[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]







                STATE OF COMPETITION IN THE HEALTH CARE
                  MARKETPLACE: THE PATIENT PROTECTION
                       AND AFFORDABLE CARE ACT'S
                         IMPACT ON COMPETITION

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

                                HEARING

                               BEFORE THE

                            SUBCOMMITTEE ON
                           REGULATORY REFORM,
                      COMMERCIAL AND ANTITRUST LAW

                                 OF THE

                       COMMITTEE ON THE JUDICIARY
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                           SEPTEMBER 10, 2015

                               __________

                           Serial No. 114-46

                               __________

         Printed for the use of the Committee on the Judiciary

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



      Available via the World Wide Web: http://judiciary.house.gov
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                       COMMITTEE ON THE JUDICIARY

                   BOB GOODLATTE, Virginia, Chairman
F. JAMES SENSENBRENNER, Jr.,         JOHN CONYERS, Jr., Michigan
    Wisconsin                        JERROLD NADLER, New York
LAMAR S. SMITH, Texas                ZOE LOFGREN, California
STEVE CHABOT, Ohio                   SHEILA JACKSON LEE, Texas
DARRELL E. ISSA, California          STEVE COHEN, Tennessee
J. RANDY FORBES, Virginia            HENRY C. ``HANK'' JOHNSON, Jr.,
STEVE KING, Iowa                       Georgia
TRENT FRANKS, Arizona                PEDRO R. PIERLUISI, Puerto Rico
LOUIE GOHMERT, Texas                 JUDY CHU, California
JIM JORDAN, Ohio                     TED DEUTCH, Florida
TED POE, Texas                       LUIS V. GUTIERREZ, Illinois
JASON CHAFFETZ, Utah                 KAREN BASS, California
TOM MARINO, Pennsylvania             CEDRIC RICHMOND, Louisiana
TREY GOWDY, South Carolina           SUZAN DelBENE, Washington
RAUL LABRADOR, Idaho                 HAKEEM JEFFRIES, New York
BLAKE FARENTHOLD, Texas              DAVID N. CICILLINE, Rhode Island
DOUG COLLINS, Georgia                SCOTT PETERS, California
RON DeSANTIS, Florida
MIMI WALTERS, California
KEN BUCK, Colorado
JOHN RATCLIFFE, Texas
DAVE TROTT, Michigan
MIKE BISHOP, Michigan

           Shelley Husband, Chief of Staff & General Counsel
        Perry Apelbaum, Minority Staff Director & Chief Counsel
                                 ------                                

    Subcommittee on Regulatory Reform, Commercial and Antitrust Law

                   TOM MARINO, Pennsylvania, Chairman

                 BLAKE FARENTHOLD, Texas, Vice-Chairman

DARRELL E. ISSA, California          HENRY C. ``HANK'' JOHNSON, Jr.,
DOUG COLLINS, Georgia                  Georgia
MIMI WALTERS, California             SUZAN DelBENE, Washington
JOHN RATCLIFFE, Texas                HAKEEM JEFFRIES, New York
DAVE TROTT, Michigan                 DAVID N. CICILLINE, Rhode Island
MIKE BISHOP, Michigan                SCOTT PETERS, California

                      Daniel Flores, Chief Counsel
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                            C O N T E N T S

                              ----------                              

                           SEPTEMBER 10, 2015

                                                                   Page

                           OPENING STATEMENTS

The Honorable Tom Marino, a Representative in Congress from the 
  State of Pennsylvania, and Chairman, Subcommittee on Regulatory 
  Reform, Commercial and Antitrust Law...........................     1

The Honorable Henry C. ``Hank'' Johnson, Jr., a Representative in 
  Congress from the State of Georgia, and Ranking Member, 
  Subcommittee on Regulatory Reform, Commercial and Antitrust Law     2

The Honorable Bob Goodlatte, a Representative in Congress from 
  the State of Virginia, and Chairman, Committee on the Judiciary    11

                               WITNESSES

Thomas L. Greaney, Professor of Law, St. Louis University School 
  of Law
  Oral Testimony.................................................    13
  Prepared Statement.............................................    16

Richard J. Pollack, Executive Vice President, Advocacy and Public 
  Policy, American Hospital Association
  Oral Testimony.................................................    31
  Prepared Statement.............................................    33

Barbara L. McAneny, M.D., Member of the Board of Trustees, 
  American Medical Association
  Oral Testimony.................................................    43
  Prepared Statement.............................................    45

Daniel T. Durham, Executive Vice President, Strategic 
  Initiatives, America's Health Insurance Plans
  Oral Testimony.................................................    65
  Prepared Statement.............................................    67

Scott Gottlieb, M.D., Resident Fellow, American Enterprise 
  Institute
  Oral Testimony.................................................    81
  Prepared Statement.............................................    84

          LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

Prepared Statement of the Honorable John Conyers, Jr., a 
  Representative in Congress from the State of Michigan, and 
  Ranking Member, Committee on the Judiciary, submitted by the 
  Honorable Henry C. ``Hank'' Johnson, Jr., a Representative in 
  Congress from the State of Georgia, and Ranking Member, 
  Subcommittee on Regulatory Reform, Commercial and Antitrust Law     4

                                APPENDIX
               Material Submitted for the Hearing Record

Letter submitted by the Honorable Tom Marino, a Representative in 
  Congress from the State of Pennsylvania, and Chairman, 
  Subcommittee on Regulatory Reform, Commercial and Antitrust Law   120

Response to Questions for the Record from Richard J. Pollack, 
  Executive Vice President, Advocacy and Public Policy, American 
  Hospital Association...........................................   123

Response to Questions for the Record from Barbara L. McAneny, 
  M.D., Member of the Board of Trustees, American Medical 
  Association....................................................   161

Response to Questions for the Record from Daniel T. Durham, 
  Executive Vice President, Strategic Initiatives, America's 
  Health Insurance Plans.........................................   164

Question for the Record submitted to Scott Gottlieb, M.D., 
  Resident Fellow, American Enterprise Institute.................   168

Response to Question for the Record from Scott Gottlieb, M.D., 
  Resident Fellow, American Enterprise Institute.................   170


 
   STATE OF COMPETITION IN THE HEALTH CARE MARKETPLACE: THE PATIENT 
       PROTECTION AND AFFORDABLE CARE ACT'S IMPACT ON COMPETITION

                              ----------                              


                      THURSDAY, SEPTEMBER 10, 2015

                       House of Representatives,

                  Subcommittee on Regulatory Reform, 
                      Commercial and Antitrust Law

                      Committee on the Judiciary,

                            Washington, DC.

    The Subcommittee met, pursuant to call, at 10:02 a.m., in 
room 2141, Rayburn Office Building, the Honorable Tom Marino 
(Chairman of the Subcommittee) presiding.
    Present: Representatives Marino, Goodlatte, Collins, 
Walters, Ratcliffe, Trott, Bishop, Johnson, Conyers, DelBene, 
and Cicilline.
    Staff present: (Majority) Anthony Grossi, Counsel; Andrea 
Lindsey, Clerk; and (Minority) Slade Bond, Counsel.
    Mr. Marino. The Subcommittee on Regulatory Reform, 
Commercial and Antitrust Law will come to order. Without 
objection, the Chair is authorized to declare recess of the 
Committee at any time.
    We welcome everyone to today's oversight hearing on ``The 
State of Competition in the Health Care Marketplace: The 
Patient Protection and Affordable Care Act's Impact on 
Competition.''
    I am going to recognize myself now for an opening 
statement.
    Today's hearing marks the beginning of a series of hearings 
on competition in the health care marketplace. The first 
hearing will undertake a broad examination of competition 
within the hospital, insurance, and physician marketplaces. 
Additionally, we will also focus on the impact that the Patient 
Protection and Affordable Care Act, or ``Obamacare,'' has had 
on competition within each of these sectors.
    There is no doubt that there has been significant movement 
in each of the hospital, insurer, and physician markets since 
the enactment of Obamacare. Hospital mergers nearly doubled 
between 2009 and 2013, the period surrounding the congressional 
debate on Obamacare and immediately after its enactment. Four 
of the five largest for-profit health insurance companies 
recently announced their intent to merge, which will be the 
subject of a separate Subcommittee hearing in the coming weeks. 
Additionally, reports of physician practices either merging or 
being purchased by hospitals has increased in recent years.
    On top of all this activity, we are spending more on health 
care than ever before, and that number is only expected to 
grow. I trust that competition will put pressure on market 
actors to deliver quality product at a reasonable price. I have 
infinitely more confidence in the judgment of a competitive 
marketplace over the judgment of government.
    Obamacare is another government experiment attempting to 
replace the will of the market with its own. An experiment 
that, in my view, has gone horribly wrong. As Chairman of the 
Subcommittee overseeing our antitrust laws in competition, I 
believe we have a duty to ensure that the laws Congress pass 
are encouraging competition and that the antitrust laws are 
being enforced effectively. Today's hearing will help inform 
Congress of the status of competition in the predominant health 
care sectors, as well as add to the record of Obamacare's 
impact on the state of competition in each of these sectors.
    I look forward to hearing from our witnesses, and I yield 
back the balance of my time, and I now recognize the Ranking 
Member of the Subcommittee on Regulatory Reform, Commercial and 
Antitrust Law, Mr. Hank Johnson of Georgia, for his opening 
statement.
    Mr. Johnson. Thank you, Mr. Chairman.
    Today's hearing is the first in a series of hearings that 
will examine the state of competition in the health care 
marketplace. It is also the third hearing that this Committee 
has held on this topic in as many years. But much has changed 
since our last hearing in September of 2013.
    Since the first open enrollment period began in October 
2013, the Affordable Care Act has already expanded coverage, 
savings and protections for millions of American consumers. 
Since provisions of the Affordable Care Act have taken effect, 
the law has resulted in the coverage of 16.4 million uninsured 
people, dropping the uninsured rate by 35 percent, the lowest 
in 50 years, and lowering the overall cost of health care for 
both insured Americans and health care providers. It saved 9.4 
million seniors more than $15 billion on prescription drugs, or 
about $1,598 for every beneficiary, and it has dramatically 
slowed the cost of health care spending, to the benefit of 
taxpayers and the entire health care system.
    The Department of Health and Human Services likewise 
reported in July that the law has slowed the cost of health 
care premiums as new competitors in local markets and price 
competition intensifies. The Congressional Budget Office also 
reported that these lower premium costs have lowered previous 
cost estimates for the Affordable Care Act by about $142 
billion, or 11 percent, while the Washington Post reports that 
``the cost of the law has been falling for several years now 
that analysts are beginning to assess the evidence of the law's 
impact from its first full year of implementation.''
    There is also ample evidence that the Affordable Care Act 
is a reaction to, not a cause of, consolidation in the health 
care marketplace. A unifying bipartisan theme of our hearings 
on this topic is that waves of consolidation among health care 
providers and insurers occurred long before the Affordable Care 
Act. Whether due to lax antitrust enforcement or bad policy, 
many local markets were highly consolidated before the 
enactment of the Affordable Care Act in 2010. According to the 
Department of Health and Human Services Report on Competition 
in Health Insurance Marketplaces, competition has intensified 
across the country as the number of health insurance issuers 
have increased in most counties. As I have already noted, this 
increased competition has had the effect of reducing premium 
growth through an influx of new plans and increased pressure 
for incumbent insurance issuers to moderate the cost of 
premiums. Preserving and promoting this competition is 
critical, and I encourage the antitrust enforcement agencies to 
do so at every opportunity.
    In closing, it is clear that now that we have put it to 
work, the Affordable Care Act is saving lives and money. Rather 
than demonizing the Administration and the law that has done so 
much for so many, we would be ensuring that the progress we 
have made in such a short time is not jeopardized by anti-
competitive behavior or consolidation. With that in mind and 
notwithstanding the consistently partisan nature of discussions 
concerning health care and the Affordable Care Act, I thank the 
Chair for calling this hearing and I look forward to future 
hearings on this subject. Few topics directly affect the lives 
of American consumers as ensuring that health care markets are 
delivering the best and most health care choices in every 
county in America.
    And with that, I would yield back. But let me say before I 
yield back, I would like to offer into the record, without 
objection, the statement of Ranking Member John Conyers.
    Mr. Marino. So ordered, without objection.
    [The prepared statement of Mr. Conyers follows:]
    
    
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                               __________
    Mr. Johnson. I yield back.
    Mr. Marino. The Chair recognizes the Chairman of the full 
Judiciary Committee, Mr. Bob Goodlatte of Virginia, for his 
opening statement.
    Mr. Goodlatte. Thank you, Mr. Chairman.
    Before we begin today's hearing, which marks the beginning 
of a series of hearings on competition in the health care 
marketplace, I think it would be helpful to clarify two points 
of overriding concern.
    First, health care is not provided in a true free market, 
and has not been provided in a free market since at least the 
onset of major government intervention in the market through 
Medicare and Medicaid.
    Second, health care as a service is unique in that nearly 
every person in America will require some medical treatment 
over the course of their lives. Health insurance is not like 
fire insurance or car insurance, where there is a hope that one 
will never have to use it. Medical costs inevitably occur and 
hopefully insurance or some funds set aside for these costs 
will be used when the time comes.
    In the face of these facts--that the health care market is 
not a fully free market and that Americans have no choice but 
to participate in the market--it is essential that we preserve 
as much competition and freedom in the overall health care 
marketplace as we can.
    We should strive to enact laws that foster competition so 
that prices are checked, patients have choices, and the premium 
quality of American health care can be maintained. Otherwise, 
costs will go up, choices will narrow, and quality will be 
diminished. That is simply the laws of economics at work.
    In 2010, President Obama signed into law the Patient 
Protection and Affordable Care Act, which I believe is 
antithetical to competition. Rather than promoting free 
markets, Obamacare put in place a regulatory structure that 
stifled competition and instituted incentives for increased 
market consolidation.
    Since the enactment of Obamacare, I have been sounding the 
alarm bells. The Judiciary Committee held hearings on Obamacare 
and competition in each of the last two congressional sessions. 
I am pleased that the Committee meets again to continue to 
sound the siren and supplement the growing record of 
Obamacare's anticompetitive results.
    One of the principal tenets of economics is that 
competition can lead to lower prices, enhanced product variety, 
greater innovation, and downward pressure on costs. When 
markets consolidate, there exists the potential for reduced 
competition resulting in the contraction of the related 
benefits.
    Of course, consolidation does not always lead to a 
reduction in competition. Market efficiencies can be obtained, 
and the expansion of successful products can be achieved more 
rapidly through transactions. However, when non-market and 
government forces compel consolidation, those underlying forces 
and their effects should be closely examined.
    Accordingly, it is vitally important that antitrust laws 
are properly and consistently enforced to prevent 
anticompetitive consolidation and conduct, and that laws that 
promote these activities are subject to strict and ongoing 
scrutiny. Continuous and vigilant oversight, such as at today's 
hearing, will help to ensure that health care markets operate 
as freely and competitively as possible, in order to provide 
consumers with premier and affordable health care.
    I look forward to the testimony of our witnesses on the 
state of competition in the predominant health care markets. 
Thank you, Mr. Chairman. I yield back.
    Mr. Marino. Thank you, Chairman Goodlatte.
    Without objection, other Members' opening statements will 
be made part of the record.
    Now I will begin by swearing the witnesses in. Would you 
please stand and raise your right hand, please?
    Do you swear that the testimony you are about to give 
before the Committee is the truth, the whole truth, and nothing 
but the truth, so help you God?
    Let the record reflect that all the witnesses have answered 
in the affirmative.
    Please be seated.
    We have a distinguished group of witnesses here today that 
I think are going to contribute a great deal to some of the 
questions that we would like to have answered.
    We will begin with Professor Thomas L. Greaney, who is a 
Chester A. Myers Professor of Law and Co-Director of the Center 
for Health Law Studies at the St. Louis University's School of 
Law. Professor Greaney also is the author of Health Law, one of 
the leading health care casebooks, as well as numerous articles 
on the intersection of antitrust and health law that have been 
published in, among other places, the New England Journal of 
Medicine, the Antitrust Law Journal, the Journal of the 
American Medical Association, and the Yale Journal of Health 
Law and Policy.
    Prior to joining the St. Louis University School of Law, 
Professor Greaney served as the Assistant Chief in the 
Antitrust Division of the Department of Justice. Mr. Greaney 
received his B.A. magna cum laude from Wesleyan University and 
his J.D. from Harvard Law School.
    Welcome, professor.
    Mr. Richard Pollack recently became the 11th President and 
CEO of the American Hospital Association, known as AHA, on 
September 1st, 2015. Mr. Pollack has been with the AHA for over 
32 years, recently serving as the institution's Executive Vice 
President for Advocacy and Public Policy, where he was 
responsible for the development, implementation and management 
of the Association's advocacy, representation and public 
affairs activities.
    Mr. Pollack started his professional career here on Capitol 
Hill, serving as a legislative assistant to former Congressman 
Dave Obey. Mr. Pollack earned his Bachelor's degree in 
Political Science and Communications from the State University 
of New York's College at Cortland, and his Master's degree in 
Public Administration from American University.
    Welcome, Mr. Pollack.
    Dr. Barbara McAneny was re-elected on June 2014 to the 
American Medical Association AMA Board of Trustees. Dr. McAneny 
is a board-certified medical oncologist and hematologist from 
Albuquerque, New Mexico, and has served in numerous leadership 
roles at the AMA. Additionally, Dr. McAneny was appointed by 
Health and Human Services Secretary Tommy Thompson to the 
Practicing Physicians Advisory Council from 2002 to 2006.
    Dr. McAneny graduated magna cum laude from the University 
of Minnesota and with honors from the University of Iowa 
College of Medicine.
    Doctor, welcome.
    Mr. Dan Durham is the Executive Vice President of Strategic 
Initiatives at America's Health Insurance Plans, known as AHIP. 
Mr. Durham has over 30 years of leadership experience with 
major policy and regulatory issues, primarily in the health 
care field. In addition to holding senior positions within 
AHIP, Mr. Durham served in high-level policy positions in the 
Federal Government, at the United States Department of Health 
and Human Services, the Social Security Administration, and the 
Office of Management and Budget.
    Mr. Durham received his B.A. from the University of Notre 
Dame and his Master's degree from Duke University.
    Mr. Durham, welcome to you also.
    Dr. Scott Gottlieb is a recent Fellow at American 
Enterprise Institute and a practicing physician. Dr. Gottlieb 
has served in various capacities at the Food and Drug 
Administration, including as a Senior Advisor for Medical 
Technology; Director of Medical Policy Development; and, most 
recently, Deputy Commissioner for Medical and Scientific 
Affairs, in addition to serving as a senior policy advisor at 
the Centers for Medicare and Medicaid Services.
    Dr. Gottlieb is also a prolific writer on health care 
issues, and has been published in leading medical journals and 
other well-respected periodicals.
    Dr. Gottlieb received his B.A. in Economics from Wesleyan 
University and his M.D. from Mount Sinai School of Medicine of 
New York University.
    Welcome, doctor.
    Each of the written statements will be entered into the 
record in its entirety, and I ask each of the witnesses to 
summarize his or her testimony in 5 minutes or less. To help 
you with the timing, you see the lights in front of you. The 
lights will switch from green to yellow, indicating that you 
have 1 minute to conclude your testimony. And when the light 
turns red, it indicates that the witness' 5 minutes have 
expired.
    I do this, and I know that some of you are probably going 
to do it. We are so intent on saying what we want to say or 
reading our statements that we pay no attention to those 
lights, and I will very politely just sort of raise the gavel 
to get your attention to ask you to please summarize. So, thank 
you.
    With that, Mr. Greaney, would you like to make your opening 
statement? Would you put your microphone on, sir?

       TESTIMONY OF THOMAS L. GREANEY, PROFESSOR OF LAW, 
               ST. LOUIS UNIVERSITY SCHOOL OF LAW

    Mr. Greaney. Thank you very much, Chairman Goodlatte, 
Chairman Marino, and Ranking Member Johnson.
    Mr. Marino. Could you pull it a little closer to you? It is 
off to the side.
    Mr. Greaney. I appreciate this opportunity to testify again 
before this Committee.
    Let me summarize my testimony with four key points.
    First of all, the Affordable Care Act both depends upon and 
promotes competition in health care markets. And secondly, 
while there is no doubt that excessive concentration undermines 
the competitive policies of the ACA, it is entirely erroneous 
to claim that the ACA is somehow responsible for this 
consolidation. Mergers to monopoly and oligopoly are efforts to 
avoid or frustrate the Act.
    Third, the recently announced health insurance mergers 
threaten competition in a variety of product markets and bear 
careful scrutiny. The only point I am going to make there is 
that you should not be taken in by the argument that consumers 
are somehow better off having big insurers confront big 
hospitals. I call that the Sumo Wrestler theory.
    And finally, my last point is that if state and Federal 
legislators are concerned about competitiveness of health care 
markets, as they should be, it is finally time to take a hard 
look at the real problems that beset the health care market--
outdated regulations, anticompetitive practices that can be 
corrected by procompetitive legislation, and payment incentives 
that wrongly encourage consolidation. Those are your real 
culprits, not the ACA.
    Okay, let me begin with my first point. The ACA does not 
regulate prices. It relies heavily on private-sector 
competition, competition between providers and payers and 
rivalry within each of those markets. Why do we need government 
regulation to help competition? Well, let's remember what that 
putative market, as we like to call it, looked like before 
health reform. There was a dysfunctional market for individuals 
and small groups; we had a non-system of service delivery, as 
hospitals and physicians each operated in their own silos; and 
we had payment systems that rewarded volume and not outcomes.
    What has the ACA done to improve market competition? My 
written testimony goes into a variety of areas, but most 
importantly it put in place efficient markets for shopping and 
bargaining in the individual and small-group market. Very 
importantly, the exchanges set up mechanisms to shop and 
compete. And remember that the ACA also put in rules that made 
insurance products now comparable, understandable, and assure 
basic levels of coverage. These are Economics 101 conditions 
for better competition.
    What do we have as a result? Well-functioning exchange 
markets that have enabled over 10 million people to shop for 
and find products.
    The doomsday predictions about the exchanges--risk 
selection would destroy the exchanges, policies would be 
unaffordable, employer-sponsored markets would crumble--proved 
to be wrong, wrong, and wrong.
    As to the commercial market, the ACA also has had important 
salutary effects. First and foremost, it forbid insurers to 
engage in medical underwriting, going after preexisting 
conditions. That sent a message to the insurance market that is 
very important. I want to channel Bill Belichek here. It said 
``do your job'' to insurers, develop health plans that control 
costs and improve quality rather than chase risk. And widely 
overlooked is what the ACA did with Medicare reform that is 
still ongoing. Medicare payment reform emphasizing now value-
based purchasing, ACOs and lots of other things, shifted 
delivery in a very important way, and we know that private 
commercial markets follow what Medicare does.
    So is everything copasetic? No. Unfortunately, 
concentration is a big problem, but a little history is in 
order. Much of that, much of the problematic concentration 
preceded the ACA. The good news is that the DOJ and FTC are on 
the job and have won a series of important victories that 
should send a clear message about future consolidation.
    I will just mention very briefly my point on insurance 
sector consolidation since my time is running short. The 
insurance market consolidation is problematic. It is going to 
take an in-depth inquiry by the Department of Justice. But the 
concept--and it is a fallacious one in my view--the idea that 
somehow we are better off where we pit dominant insurers 
against dominant hospitals, that is unsupported by the economic 
evidence, both in theory and in practice. There are lots of 
antitrust cases where we have seen large insurers and hospitals 
confronting each other, and they find a way to either conspire 
with each other, either hurting rivals or simply splitting the 
spoils of their market power. Sometimes we find out that the 
sumo wrestlers would rather shake hands than compete.
    I listed a long list of ideas for a procompetitive agenda, 
including things that would help de-concentrate markets. There 
are a number of steps that could be taken. I commend Dr. 
McAneny's testimony, which I think gives many of the ideas 
which I support.
    So I think those are the steps that would promote 
competition and advance the goals of this Committee. 
[Applause.]
    [The prepared statement of Mr. Greaney follows:]
    
    
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
                               __________
                               
    Mr. Marino. Thank you, Professor.
    Mr. Pollack?

  TESTIMONY OF RICHARD J. POLLACK, EXECUTIVE VICE PRESIDENT, 
   ADVOCACY AND PUBLIC POLICY, AMERICAN HOSPITAL ASSOCIATION

    Mr. Pollack. Chairman Marino, Ranking Member Johnson, and 
distinguished Members of the Committee, on behalf of our 
Nation's hospitals, I appreciate your inviting me to be here 
today.
    The health care landscape is rapidly changing, and 
hospitals are helping to lead the way forward. They are 
focusing on improving the patient care experience, enhancing 
quality, and lowering the cost of patient care. Many of the 
market forces reshaping health care were in place long before 
the passage of the Affordable Care Act, but the ACA has 
accelerated that pace of change.
    A major part of that change is the realignment in the 
hospital field that I would like to discuss this morning. The 
emphasis on wellness or population health has encouraged 
collaboration among providers, along with the development of 
coordinated care models. These new models are often value-, not 
volume- or cost-based, which means that providers are at 
financial risk if they don't achieve specified quality and cost 
goals.
    The Department of Health and Human Services has launched a 
number of these programs, and by 2018 it expects to move half 
of all Medicare payments to alternative models of reimbursement 
that reward value. The Department has also recognized that 
achieving these goals would require hospitals to make 
fundamental changes in their day-to-day operations that improve 
quality and reduce the cost of care.
    The hospitals and health systems realigning and 
transforming care means closely working with other providers to 
make sure that patients and communities have convenient access 
to care. That means coordinating with doctors and other 
caregivers to deliver better patient-centered care; it means 
hospitals are aligning with other hospitals to unify patient 
information, better coordinate transitions and follow-up care, 
and share financial risk, among other improvements; and it 
means partnering to keep the doors of certain financially 
failing hospitals open so that patients won't lose access to 
the medical care they and their community rely on.
    For example, a health system in Ohio acquired a small 
community hospital in bankruptcy that saved 250 community jobs 
and actually expanded access to care in that rural area, and 
many small, stand-alone, and rural hospitals are particularly 
in need of partners. Just the cost of acquiring and maintaining 
electronic medical records, which can be as much as $50 million 
for a midsize hospital, can tip the financial balance of these 
organizations.
    Outdated regulatory barriers continue to constrain the pace 
of innovation, and despite repeated calls for the Federal 
agencies to modernize these regulations, to date only one has 
been changed. For example, we have repeatedly asked the Federal 
Trade Commission, which oversees transactions in the hospital 
field, for guidance on constructing clinical integration 
arrangements that could in some instances take the place of 
mergers. However, we have not received this guidance.
    Now, despite these challenges, the results of hospital 
realignment are promising. It is even impressive. The author of 
a recent study in the Journal of the American Medical 
Association used the term ``jaw-dropping'' to describe the 
results, which found hospitalizations and costs going down for 
patients. He observed that there has been tremendous focus on 
making sure that our hospitals are safer and that treatments 
are more timely and more effective. Moreover, he acknowledged 
that the savings per patient did not come at the expense of 
quality.
    And let me highlight just one other fact, and that is that 
hospital price growth is at historically low levels, less than 
1 percent in 2015.
    Now, while I understand that this hearing is not focused on 
the recently announced health insurance acquisitions, I would 
just like to briefly touch on that point. We have serious 
concerns about two potential acquisitions and believe they 
merit the greatest scrutiny from both the Department of 
Justice's Antitrust Division as well as Congress.
    Anthem's proposed acquisition of Cigna, and Aetna's 
proposed acquisition of Humana, would eliminate two of the 
largest national health insurance companies, leaving just three 
dominant national providers of health insurance. That would 
leave consumers with fewer and, no doubt, more expensive 
options for coverage, and it would diminish the insurers' 
willingness to be innovative partners with providers and 
consumers to transform care.
    In conclusion, I just want to say that America's hospitals 
are woven into the fabric of our communities. Hospitals care 
for patients when they are sick, and we work to keep 
communities healthy. We have tried to lead the way and will 
continue to try to lead the way to reshape the system, to 
improve quality, to improve efficiency, and to make health care 
more affordable for patients and families, and we certainly 
look forward to working with the Committee on making sure that 
consumers have access to high-quality, affordable care in their 
communities.
    Thank you.
    [The prepared statement of Mr. Pollack follows:]
    
    
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    Mr. Marino. Thank you, Mr. Pollack.
    Dr. McAneny?

 TESTIMONY OF BARBARA L. McANENY, M.D., MEMBER OF THE BOARD OF 
             TRUSTEES, AMERICAN MEDICAL ASSOCIATION

    Dr. McAneny. Thank you. Good morning. I am Dr. Barbara 
McAneny. I am a cancer doctor practicing in New Mexico, and I 
am immediate past chair of the American Medical Association. 
Thank you for inviting us to participate in this oversight 
hearing on competition in the health care marketplace.
    Physicians want to participate in a health care delivery 
system that allows us to deliver high-quality and efficient 
care to our patients. We believe that competition between and 
among health care providers, facilities and insurers is an 
excellent prescription for achieving that goal.
    The Affordable Care Act, which includes provisions that are 
designed to stimulate competitive forces in segments of the 
health care market, is a disruptive force whose impact is still 
being revealed. New payment and delivery models focusing on 
quality and efficiency can foster competition by encouraging 
innovation. Physician leadership in these new models is 
critical both to protecting patients' interests and driving 
down costs.
    Indeed, preserving the ability of physicians to participate 
in alternative payment models, including small or specialty or 
rural practices, is essential because it ensures patient 
choice, preserves the doctor-patient relationship, and provides 
better competition in health care markets. Therefore, we 
recommend reassessing and removing legal barriers that inhibit 
physician engagement.
    Specifically, we strongly support the FTC and DOJ efforts 
to clarify the application of antitrust laws and urge 
additional guidance to encourage the development of physician-
guided, innovative delivery models. Currently, broad 
prohibitions under the Federal fraud and abuse laws discourage 
physicians from adopting innovative incentive programs that 
could kick-start competition. We therefore urge Congress and 
the Administration to strengthen and expand program integrity 
exemptions for physicians participating in alternative delivery 
and payment models.
    Ultimately, physicians should be able to maintain 
independent practices and participate in innovative care 
models. Anticompetitive hospital markets may undermine the 
incentive of hospitals to compete based on quality, potentially 
laying the groundwork for suboptimal care. Lifting the ban on 
new physician-owned hospitals, which have developed an enviable 
track record on quality and cost, offers one way to inject new 
competition into hospital markets.
    Similarly, we believe that competition, not consolidation, 
is the right prescription for health insurer markets. 
Competition can lower premiums, enhance patient care, and spur 
innovative ways to improve quality while lowering costs. Our 
annual study of commercial health insurance markets shows that 
70 percent are already highly concentrated. We believe that 
there must be a rigorous review of proposed mergers to 
determine their effects on competition and their consequences 
for patient care.
    In 2010, the Department of Justice found that the proposed 
Blue Cross merger in Michigan would have resulted in ``the 
ability to control physician reimbursement rates in a manner 
that could harm the quality of health care delivered to 
consumers.'' The same analysis should be applied to pending 
mergers.
    In practice, the concentration of market power among a 
handful of nationwide insurers impacts physicians' ability to 
facilitate individualized care. Doctors are left with no 
recourse to advocate for our patients, and innovation is 
stifled. Market dominance does not produce patient benefits 
when physicians are squeezed and networks are narrowed. 
Patients should be able to select their doctors based on 
quality and service, and doctors should be free to get patients 
what they need and deserve. This is a stark reminder of what is 
at stake: the health and safety of American patients.
    We are at a critical decision point on health insurance 
mergers because once the handful of national players is further 
reduced, there is simply no going back. Post-merger remedies 
are likely to be both ineffective and highly disruptive. Thus, 
we believe that the time for heightened scrutiny and careful 
consideration is now, before proposed mergers take effect and 
result in a fait accompli wherein patients and physician 
practices are permanently harmed.
    Competition plays a major role in enabling patients to 
access the high-quality care they deserve at a reasonable cost. 
We thank the Subcommittee for your continued efforts on this 
issue, and we look forward to working with you to improve 
health care competition. Thank you.
    [The prepared statement of Dr. McAneny follows:]
    
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    Mr. Marino. Thank you, Dr. McAneny.
    Mr. Durham?

   TESTIMONY OF DANIEL T. DURHAM, EXECUTIVE VICE PRESIDENT, 
    STRATEGIC INITIATIVES, AMERICA'S HEALTH INSURANCE PLANS

    Mr. Durham. Good morning, Subcommittee Chairman Marino, 
Chairman Goodlatte, Ranking Member Johnson, and Members of the 
Subcommittee. I am Dan Durham, Executive Vice President at 
America's Health Insurance Plans, and I appreciate this 
opportunity to testify on issues regarding competition in the 
health care system.
    A competitive health care system is the best way to achieve 
innovative, high-quality, affordable health care. Competition 
among health plans occurs at the local level, and the diversity 
of AHIP's membership, which includes local, regional, and 
national plans, reflects the many choices available to 
consumers.
    Innovation in payment and delivery has resulted in a broad 
range of options available in the marketplace as health plans 
continually work, in collaboration with providers, to improve 
the value of their products for consumers. Our written 
testimony highlights initiatives that our members have 
pioneered to promote quality and affordability, as well as 
consumer tools that promote patient-centered care.
    Regarding competition in the marketplace, the Department of 
Health and Human Services reports that an average of 40 plan 
options are available per county in 2015. That is up from 30 
last year. And McKinsey reports a 26 percent increase in the 
number of issuers competing on exchanges. Competition within 
local markets is evolving, with a variety of high-value 
products, from patient-centered medical homes to bundled 
payments to accountable care models. The range of collaborative 
products that drive value is vast, and health plans tailor 
these products to help meet the specific needs of local patient 
populations.
    As has been reported, there is merger activity in the 
health insurance industry. While I can't speak to the potential 
outcomes of these reviews, it is important to understand the 
broad framework that the antitrust agencies use to evaluate 
whether a particular transaction is procompetitive or 
anticompetitive, and the evolving nature of the market for 
health coverage.
    Assessing the impact of proposed mergers should start with 
a clear understanding that many mergers and acquisitions are 
beneficial to consumers. They facilitate new, high-value 
products and efficiencies that reduce cost. The Department of 
Justice has indicated, ``The primary benefit of mergers to the 
economy is their potential to generate significant 
efficiencies, and thus enhance the merged firm's ability and 
incentives to compete, which may result in lower prices, 
improved quality, enhanced service, or new products.'' The DOJ, 
along with 50 state attorneys general and insurance 
commissioners play an important role in reviewing proposed 
mergers and determining their potential impacts. This includes 
a thorough evaluation of a large body of data and other 
evidence to determine whether a merger would harm consumers by 
adversely impacting competition in specific products and 
specific geographic areas.
    Notably, there is no single national market for health 
coverage. Health plans negotiate with providers in local 
markets and offer particular types of products that differ 
widely from one another. The agencies also consider the nature 
of the market itself and whether it is undergoing changes that 
are relevant to its analysis. For example, the highly regulated 
nature of health insurance markets is relevant to an analysis 
of the potential competitive effects of transactions. This 
highly regulated market we face distinguishes health insurance 
from other less regulated markets.
    The bottom line is that consolidation should be looked at 
on a case-by-case basis and it is problematic only when a 
transaction leads to anticompetitive effects such as an 
increase in cost resulting from harmful consolidation in 
provider markets.
    There is substantial evidence in peer-reviewed research 
that shows a significant share of health care cost increases 
are driven by dominant providers charging higher prices. The 
Robert Wood Johnson Foundation study found that increases in 
hospital market concentration lead to increases in the price of 
hospital care, and that when hospitals merge in already 
concentrated markets, the price increase can be dramatic, often 
exceeding 20 percent. This study further cautions that 
physician-hospital consolidation has not led to either improved 
quality or reduced costs. Other studies that we have detailed 
in our written testimony show that anticompetitive 
consolidation in provider markets is resulting in higher health 
care costs for consumers and employers and government programs.
    Thank you again for this opportunity to testify. AHIP and 
our members look forward to continuing to work with the 
Subcommittee and other stakeholders to improve patient access 
to high-quality, affordable health care.
    [The prepared statement of Mr. Durham follows:]
    
    
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    Mr. Marino. Thank you, Mr. Durham.
    Dr. Gottlieb?

 TESTIMONY OF SCOTT GOTTLIEB, M.D., RESIDENT FELLOW, AMERICAN 
                      ENTERPRISE INSTITUTE

    Dr. Gottlieb. Thank you, Mr. Chairman and Mr. Ranking 
Member, for the opportunity to testify. My name is Scott 
Gottlieb. I am a physician and Resident Fellow at the American 
Enterprise Institute.
    The health care sector is undergoing a secular 
consolidation as payers and providers assume an historic level 
of acquisition and mergers. These trends were underway prior to 
implementation of the Affordable Care Act, but there is no 
question that the ACA hastened them.
    The consolidation of physicians at the local level should 
be a particular concern. In the end, most health care is local. 
Once an institution has monopolized the providers in its 
market, it renders market-based reforms hard to achieve and 
reduces the ability of competition to be used as a tool for 
improving quality and reducing costs.
    More importantly, the new arrangements that are being 
forged, where doctors become part of large delivery systems, 
usually with a hospital at its hub, reduces productivity. 
Compelling economies of scale are not apparent in a physician 
practice marketplace. This has been borne out by many studies 
that examine the question, some of which I review in my written 
statement for this hearing. There is a lot of evidence that as 
doctors transition to becoming salaried employees of hospitals 
and health systems, their individual productivity in terms of 
metrics such as volume and intensity of care delivered also 
generally declines.
    Looking at this in view of our broader fiscal challenges 
when it comes to health care, the only way that we are going to 
solve some of the challenges facing the entitlement programs 
like Medicare is to get more health care for every dollar of 
GDP that we spend on it. To these ends, the last thing we ought 
to be doing is adopting structures that reduce productivity.
    I know there will be some discussion today of new 
technology, and particularly drugs, as factors driving 
increases in the cost of medical care, and I want to just 
comment briefly on that. However one interprets the data on 
drug costs, it is widely agreed that many new technologies 
improve productivity by improving outcomes or obviating costly 
alternatives.
    Take oncology care. Although very costly, total spending on 
oncology care as a percentage of our $2.7 trillion national 
health care budget has been constant over the last 20 years. It 
is just less than 5 percent of total health care spending. It 
comes out to about .8 percent of GDP. But the mix of 
expenditure has changed dramatically over time. Far less money 
is being spent on services like hospitalizations and far more 
on outpatient medicines. Cancer treatments that used to make 
patients very sick and require costly hospitalizations have 
been replaced with targeted drugs that can allow patients to be 
treated at home.
    So the proportion of spending on inpatient care admissions 
fell from 64 percent of total cancer spending in 1987 to 27 
percent by 2005, according to studies. Here is what happened. 
Transferring cancer care to the outpatient setting produced 
substantial savings. It is cheaper to deliver care outside the 
hospital. This is how technology improves productivity and 
lowers costs, which brings me back to the consolidation 
underway in the market for health care services.
    This consolidation not only reduces productivity and in 
turn increases costs, it also reduces patient access. This is 
especially troubling when it comes to rural markets where there 
is a lower density of doctors and patients can find it harder 
to get care at a site near their homes. It is important to 
remember that the scope of the consolidation that we are seeing 
in health care is not a response to market factors. Rather, it 
is a deliberate function of policy choices. The ACA envisions 
doctors practicing in large integrated health systems, often 
with a hospital at its hub. The idea is that these newly 
consolidated entities will be big enough to take capitated risk 
and invest in the kinds of technologies that it is believed 
will lead to better coordination in medical care. The ACA's mix 
of policies seeks to hasten these outcomes.
    The relationships that doctor practices are forging with 
their acquiring entities are far stickier than past 
arrangements. Moreover, for doctors, the opportunity to unwind 
these business engagements and go back to their old 
configurations are much more narrow. The economics behind these 
arrangements also raises some more fundamental questions. For 
one thing, these constructs were, in part, a response to 
criticism of a fee-for-service approach to payment, which is 
widely presumed to give doctors a financial incentive to 
prescribe more care. As the analysis commonly goes, under a 
fee-for-service arrangement, doctors are paid more when they do 
more things and not necessarily when they improve outcomes. But 
in reaction to these concerns, have we merely traded one flawed 
set of financial incentives for another? After all, if the 
financial incentives work in one direction, they have to work 
in the opposite direction. If doctors will prescribe too much 
care when they are paid to do more, as critics of the fee-for-
service medicine system maintain, won't these same inducements 
work in reverse? Won't doctors prescribe too little care when 
they are paid to do less?
    This also raises another key question, and this one is 
clinical. Are patients better off on the margin when they are 
prescribed a little more care than they need or a little less? 
The body of literature doesn't fully resolve this question.
    Since all health care is local, and the lack of competition 
will soon make it much harder to implement market-based reforms 
in health care, the resulting monopolies will make more 
regulation the most obvious solution to the inevitable cost and 
quality problems. To change these outcomes, I believe that 
Congress needs to reform the ACA to remove the pervasive biases 
in the ACA that favor health system ownership of medical 
practices. At a time when the urge to merge doctors into health 
systems and turn physicians into salaried roles, there is a 
private market counter-effort to create new models that have 
physicians practicing in smaller units. Many aspects of medical 
practice are not responsive to scale, and where scale does 
help, many of the characteristics of health care that benefit 
from integration can be achieved without consolidation but by 
better use of technology.
    A legislative proposal to improve health care quality that 
manages cost would support local competition between providers 
and choice for patients. We need to improve productivity and 
preserve entrepreneurship, autonomy, and local competition that 
have long been the hallmarks of American medical progress. 
Thank you.
    [The prepared statement of Dr. Gottlieb follows:]
    
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    Mr. Marino. Thank you, Dr. Gottlieb.
    Members on the dais will now begin their 5 minutes of 
questioning, and I recognize myself for my 5 minutes.
    Mr. Pollack, I would like to begin with you, sir. There 
have been a number of reports of hospitals purchasing physician 
practices. In some cases, patients enter the same building and 
see the same doctor after the purchase, but the Medicare 
reimbursement rate for the service is significantly higher. In 
some instances, Obamacare increased these pricing disparities.
    Are Medicare reimbursement rates driving purchases of 
physician practices, and do you think that will impact 
Medicare's solvency?
    Mr. Pollack. I think, Mr. Chairman, there are two issues 
here. One is the issue of physicians wanting to be part of 
teams and wanting to be part of group practices that deliver 
care in a coordinated way, and very often they are part of the 
hospital entity. That is certainly a trend that we are seeing. 
When physicians do become part of the hospital entity and they 
deliver services within the hospital entity, there are 
requirements that have to be met that they are part of that 
facility, as opposed to providing service in their own office 
or in a different site.
    Hospital costs for those physicians are legitimately 
higher, and the Medicare rate does, in fact, reflect a higher 
amount. That is legitimate, in our view, because the regulatory 
requirements for practice in that setting are very different 
than what the requirements are in a physician office or an 
ambulatory care center. The patients we take care of in that 
setting are anyone who walks through the door, Medicare or 
Medicaid. We are open 24 hours, 7 days a week. The patients 
that are taken care of in those hospital-based physician 
clinics tend to be sicker, and we have studies that we are 
happy to submit for the record that show they are poorer and 
more economically challenged. They suffer from a more difficult 
set of circumstances. So it is, in fact, more expensive to take 
care of patients in those types of settings.
    Mr. Marino. Thank you.
    Dr. McAneny, would you like to respond to my question?
    Dr. McAneny. Yes. Thank you very much, Mr. Chairman. I take 
care of cancer patients in a very poor community in New Mexico 
which ranks at the lowest for income. While the American 
Medical Association supports the right of physicians to choose 
employment, we focus on the word ``choose.'' We don't believe 
that competition should force physicians to select employment 
over self-employment or other options.
    I do disagree with the statement that we are unable to take 
care of sicker patients in the outpatient arena. In our 
practice, if I sold to the hospital tomorrow and I saw the same 
patient and did the same services, you are absolutely correct, 
my services would be reimbursed at a higher level if I were 
hospital-based than physician fee schedule. But we do take care 
of very ill patients, and we manage to keep them in the 
outpatient arena.
    The regulatory burden that physicians have is one of the 
impediments to physician practices. The ability to be able to 
comply with all the regulatory requirements is one of the 
barriers that has driven younger physicians in particular to 
wanting to join hospitals in hopes that someone else will take 
care of all that and just let me see my patients.
    Mr. Marino. Thank you.
    Dr. Gottlieb, I have a specific question for you. In your 
testimony, you stated that there has been a net loss of 
insurers since the enactment of Obamacare. You also discuss co-
op insurance plans that have been subsidized under Obamacare. 
Can you discuss the success rate of the co-op insurance plans 
and how the declining number of insurers will affect 
competition in the insurer marketplace? You have about 56 
seconds.
    Dr. Gottlieb. I am referring mostly to the commercial 
marketplace. There has been no new net commercial insurance 
company formation since the enactment of Obamacare, actually 
since 2008. So whatever new plans we have seen, new carriers 
enter the market, we have seen offsetting losses. And actually, 
we have seen a loss of new carriers. We have seen new plans 
enter the market, but they have all been existing carriers that 
have decided to offer plans on the exchanges. They are not new 
carriers. So I don't think that is very robust competition. It 
is an indication that investors aren't allocating capital to 
start new health plans, I think because of the regulatory 
impediments and the high cost of getting into the market.
    As far as the co-ops and the provider-sponsored plans, 
particularly the hospital-sponsored plans, I think the 
Administration envisions that picking up the slack and 
providing competition. But the co-ops are all--I think almost 
all under water, and one has already declared bankruptcy, and I 
am not very optimistic that a lot of the provider-sponsored 
health plans are going to survive. We have done this in the 
past, and it has been demonstrated that hospitals don't manage 
risk well. There is a reason why insurance companies exist.
    Mr. Marino. Thank you.
    My time has expired.
    The Chair recognizes the Ranking Member, Mr. Johnson.
    Mr. Johnson. Thank you, Mr. Chairman.
    Dr. Gottlieb, do you disagree with all of the studies that 
have proven that the cost of health care insurance premiums, 
the increases in the cost of insurance premiums has gone down 
since the onset of the Affordable Care Act?
    Dr. Gottlieb. What I see is that----
    Mr. Johnson. Do you agree or disagree?
    Dr. Gottlieb. I disagree with the premise because what I am 
seeing is that costs are being shifted to consumers. So the 
cost of providing coverage for employers, which is what the 
Administration often cites, has in fact been growing less 
quickly than in the past.
    Mr. Johnson. My question has to do with the premium growth, 
the cost of premiums, the growth in the cost of premiums.
    Dr. Gottlieb. Right. So the cost that would----
    Mr. Johnson. Not shifting of cost to consumers. I am just 
talking about the cost of health care premiums and the rise in 
the cost of health care premiums. Do you agree that the price 
increases have moderated since the passage of the Affordable 
Care Act?
    Dr. Gottlieb. I disagree because the cost to consumers has 
gone up.
    Mr. Johnson. All right. Thank you. You just refuse to 
answer that question.
    Well, let me ask you this. Do you----
    Mr. Marino. Just a minute. I am going to give the witness 
30 seconds to respond to that.
    Mr. Johnson. No, no. From whose time, Mr. Chairman?
    Mr. Marino. From your time. You have to let the witness----
    Mr. Johnson. No, no, no, no.
    Mr. Marino. You must let the witness answer the question.
    Mr. Johnson. Mr. Chairman, the witness has not answered the 
question.
    Mr. Marino. Dr. Gottlieb, please respond if you would like 
to respond.
    Mr. Johnson. I have a problem with parliamentary order. 
Parliamentary inquiry, Mr. Chairman.
    Mr. Marino. Yes?
    Mr. Johnson. Who controls the time during my questioning of 
my witnesses?
    Mr. Marino. I do.
    Mr. Gottlieb, answer the question.
    Mr. Johnson. All right. Well, I am going to take exception.
    Mr. Marino. Exception noted.
    Dr. Gottlieb, you may go ahead and answer the question.
    Mr. Johnson. In fact, I am just going to--if you won't----
    Mr. Marino. No, you have to give the witness an opportunity 
to answer the question.
    Mr. Johnson. Mr. Chairman, when I ask a question and the 
witness refuses to answer the question----
    Mr. Marino. You didn't give him an opportunity to answer 
the question. You kept cutting him off.
    Mr. Johnson. The witness refused to answer the question, 
and it is my prerogative, Mr. Chairman, as the questioner, to--
--
    Mr. Marino. You still have your time, you still have your 
time.
    Mr. Johnson. My time is running because I am responding to 
your interruption of my questions.
    Mr. Marino. You continue to ask your questions, and we will 
give him 30 seconds when you are----
    Mr. Johnson. Mr. Chairman, you started at 4 minutes and 20 
seconds--I had 4 minutes and 20 seconds----
    Mr. Marino. Go ahead.
    Mr. Johnson [continuing]. When you interrupted me to try to 
give this witness an opportunity to answer my question in the 
way that he wanted to answer it.
    Mr. Marino. You have the extra time. Go ahead again with 
your questions.
    Mr. Johnson. Okay. All right.
    Now, Dr. Gottlieb, I asked you a question, do you agree or 
disagree with the studies that have shown that the rise in 
premium costs has been moderated since the passage of the 
Affordable Care Act, and you went into a discussion about 
shifting of costs to consumers. That is not my question. I will 
give you one last chance to answer my question, and I think you 
understand my question. Do you agree or disagree with those 
studies?
    Dr. Gottlieb. I disagree with those studies because I think 
they are flawed.
    Mr. Johnson. All right. Thank you. All right.
    Now, Dr. Gottlieb, do you agree that Congress should repeal 
the McCarran-Ferguson Act antitrust exemptions for insurance 
companies?
    Dr. Gottlieb. No, I do not.
    Mr. Johnson. All right. Thank you.
    Dr. McAneny, I hope I pronounced that correctly. In a 
speech in June of 2015, FTC Commissioner Julie Brill stated 
that while the antitrust agencies are watchful of 
anticompetitive behavior, not one accountable care organization 
has been challenged for anticompetitive conduct by the 
antitrust agencies. What is your response to this approach to 
provider collaborations in the health care marketplace?
    Dr. McAneny. I think the antitrust laws are very confusing 
to people, with or without an affordable care organization, to 
try to create an organization that allows us to collaborate as 
physicians, take economic risk together, and to do clinical 
integration. And I can't speak as a physician since I am not a 
lawyer to what the FTC and DOJ are doing with that, but we feel 
that if we could release some of those barriers and make those 
laws much more clear so that physicians could understand them 
and stay within the confines of the law but still be able to 
collaborate together, we wouldn't have to become employees or 
consolidate the industry in order to create a lot of new 
mechanisms that could deliver better care at a lower cost.
    Mr. Johnson. Thank you. In your written testimony you argue 
that Medicare and Medicare Advantage are distinct product 
markets. Why is Medicare not an adequate substitute for 
Medicare Advantage, and what effect would consolidation in the 
Medicare Advantage market have on physicians and seniors?
    Dr. McAneny. Thank you, sir, for that question. The AMA has 
found that very few patients will switch back and forth from 
Medicare Advantage programs to plain fee-for-service Medicare, 
in part because of the concerns of being able to pay the 20 
percent co-pay with fee-for-service Medicare. The Medicare 
Advantage programs have been given extra money to be able to 
provide better benefits, and patients respond to that.
    What we find is that when those patients consolidate into 
fewer and fewer Medicare Advantage plans, that if the benefits 
are not what the patient wants, if a physician, for example, is 
not on the panel of that Medicare Advantage program, that they 
have a distinct disadvantage in being able to get care and they 
are often forced to pick between their primary care doctor, who 
is on one, and their specialist is on another, and they need 
both of us. So we look at the managed care Medicare Advantage 
market as being distinct from fee-for-service Medicare for 
those reasons.
    Mr. Johnson. All right. Thank you.
    Mr. Greaney, in their testimony, both Mr. Pollack and Dr. 
Gottlieb observed that consolidation in the health care 
marketplace was hastened by the ACA. What is your response to 
that?
    Mr. Greaney. I think that is a bit misleading. Surely the 
Affordable Care Act encourages providers to get together, to 
consolidate, to form efficient delivery systems, and that is 
certainly true. But nothing in the ACA encourages consolidation 
to monopolies and oligopolies. In fact, just to give you an 
example, your doctor probably tells you a glass of wine with 
dinner every night is probably a good thing, but he would 
counsel against two bottles of wine, and I think that is what 
we are talking about here. We are talking about consolidation 
that is excessive.
    As I have said in my testimony, the Affordable Care Act is 
premised on having competitive units at the delivery level and 
at the insurance level so that the ACA relies on competition 
and relies on healthy enforcement of the antitrust laws. If you 
look to the string of victories the FTC has achieved, both in 
hospital markets and in challenging physician mergers, it is 
doing its job. So to that extent, blaming the ACA for 
consolidation is misleading because you would be hard pressed 
to find a health care economist or policy person who thought 
what was needed was anything but the fragmentation that we have 
had heretofore.
    Mr. Johnson. Thank you, and I yield back.
    Mr. Marino. The Chair recognizes the Chairman of the full 
Committee, Congressman Goodlatte.
    Mr. Goodlatte. Thank you, Mr. Chairman.
    Dr. Gottlieb, I think you wanted to explain your answer of 
trends with regard to insurance premiums, and I think you 
should be afforded that opportunity, so I will give that to you 
now.
    Dr. Gottlieb. Thank you, Congressman. What we have seen in 
the market and what the Administration often talks about is the 
cost of coverage, of providing coverage for employers to their 
employees and premium growth, and it is true that premium 
growth, at least in the recent years, has moderated, although 
we are seeing it accelerate quite dramatically.
    But what has happened is we have seen a very dramatic shift 
of cost to consumers. We have seen the advent of very narrow 
plans, closed drug formularies, closed networks, exclusive 
provider organizations, and all of that has served to shift 
costs onto consumers. I think that that is a big component----
    Mr. Goodlatte. Things that aren't covered by the insurance, 
in other words?
    Dr. Gottlieb. Exactly.
    Mr. Goodlatte. So the opposite of what is purported to be 
the benefit of Obamacare?
    Dr. Gottlieb. Well, closed drug formularies in particular 
is a real new phenomenon in the market. The only place where we 
had seen closed drug formularies prior to implementation of the 
Affordable Care Act was in Medicare Advantage. But Medicare 
Advantage had the protected classes which made sure that the 
formularies were robust.
    What is happening in the Affordable Care Act in the 
exchange-based plans is there are closed drug formularies where 
if the drug isn't on the plan's formulary, you are completely 
out-of-pocket and what you spend doesn't count against your 
deductible.
    Mr. Goodlatte. I need to take my time for other things. So 
what you are saying is that whether or not insurance premiums 
are moderating, that doesn't necessarily mean that the overall 
cost to the consumer and overall cost to society----
    Dr. Gottlieb. Exactly.
    Mr. Goodlatte [continuing]. The overall cost to taxpayers 
has moderated.
    Dr. Gottlieb. It has gone up quite a bit to the consumer.
    Mr. Goodlatte. Right. Thank you.
    Dr. McAneny, I may come back to Dr. Gottlieb if I have 
time, but he said that health system ownership of medical 
practices is an undesirable trend. You said that you wanted to 
make sure that they had choice. In a moment I will go to Mr. 
Pollack and give him an opportunity to respond as well. But one 
of the things that I see and one of the things I hear from my 
physicians is that they are actually in competition with the 
employees who are at the hospital, and it is very difficult to 
compete with them when there are such disparate reimbursement 
rates that take place in the hospital compared to what the 
physician may get in their private practice. What is your 
observation about that?
    Dr. McAneny. Well, Mr. Chairman, I think you summarized it 
very well, that it is very difficult for individual physicians 
to be able to compete with hospital-based physicians because 
they have the leverage that we as individuals lack to be able 
to negotiate with insurance companies. We find that the 
regulatory burden is still there in the independent market and 
that hospitals are able to purchase a lot of the same supplies 
and everything else that we need to purchase at a lower price 
or a subsidized price.
    Mr. Goodlatte. Mr. Pollack, I take your point with regard 
to the cost of operating a hospital, but I also am concerned 
that if we are trying to promote competition and there is only 
one hospital in a community, and that hospital has people 
providing services in this area, how do the private 
practitioners successfully compete with the hospital 
practitioners, if you will, in that kind of marketplace, and 
what are the trends there? I see a lot of consolidation. I 
think Dr. McAneny said it is already at 70 percent, perhaps, of 
physicians going in to work at hospitals. Where do you get the 
competition if they all go into the hospital and nobody is out 
there providing that competition?
    Mr. Pollack. I think some of the competition is among 
hospital systems, and I think what we have to remember here is 
that we have a new way of paying for a lot of care in terms of 
different mechanisms that require payment for taking care of 
people.
    Mr. Goodlatte. What if there is only one hospital in the 
community?
    Mr. Pollack. By the way, you made an eloquent point at the 
very beginning, Mr. Chairman, about how health care is a unique 
kind of market.
    Mr. Goodlatte. I agree with that.
    Mr. Pollack. There are 13----
    Mr. Goodlatte. But I am still not going to let you off the 
hook with that. We still have to find ways to compete.
    Mr. Pollack. No, no, your point is very well taken. There 
are 1,300 critical access hospitals in this country in areas in 
which there really is not competition. There are another 500 or 
so sole community providers or rural referral centers. So 
inherently, it is hard to say that competition plays out in a 
very even----
    Mr. Goodlatte. Competition amongst hospitals is an 
important issue, and we are going to get to that as a part of 
this series of hearings that we are going to hold. But right 
now I want to talk about competition between doctors working in 
the hospital and doctors who are working outside the hospital. 
How do we promote that? How do we assure that we continue to 
have competition from physicians who want to practice on their 
own; or, from a societal standpoint, from an economic 
standpoint, is it important that they be outside the system and 
practice on their own?
    Mr. Pollack. And I think that pluralistic approach still 
exists today. But I think what is important to recognize is 
that there are a lot of physicians that want to be in practices 
that are group practices, whether they are on their own or 
whether they are employed arrangements. There are a lot of 
physicians in the next generation that are coming out of 
medical school that actually want to be a part of these groups 
because they don't want to take calls 24/7 and they want to be 
part of these teams.
    Mr. Goodlatte. Mr. Chairman, if I might, I would like to 
let Dr. Gottlieb answer this same question that I just asked 
Mr. Pollack.
    Mr. Marino. Without objection.
    Dr. Gottlieb. What was the question?
    Mr. Goodlatte. The question is how do we assure continued 
competition in communities that have only one hospital system 
when the fact of the matter is more and more physicians go to 
work in the hospital and take up that competition?
    Dr. Gottlieb. I think we don't, and I practice in one such 
community. I think when the hospital monopolizes most of the 
local physicians, it is very hard to have provider-based 
competition. I do believe that provisions in the Affordable 
Care Act have skewed the market in this direction, quite 
deliberately so. I think it is part of a broader political 
philosophy that I think, to date, hasn't been successful.
    Mr. Goodlatte. Thank you, Mr. Chairman.
    Mr. Marino. The Chair now recognizes the Ranking Member of 
the full Judiciary Committee, Congressman Conyers from 
Michigan.
    Mr. Conyers. Thank you, Mr. Chairman.
    I welcome the witnesses, apologize for my late arrival.
    I would like to start off with Professor Greaney by asking 
him what he has heard or observed here today that you think we 
ought to be most cautious about in terms of this analysis 
between competing aspects of providers for the Affordable Care 
Act.
    Mr. Greaney. Thank you, Mr. Chairman. I think several of 
the things that have been mentioned today----
    Mr. Conyers. Pull that mic a little closer.
    Mr. Greaney. Several of the things that have been brought 
up today I think are absolutely valid criticisms of the current 
state of the law. I think the disparate payments between site 
of payment really makes no sense. MedPac has put out studies 
showing that those payments should be adjusted appropriately. 
That is the kind of change where I think Congress can step in 
and correct preexisting law, law that preexisted the ACA, and 
take steps.
    Chairman Conyers has been talking for many years about the 
McCarran-Ferguson Act. You heard Dr. McAneny's testimony about 
changing the fraud and abuse laws to permit and encourage 
greater cooperation short of mergers. There are many of those 
steps that can be undertaken, and I think Congress should 
devote its attention to those things because we have a lot of 
old law that is like barnacles on the hull here. There is old 
law that is dragging competition down, but they preceded the 
ACA, and Congress could and should step up to the plate and 
deal with them.
    Mr. Conyers. Thank you.
    I wanted to yield, if he needs time, to my friend from 
Georgia, Mr. Johnson.
    Mr. Johnson. Thank you, Mr. Chairman. I will go back to Dr. 
McAneny.
    You mentioned the narrowing of physician networks, which 
happens when insurance companies consolidate. Could you tell us 
a little bit more about that issue?
    Dr. McAneny. Thank you very much, Mr. Johnson, for that 
question. That is one of our major concerns. When a patient who 
has, in my field of cancer, a specific need, say a genomics 
test that says a certain drug is indicated, I have to be able 
to go to my insurance company and convince them to provide that 
medication or that service or that referral. The more 
consolidated the industry becomes, the further away it is from 
my individual patient, the harder it is for me to weave through 
the regulatory areas of the insurance company to be able to get 
to somebody who can approve that drug for that patient, and it 
often takes months.
    The more burdens that----
    Mr. Johnson. And, by the way, that is not the regulatory 
apparatus of the government. You are talking about the 
regulatory apparatus of the insurance companies.
    Dr. McAneny. Exactly, sir.
    Mr. Johnson. All right. Proceed.
    Dr. McAneny. Yes. It gets very difficult for me to be able 
to advocate appropriately for my patients. When the insurance 
company is small and local and they need me in their network, 
then they will listen to me when I try to get something for a 
patient. If I go to a national network or I am obviously always 
advocating for a patient, I become a disruptive physician and I 
am less inclined to be included in that network because I spend 
more money and I am a thorn in the side of insurance companies 
who don't want to buy those expensive drugs and processes that 
Dr. Gottlieb was talking about.
    So it is very intimidating to physicians. If you know in 
your practice that you can't do without a given payer, they 
know that they don't really have to pay attention to what you 
are requesting because you can't afford to leave.
    Mr. Johnson. And consolidation aggravates this situation.
    Dr. McAneny. It will make it far worse. Yes, sir.
    Mr. Johnson. All right. Well, let me ask Professor Greaney, 
contrary to reports that costs have gone up overall for 
consumers since the passage of the Affordable Care Act, a 
shifting of, say, premium increases to higher deductibles and 
co-pays and that kind of thing, what is your response to that, 
sir?
    Mr. Greaney. We have seen a number of studies where 
competition has lowered premiums, has lowered costs. The 
exchanges are a particularly good example where it has 
occurred, has had a very beneficial effect on cost. The 
individual markets experienced much better cost experiences, 
and I think the message here is that competition works.
    Mr. Johnson. Yes, 9.4 million seniors have saved more than 
$15 billion on prescription drugs since the passage of the 
Affordable Care Act, an average of $1,598 per senior.
    Mr. Greaney. Yes.
    Mr. Marino. You can finish, sir. The gentleman's time has 
expired, but you can finish your point.
    Mr. Greaney. Well, I was just going to mention that one 
important driver of cost is whether we get new entry into 
markets, and there is a particularly interesting example in 
Arkansas. When it expanded Medicaid, Arkansas said let's have 
the private option, let's have private insurers cover the new 
Medicaid beneficiaries. What happened there? Not only did the 
new beneficiaries get covered, but it increased competition in 
the marketplace in Arkansas, so everybody benefitted, including 
the private market. It went from two competitors to six. So 
private competition can be generated, and I think states that 
haven't expanded Medicaid are shooting themselves in the foot 
in the private market as well.
    Mr. Conyers. Chairman Marino?
    Mr. Marino. Yes, sir?
    Mr. Conyers. Could I ask unanimous consent for one question 
additional?
    Mr. Marino. Yes, sir, without objection.
    Mr. Conyers. I thank you so much.
    My last question is to Professor Greaney again, and it is 
about the implementation of the health insurance exchanges 
under the Affordable Care Act. Has it promoted competition, in 
your view?
    Mr. Greaney. Oh, most certainly. I think we have seen a lot 
of markets where there has been new entry and there has been a 
shakeup of the markets. But there are still plenty of markets 
where we haven't had much competition, new entry in exchanges, 
and that is why Congress is rightly concerned about the 
insurance mergers, because we want new entry. But if we have 
gone from five down to three, the most likely new entrants are 
going to disappear. So that is a concern on the horizon.
    Mr. Conyers. Thank you, Mr. Chairman.
    Mr. Marino. The Chair now recognizes the Congresswoman from 
California, Ms. Walters.
    Ms. Walters. Thank you, Mr. Chairman.
    I want to direct the question to Mr. Durham, and then give 
Mr. Pollack an opportunity to respond.
    Mr. Durham, your testimony raises concerns about hospital 
consolidations. The testimony cites an analysis that claims, 
``Hospitals and acquisitions increased 44 percent between 2010 
and 2014, with a total of 442 transactions occurring during 
this timeframe.'' Surely not all of these mergers have an 
anticompetitive effect, and how do we differentiate between a 
consolidation that increases competition and one that decreases 
competition?
    Mr. Durham. A very good question, Congresswoman. I believe 
that is really a detailed analysis that the Department of 
Justice conducts. They look at data that is not publicly 
available and examine it at the local market. It is critical 
that this analysis be done in specific geographic areas to 
really determine the potential impact on competition.
    As I mentioned in my testimony and oral statement, DOJ sees 
that there are circumstances where mergers can create 
efficiencies and enhance competition. So it really depends on 
what they are seeing in the local geographic market.
    We are all about driving value, moving away from the 
antiquated fee-for-service model that pays for volume and 
providing value for patients, lower cost, and higher-quality 
care. And these mergers can certainly make that happen, 
particularly when two companies have different areas of 
expertise. One may have expertise and may have done a lot in 
chronic care management, while another has done more in value 
payment models in collaboration with providers. Bringing those 
two together can bring higher value to patients, and that is 
what we are focused on in terms of bending this cost curve.
    Ms. Walters. Thank you.
    Mr. Pollack?
    Mr. Pollack. Thank you very much for that question, I 
appreciate it. Mr. Durham's testimony has a litany of studies 
that talk about how consolidation increases prices. I think a 
lot of them are old. They are old data. They are incomplete. 
For example, there is one study that is mentioned in the 
testimony that looks at 12 states, but they say that they can 
only find a relationship in three out of the 12 states. The 
three states that they look at--Ohio, Georgia, and Missouri--
have a lot of critical access hospitals, rural referral 
centers, and sole community providers, which we said inherently 
are a different situation.
    The newer studies that we have seen from JAMA show that, in 
fact, we have reduced costs. We have seen other studies that 
show that our price growth is at historic lows, and we have 
studies that I would be glad to submit to the record that do 
not show a correlation between consolidation and price 
increases.
    The last and very important point is that we also did a 
study that I would submit for the record by the Center for 
Health Transformation, and it looked at hospital deals, if you 
will, between 2007 and 2013. There were 607 in that period. 
That represents only 12 percent of our field. Of the 607 that 
occurred, all but 22 resulted in at least five hospitals still 
remaining after those consolidations. And of the 22 where there 
were less than five, if you go through the stories of each of 
those 22, some were to prevent a bankrupt hospital from going 
out of business entirely, and many were to reconfigure 
hospitals so they can exist to be an access point in 
communities that wouldn't have access to care.
    So I think in the hospital world, our arrangements are 
focused on a different objective, which is to move to the 
future in terms of rationalizing the system and finding ways to 
preserve access where many just wouldn't exist if we didn't 
have these arrangements. Thank you.
    Ms. Walters. I yield back.
    Mr. Marino. Thank you.
    The Chair now recognizes the congressman from Georgia, Mr. 
Collins.
    Mr. Collins. Thank you, Mr. Chairman.
    Mr. Greaney and Dr. Gottlieb, I have a question. I will 
frame the question and I would like, Mr. Greaney, if you would 
start; and, Dr. Gottlieb, if you would weigh in on this as 
well.
    One, I want to thank the Chairman for holding this series 
of hearings that we are going to be having looking at these 
issues and on similar topics, but I also want to focus a little 
bit today on one because I want to encourage that there be a 
hearing on this issue in particular, the effects of PBMs on 
competition in the health care market and how Obamacare may 
have affected the competition in that area.
    This summer the FTC approved CVS' acquisition of Omnicare 
without conducting a significant investigation into the 
combination of the largest long-term care pharmacy with the 
largest Part D PBM. The FTC's lack of action ties into other 
concerns I have heard from my constituents about the conduct of 
PBMs and their effect on competition.
    Independent community pharmacists play a vital role in 
Northeast Georgia, where I am from, a rural community, and 
across the Nation, but they are being crippled many times by 
burdensome regulations, and also the often, at times, abusive 
PBM practices. My constituents and I share a concern that the 
way Obamacare treats the PBMs will further harm independent 
community pharmacists.
    To that end, Mr. Greaney and Dr. Gottlieb, I would like to 
know, in your opinion, what can be done to ensure independent 
pharmacies and PBMs can compete on a level playing field? And 
in this post-Obamacare environment, has Obamacare really 
affected that? And do you feel like, aside from congressional 
action, in the PBM space, could the FTC be doing more in this 
area of PBMs and independent pharmacies, especially in the 
health care chain?
    So, Mr. Greaney, I will start with you.
    Mr. Greaney. Well, surely I agree, Congressman, that the 
PBMs are like other intermediaries in health care. They play an 
important role in containing costs and doing the bargaining. 
But if their size and their market structure is concentrated, 
we face the same problems we face in other industries. And I 
think, particularly in PBMs, there was the controversial 
decision of the FTC to allow the Express Scripts-Medco merger 
years ago----
    Mr. Johnson. Excuse me, sir. Can you pull the mic up? Thank 
you.
    Mr. Greaney. Sure. There was some question about the FTC's 
decision to let that merger go forward. At the time, the FTC 
was comforted by the fact that there would be new entry and 
smaller participants would generate more competition. The FTC 
has done retrospectives of its own decisions, and this might be 
a good time for it to do so, to look back and say how has that 
worked out. To the extent that their prior prediction has 
proven untrue, and I don't know that it has but I have heard 
talk that it has, maybe it would be time for a retrospective to 
see how the market is operating.
    Mr. Collins. Dr. Gottlieb?
    Dr. Gottlieb. I am less concerned, to be honest about it, 
about the vertical integration of PBMs trying to buy 
acquisitions outside their core space than the horizontal 
acquisitions that would increase their market concentration. 
The reality is we have a concentrated market of PBMs, and the 
Express-Medco merger would concern me more than the Omnicare 
acquisition because it is more of a vertical integration. What 
is happening is the PBMs are trying to sort of buy their way 
out of their current market to try to capture more margin from 
other market segments.
    I think that this would all be less concerning if it was 
easier for new PBMs to get started and existing PBMs that are 
small to continue to grow by trying to offer focused services 
and differentiate themselves in the marketplace. Quite frankly, 
I think the health plan consolidation will make it harder for 
smaller PBMs to continue to grow and will potentially give more 
market share to some of the existing large PBMs.
    Mr. Collins. One of the things right there that concerns me 
is there is a PBM market there, and we understand that, but my 
problem is concerning our independent pharmacies and others who 
are outside this who would provide a service in communities in 
the health care chain that are basically, because of many times 
the practices, small or large, are being worked out.
    I wasn't going to do this but, Dr. McAneny, do you all have 
anything to add on that, especially from--because I have heard 
from physicians as well who struggle with their patients to get 
drugs filled in a certain area because of restrictions, 
especially in my area, a rural area.
    Dr. McAneny. I would agree with you as another person from 
a rural area, sir. What we have found in practice is that the 
PBMs add another barrier because of their large consolidated 
structure that makes it hard for us to get patients what we 
want, and it has driven a lot of independent pharmacies out of 
business, and those were the pharmacies where, when somebody 
needs something at midnight, you can get the pharmacist to 
provide the drug. When it is a large consolidated company 
living a thousand miles away, they are not going to open a 
store to get patients something in the middle of the night.
    Mr. Collins. I am glad I am not one of the only ones that 
has actually been ringing this bell.
    This panel is great and our time is limited. Mr. Durham, I 
think we have had a chance to talk about this, how we deal with 
this in isolation. I appreciate you being here and the 
challenges of rural health care in a market in which 
consolidation is really not an aspect because you have a 
dominant player and you have a lot of smaller players due to 
many things. Obamacare, frankly, is one of them. They are 
struggling right now in many markets.
    So again, Chairman, great hearing. I think this is 
something we need to continue. Again, my folks a little bit 
more on that issue in the whole health care chain, along with 
our hospitals, because it has been effective there as well.
    With that, I yield back.
    Mr. Marino. Thank you.
    The Chair now recognizes the congressman from Texas, Mr. 
Ratcliffe.
    Mr. Ratcliffe. Thank you, Mr. Chairman.
    You know, during my time in Congress, already I have had to 
fight to protect the 700,000 Texans that I represent from the 
perversely named Patient Protection and Affordable Care Act 
because, let me assure you, the stories that I get from my 
constituents certainly confirm that the law does not protect 
them and that it is certainly not affordable. Time permitting, 
I could relate to you hundreds and hundreds and hundreds of 
examples like constituents of mine in Paris, Texas, a business 
owner who has seen his monthly cost go up $300 and his 
deductible go up $3,000; or another constituent in Gilmore, 
Texas who has seen his deductible go up over $7,000 this year. 
And now the news is even worse because we are told that the 
cost of insurance plans on healthcare.gov in Texas are expected 
to increase by another 25 percent next year. Does that sound 
affordable to anyone? I don't think so. It certainly doesn't 
seem that way to my constituents because survey after survey 
show that 80 percent of them are opposed to Obamacare and want 
to see me help get rid of it.
    And it is not just individuals. It is hospitals. The impact 
on hospitals in my district has been, frankly, gruesome. I have 
had hospitals in Gilmore and Linden and Mt. Vernon and 
Clarksville close in just the last 2 years alone. How do my 
constituents who live in those rural areas get access to life-
saving care and treatment that they need? How is this improving 
access to my constituents?
    The simple truth is that it is not, that Obamacare has 
reduced access, it has increased the cost of health care, and 
it has lowered the quality of health care in my district. So I 
appreciate, Mr. Chairman, you having this hearing so we can 
learn from these witnesses on how we can keep insurance 
affordable, hospitals accessible, and health care competitive 
under this terrible law.
    So let me turn and start with you, Dr. Gottlieb. Do you 
believe that the heavy regulatory burden under this law is 
driving solo and small group practices out of the health care 
market?
    Dr. Gottlieb. Well, I absolutely do. I think the ACA 
provisions are biased in favor of consolidation of physicians 
into large systems. I think the arbitrage that we talked about 
today between the Medicare billing system, the inpatient-
outpatient billing system is certainly one. But also if you 
look at the payment reforms, they are all structured around the 
idea of doctors practicing in integrated delivery systems, but 
they are biased in favor of a hospital owning that delivery 
system. For example, there is a need for physical 
infrastructure of the IT system. The anti-Stark provisions 
don't apply unless doctors are part of those new arrangements.
    I think there is a way to try to come up with policies that 
give an equal footing to doctors practicing independently but 
still practicing in an integrated way, but not requiring them 
to sell their practices.
    The other thing we need to keep in mind is that the law 
also increases medical practice costs quite substantially at 
the same time that physician reimbursement is being held flat 
under Medicare and probably declining commercially. So doctors 
are seeing their costs go up year over year, and they are 
seeing their revenues stay stagnant or decline. That is also 
forcing them into these arrangements.
    Mr. Ratcliffe. So, Dr. Gottlieb, what impact will this have 
on competition?
    Dr. Gottlieb. My view is--and I practice in a market that 
has a lot of doctors, but I believe in my market competition is 
declining because a handful of health systems are monopolizing 
the local providers.
    I think the bigger question before this Committee is also 
the issue of productivity. In these arrangements, there is no 
good data demonstrating that productivity actually improves 
among providers inside these arrangements and that medical 
practice itself benefits from scale. There are a lot of studies 
demonstrating the opposite. I am sure you could find one or two 
studies that demonstrate the counterpoint, but there is a body 
of literature now showing that productivity goes down, and that 
should worry us.
    Mr. Ratcliffe. Thank you, Dr. Gottlieb.
    Mr. Durham, can you comment on Obamacare's impact on access 
to mental health services and what is the insurance industry 
doing about it?
    Mr. Durham. Certainly, Congressman, I would be happy to 
talk about that. Our industry has long supported the Mental 
Health Parity Act, and health plans have been committed to 
implementing parity requirements to ensure that patients have 
access to high-quality, evidence-based treatments and care at 
affordable prices.
    Now, there is strong enforcement of parity laws, and health 
plan benefit and coverage options related to mental health 
services must be approved by state and Federal regulators. 
Health plan coverage decisions for mental health and substance 
abuse follow evidence-based guidelines and recommendations from 
leading medical and behavioral health specialists, and our 
plans are reviewing new evidence every day to make sure 
patients have access to safe and effective treatments.
    There is still more work to be done here to address the 
wide variation in clinical practice and the cost of health care 
that pose serious barriers to patient access. We are committed 
to improving the value of care for all patients, particularly 
those that are suffering from mental problems.
    Mr. Ratcliffe. Thank you, Mr. Durham.
    I see my time has expired. Mr. Chairman, I will yield back.
    Mr. Marino. Thank you.
    Seeing no other Members to ask questions, this concludes 
today's hearing.
    I want to thank all the witnesses for attending and for 
being present. You all contributed to answering questions that 
are important to us. Without objection, all Members will have 5 
legislative days to submit additional written questions for the 
witnesses or additional materials for the record.
    This hearing is adjourned.
    [Whereupon, at 11:29 a.m., the Subcommittee was adjourned.]
    
    

                            A P P E N D I X

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               Material Submitted for the Hearing Record

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 Response to Questions for the Record from Daniel T. Durham, Executive 
Vice President, Strategic Initiatives, America's Health Insurance Plans

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      Question for the Record submitted to Scott Gottlieb, M.D., 
             Resident Fellow, American Enterprise Institute
 

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    Response to Question for the Record from Scott Gottlieb, M.D., 
             Resident Fellow, American Enterprise Institute