy that is affordable and covers such life-events as 
childbirth. I've looked at the ``comparison'' Web site of Kaiser Family 
Foundation. I typed in our family's approximate situation and compared 
the different bills' results.
    The Web site does not allow me to enter our exact situation. So I 
typed in a $35,000 gross income for a 30-year-old in a family of four 
in a low-cost area of the country, not eligible for group coverage. 
Your committee's HELP bill would cost us about $491 in annual premiums 
and we would owe on our medical bills about 7 percent in co-pays. The 
House bills would be about $1,185 in premiums, and 7 percent of bills 
in co-pays. The Senate Finance Committee bill would be about $1,728 in 
premiums and we'd pay about 20 percent of the bills in co-pays. The 
House and the HELP proposals' limits on out-of-pocket, in-network costs 
are lower than Senate Finance's. In a worst case situation, we could 
owe about 39 percent of our total income under the Finance bill--and a 
good chance of bankruptcy.
    Please do as much as you can to move toward the best possible 
levels of affordability and catastrophic coverage.
    Providing help to working families such as mine will take more 
money--or it will take more savings in the health sector. If the 
Congressional Budget Office says that a public option saves money, 
please include it in the new law. We need the extra competition. As I 
said, there is almost no real competition in my State.
    Also, I've heard friends complain about the fine print, loopholes, 
and ``got 'cha' aspects of health insurance policies. I hope the final 
law can retain the HELP and Senate Finance Committee provisions that 
define medical and insurance terms so consumers can compare apples-to-
apples. I particularly like your idea of ``scenarios'' of what it would 
cost to be treated for certain common conditions.
    And I urge you to consider adding an idea I've heard that might 
help save money. In whatever ``exchange'' or ``connector'' marketplace 
established to help people shop, make sure that the consumer is told 
not just the premium cost, but also the estimated annual total cost, 
based on past medical history or on one's own estimate of one's health 
condition--for example, ``good health, fair health, poor health.'' 
Consumers Union has some data that shows that when consumers can see an 
estimate of their likely total cost, they make much better choices than 
if they only have premium information available. And if they make 
better insurance choices, they will need less subsidy help with 
premiums, deductibles, and co-pays. Total estimated cost data will help 
everyone win.

    Senator Mikulski. Ms. Robertson.

       STATEMENT OF PEGGY ROBERTSON, PATIENT/HEALTH CARE 
                    CONSUMER, CENTENNIAL, CO

    Ms. Robertson. Thank you for giving me this opportunity to 
speak today. My name is Peggy Robertson. I live in Centennial, 
CO. I have two boys, ages 10 and 3.
    Shortly after my youngest son was born, my husband and I 
began to research independent health insurance options because 
our current policy was increasing in price every year. My 
husband is self-employed and we are unable to get access to a 
group policy. We applied with Golden Rule and I was denied 
coverage based on having a Caesarian with Luke in 2006. I'm in 
perfect health and I was shocked that Golden Rule would decline 
my application.
    I called Golden Rule and they said that if I would get 
sterilized they would then be able to offer insurance to me. I 
was shocked by their comments and I immediately contacted the 
Colorado Division of Insurance to file a complaint. After 
filing a complaint, I discovered that Golden Rule is allowed to 
discriminate against women who have had a C-section. There was 
nothing I could do.
    I'd like to take a moment to read a couple of paragraphs 
from their letter of denial:

          ``The plan you applied for is an association group 
        plan and it's medically underwritten. As a general 
        rule, our underwriting guidelines require that we issue 
        coverage with a rider excluding benefits for Caesarian 
        section delivery for 3 years. However, the Colorado 
        Division of Insurance no longer allows us to place that 
        rider. Without the rider, we have decided that we 
        cannot provide any coverage for the individual. 
        Unfortunately, we cannot collect sufficient premium to 
        offset the risk of paying for a repeat C-section 
        delivery during the first 3 years of coverage.
          ``In order to consider coverage without a rider, we 
        require that certain requirements be met. One 
        requirement is that some form of sterilization has 
        occurred since the Caesarian section delivery. Also, 
        women age 40 and over who had their last child 2 or 
        more years prior to applying for coverage will not 
        require a rider.
        ``Unfortunately, since you had not met either of these 
        requirements, it would have been necessary to place the 
        C-section rider.''

    As a result, I then contacted International Caesarian 
Awareness Network to see if they could help me share my story 
and create change. They were able to do that and my story was 
covered on the front page of the New York Times. I discovered 
that in all but five States it is legal to discriminate against 
women because of a previous Caesarian, either by denying 
coverage, requiring sterilization, or charging significantly 
higher premiums than would be paid by a woman without a 
previous C-section.
    My husband and I ended up accepting an insurance plan with 
a high deductible that honestly could financially ruin us if 
there was a family medical emergency. In addition, my youngest 
son has been denied insurance coverage twice and we have had to 
find alternative health insurance for him at a higher cost and 
a higher deductible.
    As a result of my C-section, we were unable to have a third 
child. We attempted to get maternity insurance and discovered 
that the max we could receive is $4,000, and in order to 
receive that full pay we would have to have been insured by the 
same company for 3 years. Also, once a woman has had a C-
section it is almost impossible to qualify for a vaginal birth 
after Caesarian. As a result, most doctors would require me to 
have another C-section with a third child, which is financially 
impossible, much more expensive than $4,000, and therefore this 
has limited our ability to have any more children.
    Not only are women being denied coverage because of a 
previous Caesarian, but they are also being denied the 
opportunity to have a nonsurgical delivery with their next 
pregnancy because of widespread policies that ban vaginal birth 
after Caesarian.
    Thank you.
    [The prepared statement of Ms. Robertson follows:]
                  Prepared Statement of Peggy Robinson
    My name is Peggy Robertson. I live in Centennial, CO. I have two 
boys ages 10 and 3. Shortly after my youngest son was born, my husband 
and I began to research independent health insurance options because 
our current policy was increasing in price every year. My husband is 
self-employed and we are unable to get access to a group policy.
    We applied with Golden Rule and I was denied coverage based on 
having a cesarean with Luke in 2006. I am in perfect health and I was 
shocked that Golden Rule would decline my application. I called Golden 
Rule and they said that if I would get sterilized, they would then be 
able to offer insurance to me. I was shocked by their comments and 
immediately contacted the Colorado Division of Insurance to file a 
complaint. After filing a complaint, I discovered that Golden Rule is 
allowed to discriminate against women who have had a C-section. There 
was nothing I could do.
    I contacted the International Cesarean Awareness Network to see if 
they could help me share my story and create change. They were able to 
do that and my story was covered on the front page of the New York 
Times. I discovered that in all but five States, it is legal to 
discriminate against women because of a previous cesarean, either by 
denying coverage, requiring sterilization or charging significantly 
higher premiums than would be paid by a woman without a previous C-
section. My husband and I ended up accepting an insurance plan with a 
high deductible that honestly could financially ruin us if there was a 
family medical emergency. In addition, my youngest son has been denied 
insurance coverage twice and we have had to find alternative health 
insurance for him at a higher cost and a higher deductible.
    As a result of my C-section, we were unable to have a third child. 
We attempted to get maternity insurance and discovered that the max we 
could receive is $4,000, and in order to receive that full pay, we 
would have to have been insured by the same company for 3 years. Also, 
once a woman has had a C-section, it is almost impossible to qualify 
for a VBAC. As a result, most doctors would require me to have another 
C-section with a third child, which is financially impossible, much 
more expensive than $4,000, and therefore, this has limited our ability 
to have any more children.
    Not only are women being denied coverage because of a previous 
cesarean but they are also being denied the opportunity to have a non-
surgical delivery with their next pregnancy because of widespread 
policies that ban vaginal birth after cesarean.

    Senator Mikulski. Ms. Ignagni.

STATEMENT OF KAREN IGNAGNI, PRESIDENT AND CEO, AMERICA'S HEALTH 
                INSURANCE PLANS, WASHINGTON, DC

    Ms. Ignagni. Thank you, Madam Chairwoman. We appreciate the 
opportunity to testify today.
    In listening to the testimony of Ms. Robertson and Ms. 
Buchanan, our members are committed to policies that would get 
reform accomplished this year and would include a massive 
overhaul of the way the individual market works. We've 
testified to that before this committee. We remain committed to 
it, and specifically we are committed to policies where 
everyone gets covered, no one loses it, they would be portable, 
and no preexisting condition exclusions would be allowed.
    We've also had considerable focus in our membership on the 
needs of women. We've supported and advocated for reform that 
gives women equal health care for equal premiums. We also 
support the important preventive services that this committee 
has worked on and we believe they are very important to the 
needs of women and maintaining their health.
    We've provided research to this committee and other 
committees on what it will take to accomplish this objective, 
to achieve these goals in the individual market, and that is, 
encapsulating it, everyone participating in the system.
    I wanted to take this opportunity, since there has been 
considerable discussion this week about a recent report we 
issued from the PricewaterhouseCoopers Group and the reason we 
issued that report when we did. In its markup, the Senate 
Finance Committee moved away from the policy that would have 
everybody participate in the system. At that time we raised 
concerns about that moving away and we sent a letter suggesting 
it would lead to significant increases in costs, which no one 
wants.
    On September 29th, we asked PWC to look at this issue 
because in our own data we detected alarming trends by way of 
potential cost increases associated with this change. We 
received PWC's report Saturday, as in this Saturday several 
days ago, evening and we shared it with our members on Sunday. 
At that time the Senate was expected to take up health reform 
next week.
    The message of the study, which has been confirmed by 
another independent report released yesterday, is that costs 
are going to go up for individuals and working families if we 
don't have everyone participate.
    So we are in the same place, Madam Chairwoman, that we were 
when we came to this committee in March. We strongly support 
health care reform. We strongly support insurance market 
reforms that a number of the panelists and the members of the 
committee have spoken to. But we want it to work.
    During the summer we worked hard as part of a joint effort 
to bend the cost curve. If Congress were to commit to system-
wide cost containment, then the costs would go down, not up. 
Madam Chairwoman, you challenged us specifically back in the 
winter to commit to administrative simplification. We have 
taken that very seriously. That is part of our efforts to bend 
the cost curve. That's what we control, that's where we 
contribute. I'm pleased to tell you that our members have 
supported mandatory requirements that we get this done. We've 
worked with doctors and hospitals. We're pleased to stand 
behind that support and we will continue to do so.
    But if we're going to bend the curve, which would take 
pressure off purchasers, consumers, and the government, we need 
to have everyone participate and all stakeholders need to 
participate.
    Our industry has committed to reforms that would address 
the important issues we are hearing about today. We have 
proposed no longer basing premiums on gender. We agree with 
that. We also have advocated for States to adopt legislation so 
that no one is denied coverage for domestic abuse. We agree 
with that. We've supported eliminating preexisting condition 
exclusions entirely. We agree with that. And we have proposed 
an essential benefit package that provides coverage for vital 
health care services, such as prevention and maternity 
coverage.
    Our industry is committed to making these experiences that 
we've heard about today a thing of the past. It's the right 
thing to do and we stand behind that commitment.
    Thank you very much for the opportunity to testify.
    [The prepared statement of Ms. Ignagni follows:]
                  Prepared Statement of Karen Ignagni
                            i. introduction
    Chairman Harkin, Ranking Member Enzi and members of the committee, 
I am Karen Ignagni, President and CEO of America's Health Insurance 
Plans (AHIP), which is the national association representing 
approximately 1,300 health insurance plans that provide coverage to 
more than 200 million Americans. Our members offer a broad range of 
health insurance products in the commercial marketplace and also have 
demonstrated a strong commitment to participation in public programs.
    We thank the committee for holding this important hearing, and we 
appreciate this opportunity to testify. Our members are strongly 
committed to meeting the health care needs of women, and we fully 
support efforts to ensure that women are treated fairly and equitably 
under our Nation's health care system. Our testimony today will focus 
on three key areas:

     AHIP's support for comprehensive health reforms that would 
correct flaws in the current system and address the coverage needs of 
women;
     innovative programs our members have implemented to 
improve health care for the women they serve; and
     research findings showing that private health insurance 
plans are enhancing the health and well-being of female enrollees.
   ii. fixing the health insurance market to address women's health 
                                concerns
    AHIP's members have proposed far-reaching health insurance reforms. 
Our proposals directly confront the reality that the individual health 
insurance market, as currently structured, is seriously flawed and 
needs to be fundamentally overhauled.
    To solve this problem, it is important to first recognize that 
insurance works only when people pay into the system both when they are 
healthy and when they are sick. This is not the case under the current 
system, since coverage is purchased on a voluntary basis and many young 
and healthy people choose to go without coverage. Within this flawed 
system, the adoption of preexisting condition exclusions and waiting 
periods for new enrollees is an approach that plans are forced to use 
to keep coverage affordable for those people who maintain coverage on 
an ongoing basis. By adopting these practices, health insurance plans 
are working to keep costs as low as possible for as many people as 
possible--while also recognizing very clearly that major changes are 
needed to replace this inadequate system with a reformed system that 
works well for all Americans.
    Our members are aggressively promoting major reforms to accomplish 
this goal. The foundation of our proposal would eliminate rating based 
on gender and health status and, additionally, provide guaranteed 
coverage for preexisting conditions in the individual market. 
Prohibiting premium variation based on gender is a critically important 
step toward providing security and peace of mind to women and assuring 
that they receive equal health care for equal premiums. These reforms, 
when combined with a personal coverage requirement and premium 
assistance for low-income and moderate-income individuals and families, 
will ensure that no one--regardless of their gender, health status, or 
medical history--falls through the cracks of the U.S. health care 
system.
    Establishing an enforceable coverage requirement is particularly 
important to the success of the insurance market reforms we are 
proposing. If the individual coverage requirement provides inadequate 
incentives to get everyone covered, individuals and families who are 
covered in the individual market are likely to experience unintended 
consequences similar to those experienced in several States where 
insurance market reforms were enacted in the absence of universal 
coverage in the 1990s. A Milliman Inc. report \1\ released by AHIP in 
September 2007 examined the experience in the eight States that enacted 
various forms of community rating and guarantee issue laws in the 
1990s, without establishing an individual coverage requirement. A 
significant number of individuals responded to these reforms by 
deferring coverage until after they encountered health problems and, as 
a result, the Milliman report found that these States experienced 
higher premiums for those with insurance, saw reduced enrollment in 
individual health insurance coverage, and had no significant decrease 
in the number of uninsured.
---------------------------------------------------------------------------
    \1\ The Impact of Guaranteed Issue and Community Rating Reforms on 
Individual Insurance Markets, Milliman, Inc., August 2007.
---------------------------------------------------------------------------
    Other organizations--including the Commonwealth Fund \2\ and the 
Urban Institute \3\--also have recognized the need, in the context of 
comprehensive health reform, to bring everyone into the system with an 
individual coverage requirement.
---------------------------------------------------------------------------
    \2\ The Path to a High Performance U.S. Health System, Commonwealth 
Fund, February 2009.
    \3\ The Individual Mandate--An Affordable and Fair Approach to 
Achieving Universal Coverage, New England Journal of Medicine, Linda 
Blumberg, Ph.D. and John Holahan, Ph.D., June 2009.
---------------------------------------------------------------------------
    More recently, AHIP commissioned a report \4\ by 
PricewaterhouseCoopers because of our concerns about the workability of 
the current legislative proposals. We wanted outside verification of 
the trends we were seeing in our own analyses, suggesting that the 
reform construct in the Senate Finance Committee bill could lead to 
alarming unintended consequences during implementation. This study 
confirms that the current legislation will make coverage less 
affordable for individuals, families and employers, and make it harder 
to get all Americans covered. It shows that costs will go up even 
faster than they would under the current system.
---------------------------------------------------------------------------
    \4\ Potential Impact of Health Reform on the Cost of Private Health 
Insurance Coverage, PricewaterhouseCoopers, October 2009.
---------------------------------------------------------------------------
    Health insurance plans are strongly committed to working with 
Congress to avoid this outcome. Our Board of Directors has endorsed 
major proposals for expanding coverage, improving quality, and reducing 
the growth rate of health care spending. These reforms--which we 
outlined in our testimony for the committee's March 24 hearing--build 
upon the strengths of the current system and recognize that both the 
private sector and public programs have a role to play in meeting these 
challenges.
    Health insurance plans also are contributing to the reform debate 
through a system-wide simplification effort to streamline 
administrative procedures and achieve cost efficiencies for physicians 
and hospitals, and by committing to help fund a reinsurance mechanism 
during the transition to the market reforms. Together, these 
contributions will decrease costs across the health care system, reduce 
paperwork and duplication, and ensure that everyone can obtain high 
quality coverage that is portable across the entire system.
    Another critically important priority in the health reform debate 
is improving access to preventive services, which are particularly 
important for women. We support pending legislation that would 
eliminate cost-sharing for preventive services rated ``A'' or ``B'' by 
the U.S. Preventive Services Task Force (USPSTF) and for immunizations 
recommended by the Advisory Committee on Immunization Practices (ACIP). 
Providing first dollar coverage of proven preventive services is an 
important strategy for keeping people healthy, detecting diseases at an 
early stage, and avoiding preventable illnesses.
    Our members have been pro-active in designing wellness and 
prevention programs that promote healthier lifestyles and preventive 
screenings, identify and monitor patients at high risk for certain 
conditions, help ensure early diagnosis and treatment, and address the 
unique needs and circumstances of women. These programs help to improve 
quality of care and should be supported by the health reform process, 
including the flexibility for plans to offer premium discounts based on 
an individual's or an employee's participation in wellness programs.
   iii. health plan innovations addressing women's health care needs
    Health insurance plans, in addition to supporting health reform, 
have been very active in developing innovative programs to improve 
health care quality and health outcomes for women. These programs--
including several that we discuss below--focus on a wide range of 
women's priorities and health care needs.
Geisinger Health Plan's Health Management Program for Osteoporosis
    Geisinger Health Plan has implemented a program that analyzes 
claims to identify patients whose medical histories and demographic 
characteristics place them at risk of the disease, as well as those who 
have a history of bone fractures. Under this program, registered nurse 
case managers contact members at risk by phone or arrange office visits 
to provide them with key information about osteoporosis prevention and 
treatment. During these phone calls and meetings, case managers explain 
risk factors for osteoporosis, discuss ways to prevent the condition, 
and discuss the benefits of bone mineral density testing and 
medications for osteoporosis.
    When Geisinger determines that patients' age and health profiles 
place them at high risk of osteoporosis, case management nurses review 
the patients' prescriptions to avoid use of medications that could 
increase the risk of falls, and they follow up with physicians as 
needed to identify safer alternatives. Case managers work with pharmacy 
assistance programs as needed to help low-income members obtain needed 
osteoporosis medications. They may coordinate with Area Agencies on 
Aging to conduct home safety inspections to remove items that could 
lead to falls, and they can help arrange for transportation to doctor 
visits. Besides working with patients on an ongoing basis, Geisinger's 
case managers maintain regular contact with primary care physician 
offices by phone and e-mail and in person to discuss the needs of 
members with osteoporosis and help ensure that they receive recommended 
care.
    In 2009, 21 percent of Geisinger members age 65 and older are 
enrolled in the health plan's osteoporosis health management program. 
The percent of women age 67 or older with histories of bone fracture 
who had either undergone bone mineral density testing or had taken 
osteoporosis prevention or treatment medications rose by 9.4 percent 
from 2008 to 2009.
Kaiser Permanente's Domestic Violence Prevention Program
    On October 10, Kaiser Permanente and Dr. Brigid McCaw received a 
national award from the Family Violence Prevention Fund for creating 
and implementing an innovative and comprehensive approach to domestic 
violence prevention.
    This innovative program by Kaiser Permanente uses health education 
materials, posters, flyers, and other information to encourage people 
to speak up about domestic violence. Under this program, clinicians 
receive training so they are comfortable raising this issue, providing 
a caring response, referring patients to on-site domestic violence 
services, and offering information about community resources.
    The program is enhanced by Kaiser Permanente HealthConnect, which 
enables the organization's more than 14,000 physicians to 
electronically access the medical records of members nationwide. It 
includes tools that make it easier for physicians to identify victims 
of domestic violence, provide a consistent caring response based on 
clinical practice recommendations, and make referrals to other Kaiser 
Perma-
nente services and community resources.
Passport Health Plan's ``Tiny Tot'' Program for Healthy Pregnancies
    Passport Health Plan has created a ``Tiny Tot'' program to help 
mothers with preterm newborn babies to ensure a healthy transition from 
the hospital to the home. Under this program, a registered nurse is 
assigned to focus on the welfare of the newborn and to work as a 
liaison between the family and members of the infant's health care 
team, including neonatologists, pediatricians, neonatal intensive care 
unit nurses, and home care providers. The nurse helps the family with 
the paperwork for obtaining any necessary medical equipment, such as 
ventilators, and with the logistics for getting to appointments with 
specialists.
    The program also includes a strong focus on educating new mothers 
about infant care and the importance of creating a healthy home 
environment. The program's goals are to:

     decrease the average length of stay in the hospital;
     decrease or prevent hospital re-admissions and emergency 
room visits within 30 days of discharge;
     increase the percentage of members who follow up with 
their primary care physician within 30 days of discharge;
     identify newborns in need of ongoing case management 
services; and
     coordinate discharge needs.

    Enrollees participating in the ``Tiny Tot'' program have a 98 
percent compliance rate in obtaining a newborn screen within the first 
30 days. Also, since the program began in 2001, hospital re-admission 
rates for preterm babies have decreased in the range of 1 to 4 
percentage points.
    This program--and the CIGNA program discussed below--are 
particularly important, given that the rate of preterm births in the 
United States has increased by 18 percent since 1990, according to the 
March of Dimes. Babies who survive a premature birth face the risk of 
serious lifelong health problems including learning disabilities, 
cerebral palsy, blindness, hearing loss, and other chronic conditions 
such as asthma. Also, the health care costs associated with a preterm 
birth typically are 12 times as much as those for a full term, healthy 
birth.
CIGNA's Healthy Pregnancies, Healthy Babies Program
    To address the rise in preterm births, many of which are 
preventable, CIGNA implemented its Healthy Pregnancies, Healthy Babies 
program in 2006 to provide educational and care management services to 
women who are pregnant or considering pregnancy.
    Participants in the program undergo an initial risk assessment and 
routine follow-up assessments throughout their pregnancy. Based on 
these assessments, participants will receive appropriate prenatal 
education and care management, and those considered high risk will be 
assigned to a Specialty Case Management Nurse. Clinical assessments, 
risk stratification and history are managed through a single tool so 
that any member of the care team can speak to a participant 
knowledgably about her condition. Participants receive one-on-one 
counseling and support from a health coach, who can help the mother-to-
be manage the physical and emotional demands of pregnancy.
    Because early intervention can help prevent prematurity and other 
poor pregnancy outcomes, the program offers a tiered incentive that is 
higher for women who enroll early in their pregnancies. To help assure 
that pregnant members participate actively in the program, payment of 
the incentive is contingent on program completion. CIGNA also offers 
free tobacco cessation programs, as there is indisputable evidence that 
links smoking with preterm birth and low-birth weight babies. Extra 
dental care also is part of the program, as pregnancy can affect teeth 
and gums, and infections and other oral health problems can lead to 
preterm birth.
    More than 90 percent of the women who enroll in the program 
complete it, and more than 97 percent report a high level of 
satisfaction with their experience in the program. Improved outcomes 
for mothers and babies have led to savings of more than $6,000 per 
pregnancy for participants of the program.
Centene Corporation's CONNECTIONS Plus Program
    A program by Centene Corporation, known as CONNECTIONS Plus, offers 
free cell phones to Medicaid members who do not have safe, reliable 
access to land line phones. As of last year, the health plan had 
provided cell phone service to 160 pregnant women since the program's 
inception in 2007. Program participants use the cell phones to call 
their doctors, case managers, 911, and the health plan nurse line when 
they need help, and they can speak regularly with nurse case managers 
affiliated with Centene's disease management programs.
    Under this program, cell phones can be customized to member needs 
and may include numbers for transportation services, specialty pharmacy 
services, housing and shelter, parenting support, emergency crisis 
numbers, counseling, special needs services, food pantries, utility 
assistance, clothing banks, parenting support, and family support. 
High-risk pregnant women are allowed to keep their cell phones for a 
transition period (about 6 weeks) following their babies' birth.
    There is strong evidence that low-income women are at increased 
risk for preterm births. The average gestational age at delivery for 
the babies of pregnant women who have participated in the Centene 
Corporation program since 2007 is 37.79 weeks, which is well within the 
normal range.
Keystone Mercy's Healthy Ministry Program for Women
    For more than 9 years, Keystone Mercy Health Plan has offered the 
Health Ministry Program for Women, a faith-based health education and 
awareness program to reduce health disparities among minority women. 
The program helps women incorporate positive health behaviors into 
everyday life to prevent, reduce, and reverse chronic diseases and 
stress. By partnering with and bringing local health care providers to 
churches, synagogues, and mosques, the Health Ministry Program provides 
women with a safe and supportive setting in which to learn about their 
health.
    The program's goals are to:

     educate women and their families about the importance of 
prevention and early detection of disease through community-based 
partnerships;
     promote regular health screenings and check-ups to 
identify and target women at risk;
     increase participants' knowledge of stress triggers and 
stress management techniques; and
     empower women to be their own health advocates by knowing 
the risks and warning signs of chronic diseases.

    As part of the Health Ministry program, Keystone has partnered with 
six Philadelphia-area churches for the past 3 years on an initiative 
called the Forty-Day Journey. The initiative emphasizes nutrition, 
exercise, water intake, and medication compliance. It includes 
education on topics such as healthy cooking, and it features a Gospel 
aerobics class and walking clubs.
    Approximately 2,500 people, including 825 Keystone Mercy Members, 
participated in the Forty-Day Journey from 2006 to 2008. Among program 
participants with diabetes, Keystone measured the following 
improvements over 2 years:

     A nearly 20 percent drop in triglyceride levels;
     A 22 percent decline in LDL, or bad cholesterol, overall, 
and a 31 percent decline for people with Type 1 diabetes;
     A 17 percent reduction in blood sugar levels;
     A 4.6 percent reduction in weight overall, and a 3 percent 
decline for people with Type 1 diabetes.

    Program participants reported reductions in pain and improvements 
in mobility and flexibility. They also said that their overall mood had 
improved and hope for the future had increased since participating in 
the program. In 2008, the Health Ministry Program won the ``Recognizing 
Innovation in Multicultural Health Care Award'' from the National 
Committee for Quality Assurance (NCQA).
Group Health Cooperative's Teen Pregnancy and Parenting Clinic
    Group Health Cooperative has established a Teen Pregnancy and 
Parenting Clinic that provides education and support to help pregnant 
teens avoid risky behaviors--such as smoking, alcohol, and recreational 
drug use--that can lead to premature birth, low-birth weight, and 
cognitive impairments. Program participants range in age from 13 to 25.
    Two family physicians, along with family practice residents from 
Group Health's Family Medicine Residency program, provide care at the 
clinic, including antepartum care, delivery, postpartum care, primary 
care, and pediatric follow-up. The clinic team also includes a 
registered nurse, a social worker, a nutritionist, a representative 
from the U.S. Department of Agriculture's Special Supplemental 
Nutrition Program for Women, Infants and Children (the WIC program), 
and a health educator. The nurse meets with patients during every 
visit, helps assess their needs, and coordinates care with other team 
members. The social worker addresses psychosocial issues and helps 
program participants obtain community resources such as housing and 
transportation. The nutritionist helps teens create a diet appropriate 
for pregnancy; the WIC provider helps participants obtain vouchers for 
free groceries; and the health educator teaches parenting classes.
    The clinic provides care to approximately 50 teens and their 
children each year. Participating teens visit the clinic every 1 to 3 
weeks throughout their pregnancy and have follow-up visits for 2 years 
after delivery. Their children receive services through the clinic for 
up to 5 years. Health outcomes among program participants have exceeded 
those achieved among comparable populations served by Seattle-area 
community health centers.
    Since the clinic's opening in 1990, program staff have delivered 
736 babies and the percent of low-birth weight babies (those less than 
5 pounds) has been 6.7 percent, compared to a national rate of 8.3 
percent.
Prevention and Wellness Initiatives
    In a recent AHIP report \5\ entitled ``Innovations in Prevention, 
Wellness, and Risk Reduction,'' we outline case studies of health 
insurance plans that are working with other stakeholders to create 
healthier workplaces, schools, and communities, help families make 
better choices about diet and physical activity, and overcome economic, 
social, and cultural barriers to the adoption of preventive practices 
and healthier lifestyles. This report highlights a wide range of health 
plan initiatives that are combining personal health assessments, health 
coaching, changes in the work environment, and lifestyle incentives to 
help employers and their employees tackle health risks that lead to 
illness, absenteeism, lost productivity, and higher health care costs.
---------------------------------------------------------------------------
    \5\ Innovations in Prevention, Wellness, and Risk Reduction, AHIP, 
2008.
---------------------------------------------------------------------------
     iv. research findings show women benefit from private sector 
                innovations by medicare advantage plans
    AHIP recently released a study \6\ showing that Medicare Advantage 
enrollees spent fewer days in the hospital, were subject to fewer 
hospital re-admissions, and were less likely to have ``potentially 
avoidable'' admissions for common conditions examined by the study. 
While this study focused broadly on both women and men, the findings 
indicate that women are particularly well-served by participating in 
private health plans offered through the Medicare Advantage program.
---------------------------------------------------------------------------
    \6\ A Preliminary Comparison of Utilization Measures Among Diabetes 
and Heart Disease Patients in Eight Regional Medicare Advantage Plans 
and Medicare Fee-for-Service in the Same Service Areas, AHIP, revised 
September 2009.
---------------------------------------------------------------------------
    The study's findings demonstrate that the innovative programs 
developed by Medicare Advantage plans--which place strong emphasis on 
preventive health care services that detect diseases at an early stage 
and disease management programs for seniors with chronic illnesses--are 
working to help keep patients out of the hospital and avoid potentially 
harmful complications.
    The median scores for the eight plans included in this study show 
that Medicare Advantage plans improved health care for women by:

     reducing emergency room visits by 35 percent;
     reducing hospital re-admissions by 50 percent;
     reducing potentially avoidable hospital admissions by 16 
percent;
     reducing inpatient hospital days by 18 percent; and
     increasing office visits (e.g., for primary and preventive 
care) by 20 percent.

    A related AHIP study \7\ shows that women enrolled in Medicare 
Advantage spent fewer days in the hospital, were subject to fewer 
hospital re-admissions, and were less likely to have potentially 
avoidable admissions, for common conditions ranging from uncontrolled 
diabetes to dehydration. This study analyzed statewide datasets on 
hospital admissions in California and Nevada compiled by the AHRQ. The 
unique data in these States allows for direct comparisons of 
utilization rates among enrollees in Medicare Advantage plans and in 
FFS Medicare. The female-specific data for this study indicate that:
---------------------------------------------------------------------------
    \7\ Reductions in Hospital Days, Re-Admissions, and Potentially 
Avoidable Admissions Among Medicare Advantage Enrollees in California 
and Nevada, 2006, AHIP, September 15, 2009.

     Women Medicare Advantage beneficiaries in California spent 
30 percent fewer days in the hospital than those with FFS Medicare, and 
in Nevada, women in Medicare Advantage plans spent 26 percent fewer 
days in the hospital.
     Women Medicare Advantage enrollees were re-admitted to the 
hospital in the same quarter for the same condition 16 percent less 
often in California and 33 percent less often in Nevada, compared to 
FFS Medicare.
     In both States, women enrolled in Medicare Advantage plans 
were less likely--by margins of 8 percent in California and 9 percent 
in Nevada--than those in FFS Medicare to be admitted to the hospital 
for conditions described by AHRQ as ``potentially avoidable,'' such as 
dehydration, urinary tract infection, or uncontrolled diabetes.

    These findings demonstrate that by reducing the need for 
hospitalizations and emergency room care, health insurance plans are 
not only improving the health and well-being of their female 
enrollees--but also achieving greater efficiencies and cost savings.
    In both AHIP studies, utilization rates were calculated on a risk-
adjusted basis. Risk scores for Medicare Advantage and Medicare FFS 
enrollees were based on age, sex, and health status.
                             v. conclusion
    Thank you for this opportunity to testify on these important 
women's health issues. We look forward to continuing to work with 
committee members to advance meaningful health reforms to expand 
coverage, improve quality, and slow the growth rate of health care 
spending.

    Senator Mikulski. The way we're going to proceed is I'll be 
the wrap-up questioner. I'm going to turn to Senator Merkley 
from the Democratic side, then to Senator Burr, and then I'll 
be the wrap-up. I know time's moving along and, Senator, you 
were here. Senator Merkley, you will go first. Then we'll turn 
to Senator Burr and then I'll be the wrap-up.

                      Statement of Senator Merkley

    Senator Merkley. Thank you very much, Madam Chair.
    Ms. Ignagni, I wanted to ask you a little bit about your 
testimony. You noted your members are strongly committed to 
meeting health care needs of women and support efforts to 
ensure women are treated fairly and equitably. But AHIP has 
supported a 5 to 1 rating band for older Americans, which is in 
the Finance Committee bill, meaning that older Americans would 
be charged five times the cost to their younger counterparts.
    The HELP bill has a 2 to 1 rating band, and a higher rating 
band would put a disproportionate burden on older women, many 
of whom outlive men. I was wondering if you could just address 
and explore that point.
    Ms. Ignagni. Yes, sir. I appreciate the question and I'm 
happy to clarify exactly where we are. This is a question about 
how to equitably distribute costs. I want to make it very 
clear, in supporting the rating bands that we have we are not 
insensitive to the needs of older workers. What we have 
proposed is a rating system that would lighten the load on Ms. 
Robertson and Ms. Buchanan in terms of where they are in the 
age cohorts.
    At the same time, we have not ignored older workers. What 
we have suggested is a special targeted subsidy that would 
decrease the cost and the burden for individuals in the 55 to 
65 cohort, so that we wouldn't have to impose--if you go to two 
to one, it means that individuals and women at the lowest age 
cohorts would face disproportionately higher costs.
    I can tell you what that means very specifically. Someone 
in the 30 to 34 age cohort would face an increase of 38 percent 
compared to where they would be in the 5 to 1 category. We have 
tried to be very thoughtful about commenting both how to 
distribute the cost equitably, not to put too much pressure on 
younger families, but at the same time also responsibly add a 
suggestion on what to be done for older workers.
    Senator Merkley. I thank you for your comment. I just note 
that it remains a concern for this Senator.
    Ms. Ignagni. Yes, sir.
    Senator Merkley. Ms. Buchanan, to clarify, were you saying 
that your insurance company would not cover a vaginal birth 
after you had had a Caesarian and that that is a common 
practice in the industry?
    Ms. Buchanan. That's very common practice.
    Senator Merkley. I just wonder if any members of the panel 
can comment on that and how we might tackle that problem.
    Ms. Ignagni. Would you like me to comment, Senator? I'd be 
happy to.
    Senator Merkley. That would be great.
    Ms. Ignagni. We have spent a great deal of time looking at 
the individual market. Approximately 18 million people are 
covered in the individual market, as you know. We believe that 
having everyone participate would allow any type of preexisting 
condition requirements to end. We support that. We think it's 
the right thing to do. We do not think there should be any 
differentiation in terms of gender payments. We support that. 
And we don't believe that people should be paying according to 
their health status.
    Senator Merkley. So this type of requirement would be 
eliminated as far as you're concerned?
    Ms. Ignagni. Yes, sir.
    Senator Merkley. Very good.
    Ms. Furchtgott-Roth. The reason it's originated, if I might 
add, the reason it's originated is because of the lawsuits and 
the vast amounts of malpractice insurance associated with 
obstetrics. Obstetricians pay some of the highest malpractice 
premiums in the Nation. There's a big chance of being sued, and 
that's why it's regarded as safer to have a Caesarian, because 
that gets the baby out right away. If there were malpractice 
reforms accompanied by the health insurance, then these kinds 
of problems could be diminished.
    Senator Merkley. Mr. Guest, I wanted to turn to you for a 
moment. In your testimony you describe ways to help consumers 
make apples to apples comparisons of health plans and suggest 
that insurers explore ways to help consumers gauge their 
estimated annual total cost. Can you elaborate on how that sort 
of consumer-friendly information could be presented?
    Mr. Guest. Well, just in general, it covers a variety of 
things. I'll give you one example of something Consumer Reports 
is doing and then I'll also give you a longer answer for the 
record in terms of the very specific ways that one can look at 
the total, as opposed to just the premium. We have something 
called Consumer Reports Best Buy Drugs, where we've worked with 
a consortium of researchers looking at clinical evidence, 
researchers from 15, 16 States, where we have identified drugs 
that are equally effective, equally safe, and we've overlaid 
that with cost information, with price information. So we're 
saving consumers in some cases thousands, $500, $1,000, more 
than $2,000 a month. That's just one kind of information.
    But more generally, I think what would be really important 
is, also as a way to reduce costs and improve quality, we have 
been engaged in an effort for requiring hospitals to disclose 
their hospital-acquired infection rates. Now 26 States have 
laws requiring that. In Senator Casey's State of Pennsylvania, 
what they've shown, what they've found, is with the public 
disclosure of those rates it puts pressure on hospitals to do a 
better job, it enables consumers to make choices of where they 
may want to go for procedures in a hospital, and infection 
rates have come down.
    Whether it's infection rates, whether it's other adverse 
events, there's a variety of things around quality of care as 
well as cost that can help to make informed decisions.
    Senator Merkley. Thank you very much. My time is up. Thank 
you very much as a panel for your testimony. Oregon is one of 
the States that has banned gender discrimination. I think it's 
so important in health care reform that we have fairness for 
women across our entire Nation.
    Thank you.
    Senator Mikulski. Senator Burr.
    I'd like to comment that Senator Burr and I are the chair 
and the ranking member on this committee and have worked a lot 
on public health initiatives. Right now we're focusing on 
insurance reform, but because this is the HELP Committee and we 
don't have jurisdiction over the payment system, there's a lot 
we feel we need to do in terms of public health and issues 
around the management of chronic illness--the prevention of 
diabetes, heart disease. Senator Burr has been a real leader 
for these issues, and I thank him for his comity and insights 
on so many things.
    Senator Burr.
    Senator Burr. Thank you, Madam Chairman.
    I would ask of the chair unanimous consent to enter into 
the record a Washington Post article that is entitled 
``Malpractice Premiums, Rate of C-Sections Rise Together.'' I 
think that highlights for all of our witnesses as well as the 
members that there's a direct correlation here, and that if you 
want to have true reform then you've got to reform all aspects. 
You can't leave the tort challenges unchecked if you want to 
address the concerns of Caesarian birth.
    The chair referenced earlier to the report, Ms. 
Greenberger, about battered women and pointing out eight 
States. Now, I've had an opportunity to look at the report and 
from what I can gather from the report you relied heavily on 
the Women's Law Project and Pennsylvania Coalition Against 
Domestic Violence that was published in 2002 for a lot of the 
data that you put into your report.
    I guess my question is this. Did your staff go back to 
North Carolina to see if any of these things were accurate for 
North Carolina today?
    Ms. Greenberger. Yes, Senator, we did, and we know that the 
issue of domestic violence as a preexisting condition can 
manifest itself in a number of different ways. It can be that 
an insurance commissioner----
    Senator Burr. Did your staff find specific cases where 
people had been denied access because of domestic violence?
    Ms. Greenberger. That's a very fair question, and what we 
know--we know that this has come up in a conversation with 
insurance commissioner staff in North Carolina--is specifically 
that women are being denied across the country.
    Senator Burr. Ms. Greenberger, let me address North 
Carolina specifically. I'll read a letter from my insurance 
commissioner, Wayne Goodwin, and I would ask the chair 
unanimous consent to put into the record his letter to me in 
its entirety, and I'll just read a couple of sections:

          ``In North Carolina if a company or policy wants to 
        exclude something, they must declare it in an 
        application by asking the applicant directly about the 
        exclusion. Because exclusions are listed on the 
        application form and the department reviews and 
        approves the forms, we would know if a company tried to 
        consider domestic violence as a preexisting condition.
          ``My department--we are unaware of any company or 
        forms that have asked to exclude domestic violence as a 
        preexisting condition. If they did, we would have 
        denied it. My department has been unable to find a 
        single example of a company asking an applicant if they 
        have been a victim of domestic violence or a consumer 
        complaint about being asked for this insurance 
        purposes.
          ``However, the issue is far too important to leave 
        any possibility that it could happen. So to create 
        further protections, I have filed an administrative 
        rule for adoption in the North Carolina Administrative 
        Code. This is the most effective way to address these 
        concerns and add to our insurance regulations.''

    Again, Madam Chairwoman, I would ask that that be included 
into the record.
    They say there's not been an example of it.

    [Editor's Note: The letter referred to may be found in 
additional material.]

    Ms. Greenberger. If I could answer, Senator. First of all, 
I'm very glad to hear the insurance commissioner recognizing 
that the most effective protection is to have an explicit 
protection. But if I could get back to your question about the 
specific examples, they manifest themselves in many different 
ways. For example, if a woman ends up in an emergency room with 
cuts, bruises, broken arms, black eyes, typical injuries that 
result from domestic violence, we know of instances where women 
are being denied insurance coverage and neither the insurance 
company----
    Senator Burr. Ms. Greenberger, my question is specifically 
on North Carolina----
    Ms. Greenberger. I'm trying to answer it specifically.
    Senator Burr. And the insurance commissioner tells me: We 
haven't had a case, we haven't had anybody.
    Ms. Greenberger. Well, I'm trying to explain. First, I 
think it's great that he is now explicitly having a rule, 
which, as our report pointed out, didn't exist before. That's 
really excellent.
    Second, because of the way insurance companies deal with 
this issue in particular, they will often deny the coverage of 
victims and survivors of domestic violence without saying that 
that's the reason. So it's difficult.
    Senator Burr. Ms. Greenberger, I'm just going by your 
report.
    Ms. Greenberger. And I'm trying to--you asked a question 
about did we follow up and we did.
    Senator Burr. I would encourage my colleagues--well, I 
found out more information in my one phone call to North 
Carolina than I think your report did. I would point out to my 
colleagues the important part of the report is to read the end 
notes. In the end notes it specifically says that you relied on 
the 2002 study done in Pennsylvania for the data.
    Now, my point would be this. If you read on, you would find 
out that that 2002 study used early 1990 data to come up with 
their report. The conclusion that I have is that the data 
you've used to present this case is almost 20 years old, and I 
just point out the fact that the chairwoman, having read the 
report, referred to eight States that have, North Carolina 
being included with it, denied for the purpose of battered 
women. And in fact that's not what the State officials in North 
Carolina say.
    Ms. Greenberger. Actually, Senator, I really disagree with 
what you said, because what that letter just said was that your 
insurance commissioner has just changed the rules.
    Senator Burr. No, ma'am. It says they have thoroughly 
examined and had had no case where a company had had that on an 
application and no complaint from a person.
    Ms. Greenberger. Well, we talked in the report--yes, 
Senator.
    Senator Burr. My question is, can you present to us today a 
person who this happened to in North Carolina?
    Ms. Greenberger. Well, let me say two things. No. 1, the 
first issue that you raised is are the eight States and the 
District of Columbia current data and information? And the 
answer is yes, and I believe that the insurance commissioner's 
letter to you underscores that they are, that it is currently 
accurate. We have checked and that number is currently 
accurate. That's the first question you asked and I give you an 
explicit answer.
    Senator Burr. I think we'll agree to disagree, based upon 
how I read the letter. But I'll leave it for my colleagues.
    If the chair would indulge me for 2 additional minutes. I 
did not mean to get caught up for that much time and I just 
want to ask Ms. Ignagni something.
    Senator Mikulski. Please, go ahead. Then we'll turn to 
Senator Franken.
    Senator Burr. I thank the chair.
    Dr. Coburn and I introduced a bill and it focuses 
specifically on wellness prevention and chronic disease 
management. I believe these are essential features that we're 
going to have to exercise to hold down health care costs. What 
are some of the programs your member companies have put into 
place to implement these three critical elements?
    Ms. Ignagni. This is a very good question. We included, 
Senator, in our testimony a list of very specific programs, but 
let me highlight a couple of them for you. No. 1, we have quite 
a great deal of work going on across the country in large plans 
and small plans to intervene for women who may have very 
problematic and high-risk pregnancies. Case management and 
support services; there are a myriad of programs around the 
country. They've won numerous awards and I think they're path-
breaking.
    No. 2, for women who have high risks of certain chronic 
illnesses, there are similar kinds of programs going on across 
the country.
    And No. 3, for women who need transportation services, 
particularly low-income women, we've, particularly in our 
Medicaid health plans, we've pioneered a range of very specific 
services. You're right, wellness is important. Early 
intervention is key and coordinate care is the difference 
between having good health care and not having good health 
care. And particularly for women, it's very, very important.
    Senator Burr. Thank you.
    I won't ask my second question. I'll just make a general 
statement, because several of you referred to the expansion of 
Medicaid where I think the Finance Committee bill expands the 
coverage to 14 million Americans. I believe that through this 
health care debate we have to be as concerned about expansion 
of coverage as we are about access to care.
    When you take 14 million Americans and you put them into a 
health care system that MEDPAC says is denied care, or at least 
the ability to be seen, by 40 percent of our health care 
professionals, I think you have flunked on the access.
    Hold our feet to the fire to come up with a way to provide 
coverage to every American, not just shove them into a system 
that today 40 percent of the health care professionals choose 
not to see them based upon reimbursement. I think the expansion 
of Medicaid is a flunk to what the President suggested, and 
that's quality and access have to be linked. So I would point 
that out.
    The chair has shown tremendous indulgence and I thank you.
    Senator Mikulski. Senator Bennet.

                  STATEMENT OF SENATOR BENNET

    Senator Bennet. Madam Chair, thanks. I will be very brief 
because I was late. We were on the floor talking about health 
care.
    I first wanted to just thank Peggy Robertson for being here 
from my State and sharing her story, your story. It's a story I 
know well and it's one of hundreds, if not thousands, of 
stories that we've heard from across the State of Colorado, 
millions of stories across the country, of people whom the 
current system let down in a fundamental and profound way.
    I wonder, Ms. Robertson, I'll just ask you first. As you 
think about the health care reform that we're considering here 
in Washington and imagine a world post the reform discussion, 
what do you most hope to see as a consequence of the work that 
we're doing?
    Ms. Robertson. I think the big thing for me is that there 
should be all options available to women. We shouldn't be 
cornered into having to go a certain route. If I wanted a 
vebac, I should be allowed to get one. If a Caesarian was a 
better choice for me due to my health, that should be the route 
I should be able to take. But I feel right now that my options 
are very limited. So all options for women everywhere.
    Senator Bennet. Well, I want to thank you again for being 
here.
    Ms. Robertson. Thank you.
    Senator Bennet. Ms. Greenberger, just along those lines, I 
just have one question for you, which is, why is gender rating 
important to address in the affordability context?
    Ms. Greenberger. Basically, it means for those who have to 
go to the individual market, women who have less resources, 
less earnings to begin with, being charged more, which makes 
health care even more inaccessible for women. And second, 
because of the combination of the higher premiums they are 
charged because of gender rating and then the exclusion for 
maternity-related care, which in the instance of Caesarian 
sections can be even more expensive, and in some instances the 
requirement of having to buy a rider. In others, the rider's 
not even available. The expense can be so astronomical, or the 
coverage even in the rider so limited, that it basically takes 
away the ability to get insurance for maternity altogether, and 
especially if there may be some additional costs involved, like 
Caesarians.
    When you combine the gender rating and then the exclusion, 
and certainly the most obvious is the maternity-related 
exclusion, which can be a problem even if you do not have to 
face a Caesarian section, let alone if you do, it can be a very 
toxic, literally toxic situation for women, and as a result 
their families.
    Senator Bennet. Thank you.
    Madam Chair, I just wanted to say thank you to you for 
holding this hearing and for your leadership throughout this 
debate. Thank you.
    Senator Mikulski.Thank you, Senator Bennet.
    Well, this was an outstanding panel and I want to thank 
everyone for participating and really putting a great deal of 
thought into it.
    I want to lead off my questioning with both Ms. Robertson 
and Ms. Buchanan, who are young moms and who've obviously had 
significant issues. Ms. Robertson, I'm going to ask a question 
of you. I was a little taken aback by the letter you quoted, I 
believe from the Golden Rule insurance company. You read that 
letter. Are you saying that they said in that letter that you 
should have a sterilization? Did I not hear you well?
    Ms. Robertson. You heard that correctly. They said it in 
the letter, and actually a woman said it to me on the phone 
when I called as well.
    Senator Mikulski. Well, on the phone's one thing, but a 
written document is another.
    Ms. Robertson. It's in the letter, yes.
    Senator Mikulski. Could you read that?
    Ms. Robertson. Sure.

          ``In order to consider coverage without a rider, we 
        require that certain requirements be met. One 
        requirement is that some form of sterilization has 
        occurred since the Caesarian section delivery.''

    Senator Mikulski. In other words, that you would have to 
document that you had had some form of sterilization.
    Ms. Robertson. Yes.
    Senator Mikulski. That gave me goose bumps.
    Ms. Robertson. It was unbelievable.
    Senator Mikulski. First of all, that phrase, just that 
phrase, that concept, I mean, I found that bone-chilling. I 
don't know how everybody else felt about it in the room, but it 
put me on the edge of my chair. Knowing Ms. Ignagni the way I 
do, I think she's not too crazy about hearing that either.
    I think we need to, apart from reform, we need to follow 
that up. No one, no one in the United States of America, in 
order to get health insurance should ever, ever be coerced into 
getting a sterilization. I find it offensive and I find it 
morally repugnant. I intend to do something about that, whether 
it's in this reform package or not. I just don't think it's our 
country's--I do not think it's our moral and ethical framework.
    Coerced? We rail against what we ask China to do about 
coerced sterilizations. But I don't want to see it in our 
American insurance industry. Just know I feel very strongly 
about it.
    Ms. Robertson. Thank you.
    Senator Mikulski. The second thing is, let's go to the 
young mothers. Are you both working or are you stay-at-home 
moms? Ms. Robertson?
    Ms. Robertson. I'm a stay-at-home mom.
    Ms. Buchanan. I'm a stay-at-home mom as well.
    Senator Mikulski. So essentially, your insurance comes 
through your husbands, is that correct?
    Ms. Robertson. We have independent health coverage, so it's 
just an independent plan. We can't get coverage through his 
work because he's self-employed.
    Senator Mikulski. Your husband is self-employed and that's 
part of that individual market.
    Ms. Robertson. Exactly.
    Senator Mikulski. You actually don't have anyone to bargain 
for you, or you didn't have a major or even a minor employer to 
be able to be an advocate for you.
    Ms. Robertson. Not at all.
    Senator Mikulski. Do you--what about you, Ms. Buchanan?
    Ms. Buchanan. My husband is employed. He has a group 
policy, but it turned out that the insurance, individual 
market, was less than half the premium than what his group 
policy offered.
    Senator Mikulski. In Idaho the individual market was 
cheaper?
    Ms. Buchanan. Yes.
    Senator Mikulski. Than the teachers' insurance?
    Ms. Buchanan. It's divided by school district and it's a 
small district.
    Senator Mikulski. How many people are in Idaho?
    Ms. Buchanan. I don't know. Over a million, I think.
    Senator Mikulski. A million. Well, we're not going there. 
Some of our best friends are from Idaho, Wyoming, Utah, et 
cetera.
    Now this issue in our health reform is about the health 
exchange, where you could essentially go, as the President 
says, to ``the shopping mall for insurance companies.'' Have 
you had a chance to look at it? You're raising a family. I'm 
not asking you to be policy wonks. But how did you find out 
about your insurance? Here you're trying to raise a family, 
balance your family budget, probably living far more frugally, 
and your mandate to us would be to be frugal as well as working 
on health reform.
    Did you just spend hours on the phone trying to find 
insurance?
    Ms. Buchanan. When I found out that it would cost $760 a 
month for myself and a baby per month, it was pretty jaw-
dropping, and I just got on the Internet and just looked. The 
two companies----
    Senator Mikulski. There were only two companies.
    Ms. Buchanan. Yes, and the policies were basically 
identical. It was just like, well----
    Senator Mikulski. In a small State, in an exchange, you 
only had two companies that were carriers in that State. But 
you went on the Internet.
    Ms. Buchanan. Yes.
    Senator Mikulski. What about you, Ms. Robertson?
    Ms. Robertson. We had an insurance broker come to our house 
and discovered that there was nothing helpful there for him. He 
couldn't help us. Then I also got on the Internet and I just 
started filling out applications. And every year I end up 
filling out more applications because my youngest son keeps 
getting denied. It is just this ongoing thing that never ends.
    Currently my youngest son is insured by Cover Colorado, 
which insures people that can't get insurance anywhere else.
    Senator Mikulski. I don't mean to be intrusive, but what is 
the reason? Or if you're hesitant to say, that's OK.
    Ms. Robertson. What's interesting is Cover Colorado 
actually is supposed to insure people that are terminally ill. 
There is nothing wrong with my son. The first time he was 
denied for being what they call a breath-holder. When he gets 
angry, he passes out, which is actually a common thing that 
lots of toddlers do.
    This year they told me to reapply because they wanted to 
make sure he wasn't going to have a seizure due to being a 
breath-holder. He of course never had one. I reapplied this 
year and this year they said because he's in the lowest 
percentile--he's short and he doesn't weigh a lot, which my 
husband and I are both short, so of course he would be. But 
he's now been declined for being small.
    Senator Mikulski. Oh, boy, that's another sensitive one 
with me.
    Ms. Robertson. Yes.
    Senator Mikulski. Don't even go there.
    [Laughter.]
    You and I are going to have to bond after this hearing.
    But really, this is no laughing matter. But as you know, if 
there was a one-stop shop that either of you could go to in 
order to buy across State lines--a one-stop shop for you to 
identify the coverage that best suited your family, both from 
the standpoint of anticipated medical situation or pocketbook 
issues, would that be of value to you?
    Ms. Robertson. Most definitely.
    Senator Mikulski. Ms. Buchanan?
    Ms. Buchanan. Yes, as long as it was affordable.
    Senator Mikulski. But that would be it. In other words, you 
would be able to get a clear sense of what benefits are 
available and how affordable they are.
    Ms. Buchanan. Then one of my problems is I have continually 
changed my son's policies as well because the premium keeps 
going up, in an attempt to get the most for my money. I mean, 
my 2-year-old has been on four different policies and my 9-
month-old has been on three different policies. It's confusing 
and I just wouldn't want to have to keep doing that every time 
the policies went up every year, trying to reevaluate how much 
we had to spend and how much we were going to get.
    Senator Mikulski. Wow. You are your own broker in some 
ways, I understand.
    I'm going to go to Ms. Greenberger--I know our time is 
getting short, I'd love to ask everybody--and then Ms. Roth, 
and then you, Ms. Ignagni, and then we're going to close. We're 
having a meeting on health care, surprise, surprise.
    Ms. Greenberger, you wanted to say something about older 
women. Was there a particular point that you wanted to make?
    Ms. Greenberger. In particular that the savings need to be 
made in the system, everybody recognizes. I think with respect 
to older women who are covered either through Medicare or 
Medicaid, one of the things that is of importance to us is that 
there are some very important innovative care models in the 
health care reform proposals, particularly in the HELP bill, 
that could provide much better care for older women than they 
currently have right now, and all patients that are covered.
    There's a patient-centered medical homes provision, for 
example, that could mean improved care. We see the potential of 
health care reform as actually helping older women and older 
men who are covered under Medicare right now.
    Senator Mikulski. Well, the concept of the medical home, of 
course, was in the Baucus white paper, and it's something 
Senator Harkin and I picked up on. Ironically, when I had this 
terrible fall, one of the reasons I was, you can say, happy 
that I was going to Mercy Hospital was that it is my medical 
home. It's where I had my gallbladder surgery. In other words, 
all my records were there.
    Ms. Ignagni, you'd be interested to know, because it was my 
medical home as I arrived to the ER all my records were there, 
and my primary care doctor's records were also available, 
because, though not stationed at Mercy, he's affiliated with 
Mercy. It made a tremendous difference in the immediate 
response to a trauma situation, but then also on the ongoing 
medical management and the postdischarge.
    We really want to, no matter what goes forward, do that. 
This is where we can work with the industry as well. You see, I 
think that there's a lot of consensus, particularly around 
administrative simplification, quality initiatives that we've 
worked on. We're going to come back.
    But for you, what are the top three things that we need to 
get done in insurance reform?
    Ms. Greenberger. We need to make sure that we deal with the 
problems of preexisting conditions, the insurance market 
reforms that deal with gender rating and other unfair bases of 
rating.
    Senator Mikulski. Gender rating, preexisting conditions.
    Ms. Greenberger. We also want to make sure that the gender 
rating applies outside the individual market, the protections 
against it, so that it also deals with the group plans, both 
employer-provided and association and other affinity group 
provided plans as well. That's one constellation of issues.
    Preexisting conditions is a related issue that needs to be 
addressed, as well as exclusions of coverage, like maternity 
coverage. That kind of reproductive health care that women need 
is very essential.
    Another thing is the affordability, so that we get rid of 
lifetime caps, so that people like Ms. Buchanan can actually 
afford insurance, because she could be the best--and I suspect 
from what I've heard she is--the best investigator of what 
plans are out there as possible, but if none of them are really 
affordable and they have these other problems that's not--
that's what we hope health care reform will help her with.
    There are a variety of those affordability protections as 
well. And we want to make sure that there is the kind of 
competition in the market so that these reforms translate into 
actual quality, comprehensive and affordable health care for 
women and their families.
    Senator Mikulski. Very good. Thank you very much.
    We haven't even talked a lot about prevention. We could 
have this hearing now, we could come back this afternoon, we 
could then take a break and find consensus. But then this is 
going to be an ongoing debate.
    Ms. Roth, what do you think--first of all, do you think we 
need insurance reform? I know you talked extensively about your 
concerns about the impact of both the HELP Committee and the 
Finance Committee. But do you think we do need insurance 
reform, and what do you think would be the three top elements?
    Ms. Furchtgott-Roth. Well, I think that we definitely need 
insurance reform. We can see that the auto insurance, the home 
insurance, the life insurance markets, those are all working 
very well, although if we're putting in a plug for equal gender 
rating I have five boys and one girl and my three teenage boys 
have to pay far higher auto insurance rates than my teenage 
girl, and I think that that should be fixed, too, while we're 
at it.
    Senator Mikulski. We're for that.
    Ms. Furchtgott-Roth. But there's tremendous problems in 
just purchasing insurance. My husband is self-employed. I have 
a job. I have to stick to a job where the job provides 
insurance, so that my family has insurance. This just is not a 
way to run a system. I should be able to go out and buy 
insurance just like I can buy auto insurance.
    What we need is a system where it's de-linked, insurance is 
de-linked from the employer, insurance companies compete, 
preferably over State lines, so that someone who lives in a 
State such as Iowa can also get offers from companies in New 
York or California, other kinds of companies. We need 
competition, and we also need malpractice reform to deal with 
these problems of high suits and high malpractice premiums.
    What we need to do is try to make the health insurance 
market into the same market for other insurance. It really got 
messed up in the 1940s when there were wage caps, and so 
instead of offering higher wages employers offered health 
insurance.
    They've continued to offer health insurance. We need to be 
giving individuals that tax credit. Ideally, we wouldn't give 
anyone a tax credit for health insurance, but we are stuck with 
that politically because people are used to it. We need to de-
link it from the employer and give it to the individual 
American so everyone can shop around for their policy.
    Some people might want a bare-bones catastrophic policy 
with a higher deductible. Others might want more of a managed 
care policy, and people should have the choice of different 
plans. And with competition, then we will find that if an 
insurance company does what they did to Ms. Robertson that 
would be publicized. They would hopefully lose market share, go 
out of business. People wouldn't use those.
    I mean, I heard an ad on the radio for Nationwide. It said: 
``Well, have you been denied auto insurance coverage because of 
an accident? Call us up; we will give you insurance.'' We need 
people knocking down our doors to be giving us health 
insurance. We don't have that right now.
    Senator Mikulski. Thank you.
    Ms. Ignagni, we recall when you did come in March, and I 
think we've made a lot of progress and we really felt we were 
pretty much on the same wavelength with administrative 
simplification. I also thought we developed some excellent 
recommendations on our quality initiatives, because quality 
initiatives will help hospitals reduce preventable errors, 
particularly the infection issue, using incentives in both our 
Federal payment system as well as reimbursement in the private 
market for the adoption of things like Pronovost's Checklist; 
and also that significant issue of the management of chronic 
illness.
    We feel that there is much that we have found in terms of 
common ground and welcomed your insights and recommendations in 
looking at these models. Now, I want to be sure that I 
understood your testimony. Are you saying that the industry, as 
a whole, is now ready to end the practice of gender rating?
    Ms. Ignagni. Yes.
    Senator Mikulski. Is that each company or will that be a 
general policy?
    Ms. Ignagni. As a matter of where we stand on health 
reform, Senator, our membership has endorsed that as part of 
the guarantee issue, no preexisting conditions, equal premiums 
across the two genders. We have strongly embraced that as part 
of our basket of recommendations.
    The only issue here, frankly, for us, but we're 
considerably concerned about it, is the issue of, if we don't 
have everybody in, potential hyperinflation. I know that many 
leaders and you yourself are looking at that. The committee 
here spent a great deal of time talking about getting everyone 
in. We think that you're definitely in the right place. But we 
are very concerned about the changes that happened in the 
Finance Committee, because we want to get away from the 
situation where it's a voluntary market, where the younger and 
healthier don't have incentives to participate or would be 
inclined to leave until they need health care, because then we 
won't solve the problems that Ms. Robertson and Ms. Buchanan so 
articulately emphasized.
    From the beginning of the year we've been committed to a 
massive overhaul of how the insurance market works, and we've 
presented evidence of what happened at the State level when you 
didn't have everyone in, and there were just--there was this 
hyperinflation.
    I think there's a real opportunity to understand that now. 
We understand the sensitivity about penalties. We've offered 
some solutions and alternatives to that. We very much want to 
work with you. But if we don't end up with everyone in, we're 
very concerned that at the end of the process when things 
become available, people will feel very unsatisfied.
    That is the issue we're pointing to, along with the issue 
of, since cost containment across the system has been pretty 
much taken off the table, we're worried about the underlying 
costs. And we're worried that Congress has been forced into 
some tax provisions that they wouldn't otherwise have had to be 
forced into because of the lack of system-wide cost 
containment.
    Senator Mikulski. What you're saying is that the insurance 
industry, with or without legislation, but preferably with--you 
need a legislative framework, to end gender rating and the 
barriers related to preexisting conditions.
    Ms. Ignagni. Yes.
    Senator Mikulski. Those were your three. What you're 
saying, is that in order to do this, the market has to expand, 
and that means that the insurance industry is calling for an 
individual mandate?
    Ms. Ignagni. Yes. We think----
    Senator Mikulski. I just want to be sure----
    Ms. Ignagni. Yes.
    Senator Mikulski [continuing]. I understand, so I'm just 
saying it out loud.
    And by an individual mandate, what we mean is that we will 
help to cover everybody, but everybody's got to participate?
    Ms. Ignagni. Yes, Senator.
    Senator Mikulski. Is that it?
    Ms. Ignagni. Yes. And if there are concerns about the issue 
of penalties and securing a mandate in that regard, we've 
offered some alternatives to achieve universal participation. 
We are strongly committed to the market reforms and they need 
to happen.
    Senator Mikulski. What would they be? Because, as you know, 
this is a very controversial issue.
    Ms. Ignagni. It is, and that's why I wanted to make the 
point that I didn't want to come and suggest that we need 
universal participation without also recognizing what you've 
just observed. In our view, if Members of Congress were 
concerned about moving down the penalty path, that they might 
look at a basket of alternatives.
    No. 1, in the Part D program and Part B program, as you 
know, there are provisions where if you don't participate in 
year 1, you pay more in subsequent years. That's one factor, 
together we've been looking at, and I know there's been--in 
Massachusetts, for example, one of the strategies that was 
employed in the beginning of that legislation, which was 
supported on a bipartisan basis, as you know, in Massachusetts, 
was that if you didn't participate you lose your personal 
exemption at the State level.
    We have been thinking about ways to work in that concept so 
that one could couple a personal exemption consideration with 
perhaps some of the Part B, Part D types of penalties, or 
looking at that way to encourage more people to participate. 
We've been looking at auto-enrollment for people who would be 
eligible for subsidies, and we'd be delighted to confer----
    Senator Mikulski. Automatic enrollment, not the auto 
insurance?
    Ms. Ignagni. No, it's a little different than that, that's 
right.
    Senator Mikulski. The metaphors that we hear a lot of.
    Ms. Ignagni. That's right.
    But I think there are ways to solve those problems, and 
we're committed to working with you to solve the problems. But 
I think if you look at the experience in the States--and this 
is what our recent report has pointed out--is that without 
everyone in to secure the goal that everybody supports--and I 
believe everyone supports it and that's the right thing to do--
we are going to have significant unintended consequences in 
terms of costs, hyperinflation, if we don't get everyone in.
    We want to recognize that now. We don't want to let 
Americans down. It's very important. We promised that we are 
committed to this. Our industry is four-square behind it. But 
we have an obligation to explain how to get that, how to make 
that happen.
    Senator Mikulski. Well, again we could have extensive 
conversations. I've got to get to a meeting with Senators Dodd 
and Harkin. But I really appreciate every single person's 
testimony. Each have added a very important dimension to the 
conversation. As you can see, our desire was to have a 
discussion, not a debate.
    I think it's time--again, I'll come back to trying to find 
that sensible center. We will be having ongoing conversations 
with many of you at the table.
    Ms. Ignagni, I'd like to talk with you about the issues 
that Ms. Robertson raised. Knowing you and your longstanding 
commitment on many issues related to women, I'm sure that 
raised your eyebrows as well.
    Ms. Ignagni. Yes, Senator. I'm happy to talk to you at your 
convenience.
    Senator Mikulski. If you have a way that we could deal with 
the situation raised by Ms. Robertson across the board, maybe 
we could work together on it before we develop the final 
legislation--you know, developing legislation takes a long 
time. But I think perhaps we can do some of these things.
    I'm going to conclude this very important hearing and say 
that we will keep the record open for any members wishing to 
submit additional comments and questions. This committee, 
stands adjourned subject to the call of the chair.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

                   Prepared Statement of Senator Enzi

    I believe we need to fundamentally reform the insurance 
market place and offer new protections to ensure that 
consumers--including people with pre-existing conditions--can 
buy affordable, high quality health insurance. I strongly 
support ending all discrimination based on pre-existing 
conditions, whatever their cause. Everyone should be able to 
get the health care coverage they need.
    The bill I introduced in 2007, Ten Steps to Transform 
Health Care in America, ended discrimination based on 
preexisting conditions. Additionally, both the HELP Committee 
bill and the Finance Committee bill end discrimination based on 
preexisting conditions.
    I believe there are many additional things we can do as 
health care reform moves forward to improve the health of 
women. Unfortunately, the bills the Senate is considering give 
with one hand and take with the other when it comes to women's 
health.
    Multiple studies have shown, and CBO has confirmed that 
health insurance premiums will rise for many Americans if 
health care reform passes. Some studies have shown costs in the 
individual market will increase by 50 percent or more. This 
will have a negative impact on young, healthy women.
    Additionally, many of the insurance market reforms, 
including the very restrictive age rating rules capped at 2:1 
in the HELP Committee bill and 4:1 in the Finance Committee 
bill, will increase the cost of health insurance premiums for 
younger, healthier women.
    Many economists believe enacting a ``pay or play'' employer 
mandate like the one included in the HELP Committee bill will 
have a negative impact on low-income women and minorities by 
lowering wages.
    Additionally, the Finance Committee health care bill forces 
14 million more people into the Medicaid and CHIP programs. 
MedPAC reports show nearly 40 percent of doctors won't see 
Medicaid patients because of the low reimbursement rates. 
Forcing women into a program but not providing them actual 
access to care is not progress.
    In short, I don't think increasing health insurance 
premiums, cutting wages, and forcing 14 million more Americans 
into Medicaid is ``what women want.'' Madame Chairwoman, I 
believe we can do better, for women and for all Americans.

                   [The Washington Post, May 5, 2008]

        Malpractice Premiums, Rate of C-Sections Rise Together*

                          (By Kathleen Doheny)

    Monday, May 5 (HealthDay News)--As medical malpractice premiums 
increase, so do the rates of Caesarean sections, new research shows.
    The study provides a small snapshot of the association, drawing on 
data from the University of Connecticut Health Center in Farmington. 
The findings, while not national in scope, could further fuel the 
debate about whether higher malpractice rates boost the C-section 
rates, or vice-versa.
---------------------------------------------------------------------------
    * To learn more about C-sections, visit the National Institutes of 
Health.
    Sources: Jeffrey V. Spencer, M.D., maternal-fetal medicine fellow, 
University of Connecticut Health Center, Farmington; Marsden Wagner, 
M.D., perinatologist and epidemiologist, Tacoma Park, MD., and former 
director, Women's and Children's Health, World Health Organization; May 
5, 2008, presentations, American Society of Obstetricians and 
Gynecologists annual meeting, New Orleans.
---------------------------------------------------------------------------
    ``When I compared the malpractice rates to C-section rates prior to 
1999, both were declining at a similar rate,'' says study author Dr. 
Jeffrey V. Spencer, a maternal-fetal medicine fellow at UConn. From 
1999 to 2005, however, both were increasing.
    The study was scheduled to be presented Monday at the American 
Society of Obstetricians and Gynecologists annual meeting, in New 
Orleans.
    Spencer and his team reviewed the center's perinatal database from 
1991 to 2005, noting how many vaginal deliveries and how many C-
sections took place. They got the average malpractice rates from the 
primary carrier at their institution and adjusted them for inflation 
over the years.
    ``I can't say one led to the other or vice-versa,'' Spencer said. 
But he speculates the medical malpractice rates are driving up the C-
section rates. ``The theory is, doctors are practicing more defensive 
medicine. Maybe doctors are fearful of litigation,'' he added, perhaps 
likely to decide on a C-section at the first sign of any potential 
problems.
    In all, 23 percent (15,021) of the 64,767 deliveries studied were 
C-sections. Spencer's team also looked at first and repeat C-sections 
and compared those with the average malpractice premiums by year and 
found a relationship between increased malpractice rates and both first 
and repeat C-sections.
    In a second study, Spencer and his colleagues looked at the impact 
of increasing malpractice rates on what is known as ``operative vaginal 
deliveries''--delivering a child by forceps or vacuum. They found that 
16 percent (10,299) of the 64,767 deliveries were this type. From 1991 
to 2005, average malpractice rates increased from $50,345 to $126,806.
    The rates for malpractice rose, he said, even though both types of 
vaginal deliveries declined. Forceps deliveries declined from 11 
percent to less than 1 percent, and vacuum deliveries went from 17.2 
percent to 6.2 percent.
    Nationwide, C-section deliveries accounted for 30.2 percent of all 
deliveries in 2005, according to the U.S. Centers for Disease Control 
and Prevention, a record high for the Nation. In 1996, in comparison, 
20.7 percent of deliveries were by C-section.
    Another expert said the findings are nothing new.
    ``These two papers do nothing more than substantiate what we 
already know,'' said Dr. Marsden Wagner, a perinatologist and former 
director of Women's and Children's Health for the World Health 
Organization.
    One of the reasons for what Wagner refers to as the ``scandalous'' 
rate for C-section is that ``doctors are afraid of litigation.''
    ``Any physician who picks up a scalpel and does major abdominal 
surgery, which is what a C-section is, because that doctor is afraid of 
litigation, is not practicing medicine but is practicing fear and 
greed,'' he said.
    ``The increasing C-section rate has not decreased the amount of 
litigation,'' Wagner said. ``So their attempt to avoid litigation by 
doing C-section is not working.''
    Spencer agreed. ``The only thing to my knowledge that has changed 
or lowered malpractice rates are States having legislation to place 
caps on malpractice settlements.''
                                 ______
                                 
            North Carolina Department of Insurance,
                                    Raleigh, NC 27699-1201,
                                                  October 14, 2009.
Hon. Richard Burr,
U.S. Senate,
Russell Senate Office Building, Room 217,
Washington, DC 20510.

    Dear Senator Burr: Since September, media nationwide has been 
reporting on a 2008 National Women's Law Center report that includes 
North Carolina on a list of eight States that allow domestic violence 
to be used as a preexisting condition for health insurance policies. 
These media reports have, understandably, caused much confusion and 
concern from government leaders, women's advocacy groups, and 
individual consumers across not only our State, but also the entire 
country.
    I want to state as clearly as possible, that the North Carolina 
Department of Insurance and I strongly disagree with any assertions 
that the status of being a victim of domestic violence is allowed to be 
considered a preexisting condition in North Carolina.
    For Group Coverage, North Carolina General Statute 58-68-35 section 
A-1 specifically states that an insurance company may not discriminate 
against participants or beneficiaries on the basis of evidence of 
insurability, which would include conditions arising out of acts of 
domestic violence. This provides protection from allowing domestic 
violence as a preexisting condition for group plans.
    For individual/nongroup plans--there is not a statute that 
specifically lists domestic violence; however, there are several 
broader requirements that we feel address this issue. North Carolina 
Law defines a preexisting condition to mean ``those conditions for 
which medical advice, diagnosis, care, or treatment was received or 
recommended within the 1-year period immediately preceding the 
effective date of the person's coverage.'' Domestic violence does not 
meet the definition of a medical condition.
    Further, in our regulatory oversight of health insurance policy 
applications, we would not approve a company's policy application form 
that attempted to use domestic violence in its underwriting decisions.
    NCGS 58-63-15(7)b. gives the North Carolina Department of Insurance 
the authority to review all policy application forms to make sure that 
they are not unfairly discriminatory. In North Carolina, if a company 
or policy wants to exclude something, they must declare it on the 
application by asking the applicant directly about the exclusion. 
Because exclusions are listed on application forms, and the Department 
reviews and approves the forms, we would know if a company tried to 
consider domestic violence as a preexisting condition.
    We are unaware of any companies or forms that have asked to include 
domestic violence as a preexisting condition. If they did, we would 
deny it.
    My department has been unable to find a single example of a company 
asking an applicant if they have been a victim of domestic abuse or a 
consumer complaining about being asked this for insurance purposes. 
However, the issue is far too important to leave any possibility that 
this could happen, so to create further protections, I have filed an 
administrative rule for adoption in the North Carolina Administrative 
Code--this is the most efficient way to address these concerns and add 
to our insurance regulations. The new code forbidding domestic violence 
from being considered as a preexisting condition should become 
effective on March 1, 2010.
    Should you have additional questions or concerns on this issue, 
please feel free to contact me directly.
            Warmest regards,
                                             Wayne Goodwin,
                                            Insurance Commissioner.
                                 ______
                                 
                                   Consumers Union,
                                                  October 16, 2009.
Hon. Barbara Mikulski,
Senate HELP Committee,
Senate Dirksen 428,
Washington, DC 20510.
    Dear Senator Mikulski: Thank you again for inviting Consumers Union 
to testify at the October 15th hearing on issues in women's health 
insurance.
    During the hearing, Senator Merkley asked for more information 
which I said I would provide for the record. If possible, I would like 
to provide the attached for inclusion in the Record in response to his 
question.
    I hope the ``total cost'' information described in the attachment 
can be included in the final health reform legislation. It would truly 
help consumers make better choices while saving both consumers and the 
Treasury significant amounts of money.
    Thank you again.
            Sincerely,
                                                 Jim Guest,
                                                 President and CEO.
                                 ______
                                 
          Response to Question of Senator Merkley by Jim Guest
    Question. Mr. Guest, you talked about the importance of having 
apples-to-apples information for consumers to compare plans, including 
examples of total costs a person would likely face. Can you explain a 
little more about how that would work?
    Answer. Thank you for the question. We believe that if you 
correctly structure the information given consumers in the Exchange-
Connector system, you can:

           provide enormous help to consumers in ensuring that 
        they pick the best policy for themselves, and
           save consumers and taxpayers substantial amounts of 
        money by maximizing insurance coverage and minimizing consumer 
        out-of-pocket costs and taxpayer subsidy costs.

    The first thing that consumers need is standard definition of 
terms, so that they can comparison shop.
    We have examples of consumers who thought they were buying hospital 
insurance coverage, but the fine print showed that the coverage started 
on the second day, after the huge costs of initial lab testing and use 
of the surgery rooms. Standard definition of terms that all insurers 
would be required to use would ensure that hospitalization meant 
hospitalization in all policies. Consumers often think they have 
pharmaceutical coverage and then find that chemotherapy and/or 
antiemetics necessary for chemotherapy are not covered. A definition of 
pharmaceutical coverage would prevent these kinds of ``got 'cha' 
exceptions and allow consumers to shop on quality and price.
    Insurance terms (e.g., co-insurance, tiers, etc.) should also be 
standardized.
    Second, most people are unaware of the huge expense of major 
procedures, or even relatively common ones like childbirth. It would be 
very helpful to require giving consumers ``scenarios'' of how the 
insurance plan they are considering covers certain common conditions. 
These would be defined and developed by the Gateway administrator in 
consultation with medical experts and could include such examples as 
childbirth, treatment of a certain level of prostate cancer, compound 
leg fracture, etc. Not only would this show consumers why insurance is 
important, but it would allow consumers to see that actuarially 
equivalent policies can have wildly different levels of protection for 
specific conditions. Our May issue of Consumer Reports (attached)* 
showed two policies that appeared to be similar in premiums and 
deductibles, yet in a case of successfully-treated breast cancer, one 
policy left the consumer with $37,767 out-of-pocket, while another one 
covered all but $7,668.
---------------------------------------------------------------------------
    * The Report referred to may be found at www.consumerreports.org/
health/insurance/health-insurance/overview/health-insurance-ov.htm.
---------------------------------------------------------------------------
    The most important thing you can do to help consumers pick the best 
plan is to give them information, upon enrollment and at each open 
enrollment period, of the plan's estimated total cost (premiums, 
deductibles, co-pays), based on their past year's medical use or (on 
first enrollment) their estimate of their health status (e.g., good, 
fair, poor).
    Consumers Union has just received a study by Destination Rx\1\ of 
92,000 Medicare Part D enrollees that shows that if people selected 
just on the basis of picking the lowest premium, their total spending 
on drugs (premiums, deductibles, co-pays, donut) would be about $205 
million annually. When other data is presented, such as the total cost 
of the plan (based on their recent drug usage and past history), they 
only spend about $172 million--a savings of $33 million among just 
92,000 individuals. Of course, by selecting the best Part D plan for 
themselves, taxpayers also benefit through reduced low-income 
subsidies, minimized co-payments, and reduced catastrophic cost 
subsidies.
---------------------------------------------------------------------------
    \1\ We have used data from Destination Rx in a number of our 
publications. They provided us with the data that showed that random 
assignment of LIS beneficiaries in Part D to low-cost premium plans 
often failed to ensure assignment to the best plan, from both the 
beneficiary and the taxpayer point-of-view. This led to the 
``intelligent assignment'' amendment of 2007 that CBO scored as saving 
$ 1.2 billion over 10 years.
---------------------------------------------------------------------------
    We believe that the same shopping ``principle'' applies to the non-
Rx health insurance market: if consumers using the proposed 
``Exchanges'' saw the total probable cost of premiums, deductibles, and 
co-pays based on their past year's medical use or self-described 
medical condition (e. g., ``excellent, good, fair, or poor'' health 
status as defined through regulations), they would tend to select the 
lowest total cost plan--and thus minimize the deductible and co-pay 
subsidies needed for those under 400 percent of FPL.
    We urge you to amend the health reform bills to require that among 
the information given to consumers in the insurance policy and/or in 
the exchange, there be ``an estimate of the total annual cost for a 
person enrolled in the policy, based on the individual's past medical 
cost or based on self-assessed health status (data and estimates to be 
developed by the Secretary through regulations and subject to all 
privacy safeguards). This would be similar to the Medicare ``drug 
compare'' Web site, where an individual can type in their medications 
and see an estimated total annual cost. Very often, the lowest cost 
plan is NOT the plan with the lowest premium.
    Further immediate, scorable savings could be achieved in Medicare 
Part D (and probably Part C), if you required that in each open 
enrollment period, whenever possible beneficiaries were given an 
estimate of their total cost for the coming plan year, based on past 
Part D usage. They could then be shown the 5 or so lowest-cost plans 
(counting premiums, deductibles, and co-pays) that would meet that past 
usage. This could be achieved by amending 1860D-1(c)(3)(A)(ii). (This 
would be somewhat similar to the requirement in MMA that a pharmacist 
tell a beneficiary if their plan covers a lower cost generic.)

    [Whereupon, at 12:30 p.m., the hearing was adjourned.]

                                   

      
