    [House Hearing, 115 Congress]
    [From the U.S. Government Publishing Office]

             FRAUD, WASTE, AND ABUSE UNDER THE AFFORDABLE CARE ACT

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

                                    HEARING

                                   BEFORE THE

                          SUBCOMMITTEE ON HEALTH CARE,
                       BENEFITS AND ADMINISTRATIVE RULES

                                     OF THE

                             COMMITTEE ON OVERSIGHT
                             AND GOVERNMENT REFORM
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                JANUARY 31, 2017

                                   __________

                                Serial No. 115-9

                                   __________

    Printed for the use of the Committee on Oversight and Government Reform

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                  Committee on Oversight and Government Reform

                         Jason Chaffetz, Utah, Chairman
    John J. Duncan, Jr., Tennessee       Elijah E. Cummings, Maryland,
    Darrell E. Issa, California              Ranking Minority Member
    Jim Jordan, Ohio                     Carolyn B. Maloney, New York
    Mark Sanford, South Carolina         Eleanor Holmes Norton, District of
    Justin Amash, Michigan                   Columbia
    Paul A. Gosar, Arizona               Wm. Lacy Clay, Missouri
    Scott DesJarlais, Tennessee          Stephen F. Lynch, Massachusetts
    Trey Gowdy, South Carolina           Jim Cooper, Tennessee
    Blake Farenthold, Texas              Gerald E. Connolly, Virginia
    Virginia Foxx, North Carolina        Robin L. Kelly, Illinois
    Thomas Massie, Kentucky              Brenda L. Lawrence, Michigan
    Mark Meadows, North Carolina         Bonnie Watson Coleman, New Jersey
    Ron DeSantis, Florida                Stacey E. Plaskett, Virgin Islands
    Dennis A. Ross, Florida              Val Butler Demings, Florida
    Mark Walker, North Carolina          Raja Krishnamoorthi, Illinois
    Rod Blum, Iowa                       Jamie Raskin, Maryland
    Jody B. Hice, Georgia                Vacant
    Steve Russell, Oklahoma              Vacant
    Glenn Grothman, Wisconsin            Vacant
    Will Hurd, Texas                     Vacant
    Gary J. Palmer, Alabama
    James Comer, Kentucky
    Paul Mitchell, Michigan

                       Jonathan Skladany, Staff Director
                        William McKenna, General Counsel
    Sean Hayes, Health Care, Benefits and Administrative Rules Subcommittee
                                 Staff Director
                            Natalie Turner, Counsel
                        Sharon Casey, Deputy Chief Clerk
                     David Rapallo, Minority Staff Director

                                    ------

         Subcommittee on Health Care, Benefits and Administrative Rules

                           Jim Jordan, Ohio, Chairman
    Mark Walker, North Carolina, Vice    Raja Krishnamoorthi, Illinois
        Chair                                Ranking Member
    Darrell Issa, California             Jim Cooper, Tennessee
    Mark Sanford, South Carolina         Vacant
    Scott DesJarlais, Tennessee          Vacant
    Mark Meadows, North Carolina         Vacant
    Glenn Grothman, Wisconsin            Vacant
    Paul Mitchell, Michigan
                                C O N T E N T S

                                  ----------
                                                                       Page
    Hearing held on January 31, 2017.................................     1

                                   WITNESSES

    Ms. Vicki Robinson, Senior Counselor for Policy, Office of
      Inspector General, U.S. Department of Health and Human Services
        Oral Statement...............................................     5
        Written Statement............................................     7
    Mr. John Dicken, Director, Health Care, U.S. Government
      Accountability Office
        Oral Statement...............................................    14
        Written Statement............................................    16
    Mr. Jonathan W. Siegel, Citizen, Rochester, New York
        Oral Statement...............................................    29
        Written Statement............................................    31

             FRAUD, WASTE, AND ABUSE UNDER THE AFFORDABLE CARE ACT

                                  ----------

                           Tuesday, January 31, 2017

                      House of Representatives,
             Subcommittee on Health Care, Benefits and
                                   Administrative Rules
                  Committee on Oversight and Government Reform,
                                                       Washington, D.C.
        The subcommittee met, pursuant to call, at 2:00 p.m., in
    Room 2247, Rayburn House Office Building, Hon. Jim Jordan
    [chairman of the subcommittee] presiding.
        Present: Representatives Jordan, Walker, Issa, Meadows,
    Grothman, Mitchell, Krishnamoorthi, Lawrence, and Norton.
        Also Present: Representative Cummings.
        Mr. Jordan. The Subcommittee on Health Care, Benefits, and
    Administrative Rules will come to order.
        Without objection, the chair is authorized to declare a
    recess at any time.
        It is my understanding that the Democrat Caucus has not
    designated who all the members are. We know the ranking member,
    and we're pleased to have Mr. K here and Ms. Lawrence as well,
    but I understand we don't know for sure who all is on this
    committee. So we need to do a unanimous consent that all
    members of the Committee on Oversight and Government Reform be
    allowed to fully participate in today's subcommittee hearing.
        Without objection, so ordered.
        Welcome to the new Congress.
        And, Mr. Krishnamoorthi----
        Mr. Krishnamoorthi. Yes, sir.
        Mr. Jordan. --we appreciate you being here and being the
    ranking member. And if you'd like to--we have Mr. Mitchell, and
    I know a number of other new members to the Oversight Committee
    will be joining us from potentially the Democrat side as well.
    So we want to welcome Mr. Mitchell to the committee this
    afternoon.
        Let's start with opening statements and then get right to
    our witnesses. And we appreciate our witnesses being here
    today, talking about this important subject.
        Health insurance premiums are soaring. President Obama and
    the administration promised multiple times that the Affordable
    Care Act would lower health insurance premiums by $2,500.
    American families are still waiting to see those reductions.
    Instead, the health insurance premiums have skyrocketed under
    the Affordable Care Act. There has been about a 25-percent
    average increase in premiums just this year. Some Americans
    have experienced even higher premium increases and had to drop
    coverage because it became just too darn expensive.
        Under the Affordable Care Act, there are not just rising
    premiums; many Americans have also seen massive increases in
    the cost of their deductible. Healthcare costs are one of the
    top concerns for families, and even people with insurance
    oftentimes can't afford to use it, especially individuals
    enrolled in high-deductible health plans under the ACA.
        There were promises from the administration about increased
    competition. In fact, though, in most parts of the country,
    there are only one or two insurers participating in the health
    insurance exchange in 2017. Insurers are seeing unprecedented
    losses on the exchanges. Losses on the exchanges are reaching
    into the billions of dollars for the health insurance industry.
    As a result, several large insurers are pulling out of the
    exchanges.
        According to the Heritage Foundation, before the ACA was
    implemented, there were 12 insurers participating in the
    individual market in North Carolina. Today, only two insurers
    are participating in the exchanges in that State. In many areas
    of North Carolina, there is only one insurer selling coverage
    on the exchange.
        And, finally, of course, we cannot forget the Affordable
    Care Act was sold on one of the biggest political misleading
    statements of all time: If you like your plan, you can keep it;
    if you like your doctor, you can keep your doctor. Even the
    President had to apologize for that one.
        As we examine healthcare reform proposals, it is important
    to keep these realities in mind. While millions of individuals
    receive health coverage under the Affordable Care Act, many
    more are being harmed by the skyrocketing healthcare costs.
        Today, I want to hear from the Health and Human Services
    Inspector General and the GAO on implementation of the
    Affordable Care Act and their recent and ongoing work in this
    area. Both of these agencies have done excellent work reviewing
    the Affordable Care Act programs and activities, and I want to
    hear their recommendations on how we can use lessons learned
    from the implementation of some of these programs to improve
    future programs.
        The work of HHS OIG is critical to ensuring the integrity
    of Heath and Human Services programs, and I am constantly
    impressed with the great work that comes out of their office. I
    look forward to hearing about the OIG's work relating to the
    Affordable Care Act.
        Thank you, Mrs. Robinson, for testifying on behalf of OIG's
    office today.
        The General Accountability Office has also done great work
    examining the early impact of the Affordable Care Act on
    private health insurance markets, and I look forward to
    learning more about their findings.
        So thank you, Mr. Dicken, for testifying on behalf of GAO
    today.
        And we are also pleased to have Mr. Jonathan Siegel here
    with us today to hear about his experiences under the ACA.
        Thank you again for your willingness to be here and to
    testify.
        I look forward to the discussion today. Congress needs to
    find a way to help make sure Americans have access to
    affordable health insurance and can choose among a variety of
    plans.
        With that, I would now yield to our ranking member for his
    opening statement, and then we'll get right to our witnesses
    and our hearing.
        The gentleman from Illinois is recognized.
        Mr. Krishnamoorthi. Thank you, Mr. Chairman.
        And thank you to our witnesses for joining us today.
        Millions of people now have high-quality, affordable health
    care as a result of the Affordable Care Act. One of my
    constituents wrote this to me, and I quote: ``We are so
    grateful for the changes brought about the ACA in our
    situation. They have truly been life-changing for us. For the
    first time, our family has access to dental coverage. This
    means we actually go to the dentist. Before, this was a rare
    thing and only when in pain. For the first time, our
    preventative care is covered. This means my children are up to
    date on their vaccines and physicals because it is not costing
    me hundreds of dollars out of pocket. For the first time, we
    have hope that we may be able to dig out of the mountain of
    medical debt we have accumulated through a $10,000-a-year
    deductible plan that we were locked into because of preexisting
    conditions because we now can get reasonable coverage through
    the marketplace.''
        Mr. Chairman, there are millions of people with similar
    stories all across the country, and all of our offices are
    being flooded by correspondence relating the same.
        In addition, as a former small-businessman, I know that the
    ACA has allowed entrepreneurs to flourish because they don't
    have to worry that starting a new business means they can't
    afford health care. When people have high-quality, affordable
    health care, they can afford to follow their dreams, their
    talents, become entrepreneurs like myself, start businesses,
    create jobs, and grow the economy. When they are fearful about
    losing their health insurance or are buried under medical debt,
    none of those things are possible.
        The Affordable Care Act empowered millions of people. One
    of them is a witness today, Mr. Jonathan Siegel.
        And thank you, sir, for joining us.
        He will testify that the guarantee of affordable coverage
    under the ACA enabled him to start a new business.
        But there is a lot of fear in the country that those gains
    will be taken away by House Republicans if and when they repeal
    the Affordable Care Act. In fact, today, House Republicans have
    not offered an alternative to replace the ACA that offers the
    same coverage at a similar or lower cost. Let me repeat that:
    Today, House Republicans have not offered an alternative to
    replace the ACA that offers the same coverage at a similar or
    lower cost.
        The consequences will be seriously harmful to Americans.
    First, a recent CBO and Joint Committee on Taxation analysis
    estimates that 18 million Americans would lose their health
    insurance in just the first year following a repeal without
    replacement. Second, the CBO and Joint Committee on Taxation
    estimates that premiums would increase by 20 to 25 percent more
    than currently projected in the first plan year following
    repeal.
        These consequences are not limited to those who bought
    their health care on exchanges. ACA protections apply to all
    health plans, including those that many Americans get through
    their employer. Employer-provided insurance plans would no
    longer be required to offer the same level of care that they do
    today. Employees with preexisting conditions would have
    restrictions placed on their care. The lifetime cap on out-of-
    pocket expenses would disappear. And we'd return to the days
    when parents could no longer have young-adult children under 26
    on their plans. Removing these protections will hurt
    businesses, workers, and families in my district and across the
    country.
        Third and finally, the economic consequences of repeal
    without replace would be catastrophic. My home State of
    Illinois stands to lose over 100,0000 jobs and $13 billion in
    gross State output. My district alone would lose 4,000 jobs.
    Ohio, your home State, sir, could lose up to 126,000 jobs.
        Repealing without replacing is foolhardy and reckless. What
    House Republicans have proposed so far inspires little trust
    that their plans will actually help Americans. We will not sit
    idly by while the ACA is torn down without any replacement. We
    need a replacement that offers coverage at similar or lower
    costs.
        I yield the balance of my time.
        Mr. Jordan. I thank the gentleman.
        We have three goals, I think, for today's hearing. One, we
    want to review the impact of the ACA on the health insurance
    market, including its impact on affordability, quality, choice,
    and access. Two, we want to understand the Federal Government's
    implementation of the ACA and how taxpayer dollars were spent,
    if there was any waste, any fraud, any abuse in those areas.
    And, three, as I think the ranking member was getting to in his
    comments, we have a big debate going on here in Congress, and
    we want to gather as much information as we can as we are
    debating the repeal, something I think should happen, of the
    Affordable Care Act. So those are our three goals.
        We'll hold the record open for 5 legislative days for any
    members who would like to submit a written statement.
        And I want to recognize Mr. Grothman for being here. It's
    the first time he's been a part of this subcommittee.
        And I recognize, if he would like a short opening
    statement, our new vice chair, Mr. Walker from North Carolina.
        Mr. Walker. Jim, I thank you for your work as the chairman
    and hope that we are able to really fulfill our promises to the
    American people in getting to the bottom of some of the issues
    and concerns that we have with the ACA as a whole.
        I've been privileged to work with you the last couple
    years. I know your heart is to work with all communities, and
    you have a record of that. And we look forward to seeing what
    we can get done. Thanks. I'm privileged to be part of it.
        Mr. Jordan. Thank you.
        Ms. Vicki Robinson, Senior Counselor for Policy for the
    Office of the Inspector General at the U.S. Department of
    Health and Human Services, is with us today, as well as Mr.
    John Dicken, Director of Health Care at the United States
    Government Accountability Office, and Mr. Jonathan Siegel from
    Rochester, New York.
        Welcome to you all.
        Pursuant to committee rules, all witnesses will be sworn in
    before they testify, so please rise and raise your right hands,
    if you would, please.
        Do you solemnly swear or affirm that the testimony you're
    about to give will be the truth, the whole truth, and nothing
    but the truth, so help you God?
        Let the record show that each witness answered in the
    affirmative.
        You guys are way ahead of me. You've done this before.
    You're already seated. So let's start with our first witness.
        Ms. Robinson, you get to go first. And you know how it
    works. You get 5 minutes, give or take a few seconds, and then
    we'll go to the next one.

                           WITNESS STATEMENTS

                      STATEMENT OF VICKI ROBINSON

        Ms. Robinson. Well, good afternoon, Chairman Jordan,
    Ranking Member Krishnamoorthi, and other distinguished members
    of the subcommittee. Thank you for the opportunity to discuss
    our work overseeing the Federal and State health insurance
    marketplaces established under the Affordable Care Act.
        We are committed to combating fraud, waste, and abuse and
    promoting integrity, efficiency, and effectiveness in the
    programs run by the Department of Health and Human Services.
    Our work looks retrospectively to determine whether programs
    have worked as they should and prospectively to identify
    weaknesses to avoid and best practices to replicate in the
    future.
        To oversee the marketplaces, we examined core program
    integrity questions: Are taxpayer funds being expended
    correctly for their intended uses? Are the right people getting
    the right benefits? Is the Department managing and
    administering the programs effectively and efficiently?
        We identified three types of vulnerabilities: one, the need
    for tighter payment controls to prevent wasteful spending; two,
    the need for more reliable processes to ensure accurate
    eligibility determinations for applicants; and, three, the need
    for improved management.
        Our findings and recommendations are detailed in my written
    testimony and in our reports. Let me offer some examples,
    starting with our payment accuracy work.
        CMS was hampered in its administration of the Advanced
    Premium Tax Credit that provides subsidies to help consumers
    afford insurance. At the start of the program, CMS used a
    manual financial process that did not collect data on enrollee-
    by-enrollee policy-level payments. Rather, CMS collected only
    aggregated payment data from insurers. As a result, we found
    that CMS was not able to verify the accuracy of the payments to
    insurers, nor that enrollees benefiting from these payments had
    paid their portion of the premium as required.
        We also found deficiencies in the administration of the
    establishment grant program that provided Federal funding to
    States to set up marketplaces. Most States we examined failed
    to allocate costs properly between their establishment grant
    funding and funding for other programs that shared systems with
    the marketplaces, such as Medicaid. This resulted in States
    over-claiming Federal establishment grant funding.
        Further, we found vulnerabilities in eligibility
    verification processes at both the Federal and State
    marketplaces. For example, we found that the marketplaces did
    not always properly verify Social Security numbers,
    citizenship, and household income.
        Finally, we identified weaknesses in management of the
    Federal marketplace, including poor oversight of the many
    contractors engaged to build it. For example, CMS waited far
    too long to hire a systems integrator to coordinate the work of
    the contractors.
        We examined CMS's management of the Federal marketplace
    across a 5-year period. We identified many missteps that
    contributed to the poor launch of the healthcare.gov website.
    We also identified better management practices that contributed
    to its subsequent improvement. These included, for example,
    assigning clear project leadership and fully integrating
    technical and policy staff. Our work offers important lessons
    to inform the management of complex policy and technology
    projects now and in the future.
        To close, protecting taxpayer investments and consumers
    requires vigilance and sustained focus. Program integrity
    should remain a priority for the design and operation of
    current and future programs. Preventing, detecting, and
    remediating problems is our collective mission.
        Thank you again for inviting me to appear today, and I look
    forward to answering your questions.
        [Prepared statement of Ms. Robinson follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Jordan. Thank you, Ms. Robinson.
        Mr. Dicken, you're recognized for 5 minutes.

                        STATEMENT OF JOHN DICKEN

        Mr. Dicken. Thank you.
        Chairman Jordan, Ranking Member Krishnamoorthi, and members
    of the subcommittee, I'm pleased to be here today as the
    subcommittee discusses the Patient Protection and Affordable
    Care Act.
        Ms. Robinson highlighted some of the Inspector General's
    findings related to program integrity. My comments focus on the
    Affordable Care Act in relation to health insurance markets,
    highlighting findings from recent GAO reports on insurer
    availability, variation in premiums, and enrollee satisfaction.
        The Affordable Care Act contained provisions that affect
    how issuers determine health insurance coverage and premiums
    and how they market their plans. Many of these provisions took
    effect in 2014.
        For example, the act prohibits issuers from denying
    coverage or varying premiums based on health status or gender.
    The law also requires health plans be marketed based on metal
    tiers--bronze, silver, gold, and platinum--to help consumers
    compare the relative value of each plan.
        It also required the establishment of health insurance
    exchanges in each State through which consumers select from
    among participating health plans. About 11 million individuals
    purchased health plans through the exchanges in 2016.
        Given the act's reliance on the participation of private
    health plans, the law required GAO to report on competition and
    concentration in health insurance markets. In a 2016 report, we
    found out health insurance markets were concentrated among a
    small number of issuers in most States from 2010 through 2014,
    where the three largest issuers had at least 80 percent of
    enrollment. In 2014, enrollment in exchange plans during their
    first year was generally more concentrated among a few issuers
    than was true for the overall markets.
        GAO has also reported on consumers' access to health plans
    offered through the exchanges. In 38 States for which GAO had
    sufficiently reliable data, we found most consumers had six or
    more bronze-, silver-, and gold-tier plans available through
    the exchanges in 2014 and 2015. For example, 94 percent of
    counties had at least six silver-tier plans available in 2015.
        Since GAO issued the report, HHS has reported a decline in
    the number of issuers participating in the federally
    facilitated exchanges in 2017. According to HHS, all consumers
    continue to have multiple plan options, but for about 21
    percent of them the options were limited to plans offered by a
    single issuer.
        GAO also reported on the considerable variation in health
    insurance premiums available to consumers in 2014 and 2015.
    First example, in Arizona in 2015, the lowest-cost silver plan
    for a 30-year-old consumer was $147 per month, but in Maine the
    lowest-cost silver plan for a 30-year-old was $237 per month.
        The range of premiums also varied considerably by State.
    While the lowest-cost silver plan for a 30-year-old in Arizona
    was $147 per month, the highest-cost silver plan in 2015 was
    $545 per month, a difference of 270 percent. In contrast, in
    Rhode Island, 2015 premiums for silver plans available to a 30-
    year-old range from $217 to $285 per month, a difference of
    just 32 percent.
        More recent analyses by HHS found that premiums for
    exchange plans increased more in 2017 than in earlier years, an
    average of 25 percent from 2016 to 2017 for the second-lowest-
    cost silver plans in States that use the federally facilitated
    exchange. In comparison, average premiums for these plans
    increased 2 percent from 2014 to 2015 and 7 percent from 2015
    to 2016.
        Finally, let me close with key findings from a 2016 GAO
    report on enrollees' experiences in health plans offered
    through the exchanges.
        Most exchange enrollees report being satisfied overall with
    their plans in 2014 through 2016, according to three national
    surveys. This report satisfaction was either somewhat lower
    than or similar to that of enrollees in employer-sponsored
    plans.
        While most enrollees expressed overall satisfaction,
    concerns about enrollees' experiences with exchanges plans were
    revealed in other information GAO collected from stakeholders
    and literature. Often, these were consistent with longstanding
    consumers' concerns about private health insurance generally,
    such as affordability of out-of-pocket expenses and
    difficulties understanding coverage terminology.
        Mr. Chairman, this concludes my statement. I would be glad
    to answer any question to you or the members of the
    subcommittee may have.
        [Prepared statement of Mr. Dicken follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Jordan. Thank you, Mr. Dicken.
        Mr. Siegel, you're recognized.

                    STATEMENT OF JONATHAN W. SIEGEL

        Mr. Siegel. Thank you, Mr. Chairman, Mr. Ranking Member,
    members of the committee. It is a pleasure to be with you
    today. I come as a husband, a father, and an independent
    businessman, but, most of all, I come as a citizen of our
    beloved country.
        Here is my story. In 2012, I was laid off. I was 56, with
    one child still in high school and the other just having
    graduated. I was lucky. I got a severance that provided the
    resources for me to continue my insurance through COBRA for the
    rest of 2012 and 2013.
        A friend invited me to be a founding partner of a new
    market research agency. Most importantly, by the time we
    started the firm, the effective launch of the ACA was only a
    year away. Because of the ACA, I could start this business
    knowing that my family would continue to get affordable
    insurance no matter how the business did. Without the ACA, I
    would not have had the courage to launch my own business but
    would have sought the sanctuary of traditional employment.
        We have purchased our insurance without subsidy, a gold
    plan, on the exchanges since the ACA began. Our premium is
    about $1,360 a month, plus an additional $60 a month for dental
    insurance--$600 less a month than our COBRA plan was.
        Because New York State took the Medicaid expansion, I know
    that, no matter what happens to me, my family will get
    affordable health care. Affordability is a big issue for us. My
    spouse of 30 years has MS. She is the bravest person I know,
    taking her shots for over 20 years. The cost of her medications
    is over $30,000 a year at free-market prices. Yes, we do
    participate in a manufacturer's program that gives some people
    access to their meds without charge, but we don't know when it
    will end. Even so, there is the cost of ongoing doctor visits,
    MRIs, and other tests.
        The ACA and the Medicaid expansion also protect my
    children, now 21 and 23. They are working at jobs that do not
    provide health insurance. We make sure they have it today. It
    is a great comfort to an aging parent to know that the ACA
    assures that they can continue to have affordable coverage when
    they turn 26 no matter their employment situation.
        In all of these ways, the ACA enhances my security, reduces
    anxiety, and furthers freedom, not just for me but for all
    Americans who at any time may find that employer-based
    insurance just doesn't work or isn't available to them.
        The possible replacement of the ACA with insurance options
    that are unwise, inadequate, and discriminatory threatens us.
    We may not receive subsidies, but we are not making much more
    than the cutoff point for subsidies. About 20 to 25 percent of
    our income today goes for medical and dental insurance and
    health care. I don't know what that percentage will be when
    purchase becomes voluntary and insurance can pedal anything
    they want, skimming away those lucky enough to be perfectly
    healthy.
        What happens if, without the ACA, the cost of adequate
    insurance goes up to $3,000 or more a month? How can anyone
    afford that for years on end? My spouse is, after all, only 57
    years old. What happens if no one will insure her at any price?
        Some people say that high-risk pools are a solution. I've
    got to tell you, there are few words more frightening to me
    than those. The term is a misstatement. My spouse is not a high
    risk. It is the healthy who are high risk, because we do not
    know what illness will strike us or when. So these pools are
    really pools of high-cost citizens. That is a real complaint
    some people have about my spouse: She has the nerve to need
    expensive care to treat an illness.
        Once it is clear that it is the cost, not the risk, that is
    a problem, it is obvious why so many of us fear high-risk
    pools. To work for the patient, you have to have clear rules
    for who gets put in them, you have to assure that they don't
    pay for more insurance than others would pay, and you need to
    assure that they get all the care they need.
        I have yet to see a proposal that provides these
    protections. Instead, we have vague promises of Federal and
    State support. Without these protection, high-risk pools are
    not insurance or health care; they are just vicious cruelty to
    ordinary Americans who've worked hard, played by the rules, but
    have had a little bad luck.
        A better name for high-risk pools without these protections
    is death pools. The goal of their advocates, in my view, is to
    shunt off to one side the folks who cost too much, whose fate
    is too hard, and let them die out of sight and out of mind. My
    spouse is not someone to shunt off, to cast away. She is a
    human being who has as much right to quality health insurance
    and care at a price she can afford as any of us.
        I am also frightened by some proposed changes to Medicaid.
    The object of these proposals seems to be to reduce it by
    cutting what it covers or tightening eligibility. Paint it as
    you will, but the real goal seems to be punishing low-income
    people for the sin of being low-income. There is a good chance
    that will include my children. My children and all people with
    low income do not deserve this. They are children of God, just
    like the rest of us.
        In closing, the story of the ACA is not just my story or
    the stories of millions of other people. It is first and
    foremost a story about democracy. Democracy is not just a set
    of rules about who gets power and under what conditions;
    democracy is also about assuring equal dignity to all citizens.
        The argument over health care and health insurance is thus
    the latest battle in the unending struggle that Lincoln
    described many years ago, the struggle that to me defines the
    United States and the highest purpose of citizenship, the
    struggle to assure that government of the people, by the
    people, and for the people shall not perish from the Earth.
        Thank you.
        [Prepared statement of Mr. Siegel follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
        Mr. Jordan. I thank you, Mr. Siegel.
        Real quick before we recognize the gentleman from North
    Carolina, I just wanted for clarification, because I wasn't
    sure I understood, you currently don't have a plan that is--
    you're not receiving a subsidy from the government in the form
    of a refundable tax credit or anything else under your----
        Mr. Siegel. No. That's correct. No subsidy.
        Mr. Jordan. So you're paying for your insurance on your
    own.
        Mr. Siegel. Entirely. Have since day one.
        Mr. Jordan. Okay. I just wanted to make that clear.
        I want to welcome the ranking remember of the full
    committee, Mr. Cummings, and would now recognize the gentleman
    from North Carolina.
        Mr. Walker. Thank you, Mr. Chairman.
        Mr. Siegel, thank you for the courage you expressed today
    in sharing your story. I'm obviously impressed with how much
    you love your wife as well. You can tell she means a lot to
    you. Mine does as well, a nurse practitioner. We've been
    married 24 years.
        Most of my career I've spent as a minister, a pastor. I
    worked in the refugee camps in Europe, visited many people.
    I've seen destitute and despair, health, the funerals, you name
    it, have been across the board.
        I'm also concerned about the millions of people who have
    been damaged, even unintentional, by the Affordable Care Act.
    In fact, if you want to get down to raw numbers, we have 11
    percent of North Carolinians who still don't have any insurance
    of any kind.
        So I don't want to get into all the bits and pieces of the
    numbers, but, according to your most neutral polling, 25
    percent of the population have been damaged by either higher
    premiums, lost insurance, or something along when it comes to
    dealing with ObamaCare or the Affordable Care Act.
        In fact, even moving it from the individual aspect and even
    getting it to the business, it was President Clinton and the
    Minnesota Governor who recently talked about the damage the ACA
    has caused for small businesses. According to a Gallup poll not
    too long ago, 70-something percent believed it should be
    altered, overhauled, or completely repealed.
        So where I want to dial down my questions today, after
    giving a little bit of a preface there, is specifically I would
    like to talk to Mr. Dicken about some questions that we have on
    some broken promises when it comes to the Treasury.
        Under ObamaCare's reinsurance program, section 1341
    directed the HHS to collect--let me make sure we get this
    number correctly--$5 billion and send it directly to the United
    States Treasury to pay for ObamaCare's cost. HHS sent the money
    to insurance companies instead and disregarded the Treasury and
    the American people. As of 2015, HHS denied the Treasury and
    taxpayers now up to $3.5 billion that they were owed.
        So I really don't have a lot of questions, but just one
    major one here would be this, if you would answer it. Since
    September of last year, GAO issued a ruling concerning HHS's
    actions. What did GAO determine with this report?
        Mr. Dicken. Thank you, Congressman Walker.
        And you're correct that last year GAO did issue a legal
    opinion looking at the payments under the program. As you
    indicated, the Affordable Care Act indicated that both the
    payments that were collected were to be provided some to the
    general Treasury, some in reinsurance payments to the payers.
        In fact, the collections were less than the amount that HHS
    had fully intended to include in the reinsurance and paid all
    of that to the insurers instead. GAO's legal opinion indicated
    that, in fact, those payments should have also been to the
    general Treasury.
        Mr. Walker. Obviously, this is a pattern for the last 3
    years. Can you share what the reasoning was, as far as
    disregarding the Treasury, which, as we know, is basically
    taxpayers' money? Why was it disregarded? Can you brief us on
    that?
        Mr. Dicken. Yeah, I would defer to--you know, I think,
    certainly, HHS's attorneys would be able to speak to the legal
    reasoning there, but that, in general, because the collections
    were less than the amount that are authorized, that was the
    priority that HHS made in giving the reinsurance to the
    insurers first without payments to the Treasury.
        Mr. Walker. Do you still--well, let me ask you this. Do you
    have any idea how much is still owed to the U.S. Treasury that
    the previous administration refused or denied to pay?
        Mr. Dicken. I don't have that at my fingertips but
    certainly can follow up.
        Mr. Walker. Do you have any kind of ballpark? Is it in the
    billions of dollars?
        Mr. Dicken. I think it indicated that the requirement was
    for several billion, Treasury. Some of those payments could
    still be made, because those collections for 2016 would
    actually be made in 2017. And so some of that is still being
    reconciled.
        Mr. Walker. Thank you, Mr. Dicken.
        Mr. Chairman, I yield back.
        Mr. Jordan. I thank the gentleman and would now recognize
    the ranking member from Illinois for his 5 minutes.
        Mr. Krishnamoorthi. Thank you, sir. I would like to yield
    to the ranking member of the general committee to make a few
    comments, please.
        Mr. Cummings. Thank you very much.
        I want to thank you, Mr. Chairman.
        And I want to take an opportunity to officially welcome
    Congressman Krishnamoorthi to his first Oversight Committee
    hearing. We're very fortunate to have him on our committee. He
    brings a valuable perspective as a small-businessman and
    entrepreneur and as a lawyer and a public servant.
        We also are fortunate that he has accepted the
    responsibility of serving as the ranking member on this very,
    very important Health Subcommittee. This subcommittee takes up
    some of the most important issues that come before our
    committee, not the least of which is the Affordable Care Act.
        Recent polls have shown that the number-one issue, even
    beyond this, by the way, is another subject that he, I'm sure,
    will touch on at some point, and that is the cost of
    prescription drugs. That is the number-one issue with regard to
    independents, Democrats, and Republicans.
        And in recent hearings we've had testimony about how, Mr.
    Chairman and Ranking Member, about how the cost of prescription
    drugs, these folks who are improperly and because of greed
    raising the prices of these drugs, that, too, is going into the
    cost of health care, and very significant.
        And so we are truly at a crossroads with regard to the ACA.
    Congressional Republicans are moving forward to repeal this law
    without having an adequate replacement. As a matter of fact,
    they had a deadline, I think, of yesterday or today. They
    didn't meet the deadline. If they do this, it will be nothing
    short of disastrous for tens of millions of Americans who have
    gained coverage thanks to the ACA.
        It will also be disastrous for Americans with employer-
    provided insurance who have benefited from the ACA's many
    consumer protections. People with employer-provided insurance
    no longer have caps on the annual and lifetime coverage
    benefits. They now have free preventive care like cholesterol
    screenings and mammograms. And there is no price that you can
    pay or put on prevention, no price that you can put on
    wellness. And so they cannot be treated any differently by
    their insurance company because of a preexisting condition.
        Repealing the ACA would also have disastrous effects on our
    economy. Repeal would completely destabilize the insurance
    market, drive premiums up, and cost millions of jobs across our
    entire country. This is not what the American people want, and
    it is certainly not what they need.
        All types of statistics have been cited with regard to
    people who want to repeal, but a lot of times when people--you
    need to dig into those numbers a little bit and discover that
    there are a whole group of people that want to expand the
    Affordable Care Act.
        And so we've got a situation here where we have to keep in
    mind that health care should not be a privilege, it must be a
    right. When you have an unhealthy society, you have a society
    that cannot be all that God meant for it to be.
        And so I am excited about our new ranking member. I know
    that he will bring much to this discussion. He is here for a
    reason, and that is to make a difference.
        I would only say this. Mr. Ranking Member, you weren't here
    when we voted for the Affordable Care Act, but I've told my
    constituents many times that in my 14 years as a member of the
    Maryland legislature and my 21 years as a Member of this
    legislature there is nothing that I have done that has been
    more important than pulling that lever for the Affordable Care
    Act. Because I have absolutely, unequivocally no doubt that we
    have saved lives and we will continue to save lives. We can
    repair--there are things that probably need to be done, but we
    must make sure that the American people are healthy.
        And, with that, I would thank the ranking member for
    yielding, and I yield back.
        Mr. Jordan. I thank the gentleman.
        The ranking member is recognized.
        Mr. Krishnamoorthi. Thank you, Mr. Ranking Member. I agree
    with your comments that it appears to me that we should mend
    the ACA, not end it--mend, don't end it.
        I have a couple questions. Thank you so much to the
    witnesses for coming today. I was heartened to learned from Mr.
    Dicken that the people on the ACA were about as satisfied, in
    terms of their satisfaction levels, as compared to those in
    employer plans.
        Is that generally correct?
        Mr. Dicken. Yeah. The surveys we saw, there were generally
    satisfaction levels in the 70 or 80 percent overall
    satisfaction, which was similar to or somewhat lower than for
    employer-sponsored plans.
        Mr. Krishnamoorthi. Right. And I would surmise that their
    satisfaction levels would go down if they had no health
    coverage, if there was a repeal without replacement, correct?
        Mr. Dicken. This was satisfaction with their health plan,
    so I can't speak to what satisfaction would be without the
    health plan.
        Mr. Krishnamoorthi. Sure.
        And, Ms. Robinson, thank you so much for your testimony and
    investigating the issues related to the ACA.
        I presume that you didn't look at waste, fraud, and abuse
    before the ACA was instituted, right?
        Ms. Robinson. Thank you for that question.
        We've done a lot of work looking at fraud, waste, and abuse
    in the Medicare and Medicaid and other HHS programs before the
    Affordable Care Act. But our jurisdiction is to look at
    programs of the Department, so if you're asking whether we
    looked at, sort of, private insurance before the Affordable
    Care Act, we did not.
        Mr. Krishnamoorthi. Right.
        Now, Mr. Siegel, I want to sincerely thank you for
    appearing before the subcommittee today. I know you run a small
    business and are taking valuable time out of your small
    business to be here today. As a small-businessman, I know that
    that is a big sacrifice on your part.
        I want to ask a few questions about your experience with
    the ACA. You testified that after you were laid off in 2012 you
    wouldn't have had the ability to start your own business had it
    not been for the ACA. Can you explain why that is?
        Mr. Siegel. I wouldn't have had the courage. And the reason
    I wouldn't have had the courage is because the prospect of not
    having insurance, especially for my wife, is frightening.
        You can spend tens of thousands of dollars a year on
    medication for MS, even if you don't have a problem with
    relapses and other problems, which we have been spared. And she
    was 53. She was 52 or 53, whatever it was. So that is at least
    12 years till Medicare. I can't screw around with that. I can't
    take a chance. She has to have insurance.
        And the private market in New York before the ACA, as I
    said, was incredibly expensive. It's cheaper under the ACA than
    it was before. That's not true of every State, but it's true of
    New York.
        Mr. Krishnamoorthi. You know, as a small-businessman
    myself, I understand the risks of going out on your own. We
    want more people to do what you did. We want people to go out
    on their own and create new businesses and new jobs. That's how
    we grow our economy. Worries about health insurance, whether it
    is affordable, whether it will cover preexisting conditions,
    can hold prospective entrepreneurs back.
        And the economic effects of repeal are not just anecdotal.
    According to The Commonwealth Fund, repealing the ACA would
    lead to the loss of 2.6 million jobs in 2019 alone, mostly from
    the private sector.
        Now, Mr. Siegel, can you tell the members of this committee
    directly about how the threat of repeal affects you and your
    family today?
        Mr. Siegel. If the ACA is repealed, I'm not sure how I
    would get insurance and if I could get it for my wife. And my
    kids, I don't know, they are going to turn 26, 27 soon enough.
    And, you know, I'll pay for them as long as I can get them
    insurance, but I don't know. So it's about that simple.
        Mr. Krishnamoorthi. And what does that do to--you know,
    what are your anxiety levels right now?
        Mr. Siegel. I have not slept very well since the election,
    to be honest with you.
        Mr. Krishnamoorthi. So it's affected your health.
        Mr. Siegel. It's affected my anxiety. I don't know that it
    has affected anything else yet. We shall see. I hope not.
        Mr. Krishnamoorthi. Now, Mr. Siegel, can you tell us a
    little bit about your business and how it's grown since you
    started?
        Mr. Siegel. Sure. We are a small market research firm. We
    do mainly survey research on product development. And we have
    grown from essentially nothing our first year to this year--I'm
    not going to tell how much we make because we're an LLC and
    that will tell you how much I make, but I made a good living
    this last year. Let me put it that way.
        Mr. Krishnamoorthi. Great.
        Thank you.
        Mr. Jordan. I thank the gentleman from Illinois.
        Ms. Robinson, in your opening statement, you talked about
    most States didn't have any type of accurate accounting for how
    ACA dollars were allocated and what they got from the Feds.
    Something to that effect you said in your opening statement.
        Ms. Robinson. Thank you, Chairman.
        I think you're referring to the work we did looking at the
    establishment grant program----
        Mr. Jordan. Yes.
        Ms. Robinson. --which looked at cost allocation. So if
    you've got a marketplace in the States that's sharing a system,
    you need to allocate the costs between the funding for the
    establishment grant for the marketplace and other programs that
    may share the same system, such as the Medicaid eligibility----
        Mr. Jordan. And the States weren't accurately accounting
    for all that.
        Ms. Robinson. Correct. In many of the situations we looked
    at, States were not accurately----
        Mr. Jordan. And was the inaccurate accounting, did it
    result in more Federal dollars coming to the State or less?
        Ms. Robinson. What it resulted in, often, was too much
    establishment grant funding going to the State. In some----
        Mr. Jordan. Oh, imagine that. They got more. They erred on
    the side where they got more. Imagine that.
        Ms. Robinson. In some cases, however, some of that funding
    could be allocated to the Medicaid program. So we did recommend
    that CMS and the States work together to----
        Mr. Jordan. In your report, you also said there were
    insufficient payment controls that led to wasteful spending.
    You said CMS lacked controls to ensure that financial
    assistance payments were correctly calculated. And you said CMS
    lacked controls to ensure effectively that APTC payments were
    made only for the enrollees who paid their monthly premiums.
        It sounds like a lot of screwing up going on.
        Ms. Robinson. Chairman, we did find a number of
    vulnerabilities and internal control weaknesses in our work,
    yes.
        Mr. Jordan. Yeah.
        And the GAO, you guys did a little--it looks like a little
    experiment here, where you had 15 fictitious folks, right,
    fictitious people applied for coverage. And how many of those
    15 got coverage and got the subsidy and got credit for it all,
    Mr. Dicken?
        Mr. Dicken. Right. So, for the open enrollment in 2016, we
    had 15 fictitious applicants. All of those initially received
    coverage that would've been subsidized----
        Mr. Jordan. Every single one?
        Mr. Dicken. Initially, yes.
        Mr. Jordan. Wow. So they didn't catch anybody who was
    trying to rig the game and mess with the system, did they?
        Mr. Dicken. There was some documentation that was requested
    over time. So, over time, you know, one was not retained; it
    was terminated. But, initially, we did receive all 15 approvals
    for----
        Mr. Jordan. Even though some fictitious documents were also
    sent along after the initial entry, right?
        Mr. Dicken. That's correct. We----
        Mr. Jordan. Wow. So they were batting 1,000 in ripping off
    the taxpayer.
        Mr. Dicken, I'm just curious, not so much as GAO guy but as
    just a citizen who follows the press, are you familiar with the
    name Jonathan Gruber?
        Mr. Dicken. Familiar with him as a healthcare economist,
    yes.
        Mr. Jordan. Yeah. And do you remember, you know, some of
    the statements that he made back when this thing was--when they
    were passing this law and some of the statements that came from
    the administration? Do you remember some of those, for the
    promises that were made?
        Mr. Dicken. I've seen some of Dr. Gruber's research. I've--
    --
        Mr. Jordan. Let me remind you of some of the things. I just
    want your comment if these actually turned out to be true.
        Many folks said back when this was being debated and
    initially passed, they said, if you like your plan, you can
    keep your plan. Was that an accurate statement? Did that turn
    out to be accurate?
        If you can give me some short answers, because I've got a
    lot of questions to ask you.
        Mr. Dicken. So, certainly, there are dynamic changes, and
    so many newly covered people were covered through the
    exchanges. Some people that were previously covered through
    plans----
        Mr. Jordan. You've got to give me shorter answers than
    that.
        Mr. Dicken. --did change to other plans.
        Mr. Jordan. Yeah, okay. That's what I thought.
        And we also said, if you like your doctor, you can keep
    your doctor. Did that turn out to be true? Was that accurate
    for all Americans, like it was presented?
        Mr. Dicken. Certainly, to the extent that individuals
    changed plans at different networks----
        Mr. Jordan. Yeah. Lots of people had to get new doctors.
        Did premiums go down, like we were promised? Have premiums
    gone down?
        Mr. Dicken. Well, we've seen that--you know, it's hard to
    compare premiums before and after. For a number of reasons,
    we've seen premium increases, I think as you mentioned----
        Mr. Jordan. Twenty-five percent.
        Mr. Dicken. --in the most recent year, of 25 percent in the
    exchange.
        Mr. Jordan. Yeah. So premiums didn't go down on average
    $2,500 either, did they?
        Mr. Dicken. We've not compared before and after, but
    premiums in the most recent year have gone up 25 percent.
        Mr. Jordan. Do you remember when this thing was rolled out?
    Did the website work very well when this thing was first rolled
    out?
        Mr. Dicken. So, certainly, there were a number of technical
    challenges and problems that were widely known----
        Mr. Jordan. And was the website secure? All this
    information, private information, was it secure at the time it
    was rolled out? Do you remember that?
        Mr. Dicken. GAO has done work looking at and made a number
    of recommendations to try to improve the privacy and security--
    --
        Mr. Jordan. Yeah, because it wasn't secured.
        Have emergency room visits declined under the Affordable
    Care Act, as we were promised to do?
        Mr. Dicken. I don't believe GAO has evaluated, kind of,
    what----
        Mr. Jordan. I figured that was one you probably hadn't
    looked at, but they've went up dramatically.
        And what about the co-ops, these co-ops that were created
    that were supposed to be, you know, just apple pie, wonderful,
    you know, be-all, end-all, save-all, 23 of them that were
    created, how have they done?
        Mr. Dicken. Yeah, so we've evaluated those. There are five
    that are still being offered in 2017.
        Mr. Jordan. Yeah. So 23 originally, and only 5 or so--
    another way of saying that is 18 have already went bankrupt,
    right?
        Mr. Dicken. And one is in the process of trying to
    transition, but----
        Mr. Jordan. So I count nine false statements: like your
    plan, keep your plan; like your doctor, keep your doctor;
    premiums are going to go down, they're going to go down on
    average $2,500, website won't work, website's not secure,
    emergency room visits declined, co-ops have went--18 of 23 have
    went bankrupt even though they were promised--and deductibles
    have actually increased dramatically when they were said they
    were going to decline. So nine false statements.
        And now we find out--so we were misled. And now we find out
    when the plan's actually put in place, most States don't have
    an accurate accounting of how the dollars are spent,
    inefficient payment controls that led to wasteful spending. CMS
    lacked controls to ensure financial assistance payments were
    correctly calculated. CMS lacked controls to ensure effectively
    that APTC payments were made only for enrollees who paid their
    monthly premiums. And when you guys ran a little experiment and
    had 15 fictitious people, 15 made-up folks who signed up for
    it, they all got the subsidy.
        And yet we have people say, oh, this thing is wonderful,
    we've got to keep it. That's just amazing to me. This thing has
    got to go. And that's what we're going to be working on here
    over the next several weeks, to put in a plan--I start from the
    simple premise, health care gets better and costs less when
    ObamaCare is gone. And that, to me, seems to be the direction
    we have to go.
        So, with that, I would yield to, if the gentlelady is
    ready, Ms. Norton.
        Well, we can go to Mr. Cummings, and then we'll go to----
        Mr. Cummings. Would the gentleman yield?
        Mr. Jordan. Well, actually--yeah.
        Mr. Cummings. Let me ask you, President Trump has said that
    he is going to provide health care for everyone and that it
    would be cheaper.Can you tell us about that plan so that the
    American people will be aware? Are you aware of it, of how
    that's going to work? Mr. Chairman? Chairman, I yield----
        Mr. Jordan. I thought you were asking our----
        Mr. Jordan. I'm asking you.
        Mr. Jordan. I'm not sure what Mr. Trump had in mind. I
    don't know what you have in mind sometimes when you make
    statements, and I don't know what everyone has in mind when
    they make statements.
        But what I do know is what I just outlined, the false
    statements that were made when the Affordable Care Act was
    presented to the American people and----
        Mr. Cummings. Well, I reclaim my time. I reclaim my time.
        Mr. Jordan. --all the fraud that the witness has said----
        Mr. Cummings. You're not answering the question. I reclaim
    my time. Thank you. I just wanted to know so that the general
    public would know what the President's talking about.
        I'd like to take a few minutes to discuss what we can
    expect our healthcare system to look like under a Trump
    administration.
        President Trump has claimed that his replacement to the ACA
    would provide, and I quote, ``health care that is far less
    expensive and far better than the ACA,'' end of quote. But
    based on the actions of President Trump, actions taken so far,
    the only thing that TrumpCare seems to be doing is creating
    chaos in the insurance market and leaving millions of people
    uncertain about their health care.
        On January 20th, President Trump issued an Executive order
    that directs Federal agencies to, quote, ``waive, defer, and
    grant exemptions from or delay implementation of any provision
    of the act,'' end of quote.
        What this will mean for people with the ACA insurance isn't
    entirely clear since the order is short on concrete details,
    but it does raise serious doubts about whether consumers,
    including those with employer-sponsored insurance, will
    continue to enjoy the benefits and protections they received
    under the ACA, such as no caps on annual and lifetime limits,
    free preventive care, and comprehensive coverage of essential
    health benefits.
        Mr. Siegel, as a small-businessman and an ACA plan
    enrollee, how does all of this uncertainty impact you and your
    ability to run your business?
        Mr. Siegel. As I said, I have not had slept well since the
    election. To the extent that I'm focused on that instead of
    focusing on our business, it takes time away.
        How do I put this? I don't know that this new
    administration understands. And when people don't understand,
    it makes it very hard to plan for the future at all, because
    you don't know what they're going to do.
        Mr. Cummings. Yeah.
        The uncertainty is also affecting insurance companies, Mr.
    Siegel. The Urban Institute recently released findings from
    interviews with executives from 13 insurance companies that
    offer coverage in the individual market in 28 States. Most of
    the executives interviewed warned that repealing the individual
    mandate would drive up premiums, up to 20 percent more than
    currently expected. And some insurers warned that they might
    leave the market altogether.
        Now, Mr. Dicken, you have studied the individual insurance
    market closely, have you not?
        Mr. Dicken. Yes, GAO has.
        Mr. Cummings. And does it surprise you that insurers are
    wary of repealing fundamental aspects of the ACA without having
    a comparable replacement plan in place?
        Mr. Dicken. Well, certainly, insurers in the next few
    months will be setting benefits and premiums for 2018 and so
    certainly need to understand the Federal and State rules that
    they'll be working under.
        Mr. Cummings. And so, in addition to creating instability
    in the insurance market and uncertainty among consumers, it
    appears that the Trump administration is taking steps to
    actively prevent people from enrolling in coverage. According
    to a recent Politico article last week, the Trump
    administration canceled TV advertisements for open enrollment
    that had already been placed and paid for, even though the last
    day to enroll wasn't until today.
        But, Ms. Robinson, as you've stated in your written
    testimony, the IG's central mission is to, quote, ``protect the
    integrity,'' end of quote, of the ACA and other Federal health
    programs. Do you plan to look into this issue?
        I think they reversed that now, right? In other words, they
    put the ads back up.
        Ms. Robinson. Thank you for that question.
        Mr. Cummings. By the way, I was in my district on Monday
    telling my constituents to enroll.
        But go ahead.
        Ms. Robinson. Thank you for that question. I don't have
    that particular detail about this.
        Mr. Cummings. Okay.
        Ms. Robinson. I've seen some of the same reports that
    others have seen.
        Mr. Cummings. Even if the money that has been wasted on the
    ads that never aired is somehow recovered, it is still deeply
    concerning that the Trump administration would intentionally
    sabotage the final week of open enrollment in this way,
    especially since we know that young and healthy people tend to
    wait until the last minute to enroll.
        If this is any indication of the future of TrumpCare, we
    will need the IGs to remain vigilant in the oversight--in his
    oversight responsibilities, and, as the primary oversight body
    of the House, I hope that we will do the same.
        And so we will continue to look over this again. Health
    care in the great country called the United States should not
    be a privilege but a right.
        And, with that, I yield back.
        Mr. Jordan. I thank the gentleman.
        The gentleman from Michigan is recognized.
        Mr. Mitchell. Before I joined this esteemed body, I retired
    as the CEO of an education group. We had 650 employees. A fair
    number were part-time. Anybody who was scheduled more than 9
    hours a week on a regularly scheduled basis had health care.
    They had health care for themselves, and they could buy health
    care for their family relatively inexpensively.
        The Affordable Care Act, when that came into place and the
    requirements were finally rolled out by HHS, increased the cost
    for part-time employee health care by 50 percent year one for
    my company.
        So my question for Ms. Robinson or Mr. Dicken: Did you do
    any analysis when you looked at the fraud, the waste, at the
    immediate impact on health insurance premiums, never mind
    copays and deductibles, for privately sponsored healthcare
    programs and what the impact was in the first few years?
        Mr. Dicken. We've not directly looked at the changes in
    employer-sponsored health premiums. There are some surveys that
    look at that by other organizations, but GAO has not reported
    on that.
        Mr. Mitchell. Did HHS look at this issue?
        Ms. Robinson. We have not looked at that issue. Our focus
    is really on HHS dollars and the expenditure of HHS funds.
        Mr. Mitchell. Well, but as my constituents view it, whether
    their money that they paid for premiums, whether it's the
    employer paying for premiums, whether it's their tax dollars
    that they pay the Federal Government, it's all their money. So
    would it not make sense to look at waste as it's viewed in
    terms of the immediate and then long-term impact on healthcare
    costs in America by looking at what suddenly the change in
    costs were? As I indicated, for our company it was dramatic,
    and a number of others I know of.
        Mr. Dicken. Yeah, certainly, we're glad to work with the
    subcommittee on looking at healthcare costs and trends in the
    markets. Certainly, employers--there have been longstanding
    increases overall in health insurance costs, even for--Federal
    employees have seen increases in healthcare costs in recent
    years.
        Mr. Mitchell. Let me change direction for a second
    question. There were concerns with those who are receiving
    subsidies or payments. Can you tell me how many people in year
    one received subsidies that were improper or determined to be
    inaccurate the first year?
        Ms. Robinson. So that's a very important question. We don't
    have the number of folks, but what we did look at was the risk
    to the programs of potentially weak controls on eligibility. So
    our work----
        Mr. Mitchell. Let me ask you, why--I mean, we're subjected
    to audits as a company. Why would we not know how many people
    received subsidies that were found to be inappropriate and/or
    fraudulent, whatever term you want to put on it? How would we
    not investigate that and not know?
        Ms. Robinson. So, Congressman, my office does investigate
    when we get allegations of an improper person being in the
    marketplace. Our work initially set out to figure out whether
    there were adequate safeguards to prevent fraudulent or
    improper information from impacting the eligibility
    determinations.
        Mr. Mitchell. So at this moment, we still don't have either
    year one or any year since any idea of an approximation of the
    number of people that receive payments that we--they should not
    have?
        Ms. Robinson. My office does not have that information.
        Mr. Mitchell. Does HHS, in general, have that?
        Ms. Robinson. I don't know.
        Mr. Mitchell. Do we--you lead me to believe, then, we don't
    know how much those inappropriate payments total up to be to
    the taxpayers. Is that correct?
        Ms. Robinson. I do not have that information.
        Mr. Mitchell. Mr. Dicken, do you have that information?
        Mr. Dicken. No, but I will note that the GAO has
    recommended that HHS develop a fraud risk assessment to get at
    some of the questions that you are getting at, so they have an
    overall understanding of what the fraud risk potential is and
    how they can manage those risks.
        Mr. Mitchell. I readily admit, as I say, I'm subject to
    freshman hazing here as a freshman Member of Congress, but I
    spent 35 years in private business, and I have to say, Oh, my
    God. How is it that we don't have the means by which to figure
    out those that we didn't, and how much it has cost us here?
    We're analyzing fraud and abuse. How do we not think about it
    was a problem?
        Ms. Robinson. Well, Congressman, I think you're raising a
    really important question about transparency in government. And
    one of the things that we have been recommending to CMS and the
    marketplace is to look at things like having the right kinds of
    data to be able to figure these things out. And so, for
    example, in our work looking at the accuracy of the subsidies,
    what we----
        Mr. Mitchell. Well, let me stop you and ask a question.
        Ms. Robinson. Yeah.
        Mr. Mitchell. But if we're making a payment to a private
    carrier or somebody else, we certainly would insist on that
    kind of transparency of them, and we would recover the money if
    it was improperly paid, wouldn't we?
        Ms. Robinson. Yes, Congressman.
        Mr. Mitchell. So we fail to undertake a basic function of
    the department of government is to make sure we're not throwing
    money out of the window.
        Ms. Robinson. Well, Congressman, that's why we've done the
    work. We've looked at the controls that CMS has on the accuracy
    of the payments, is to be able to make recommendations to
    strengthen those controls.
        Mr. Mitchell. Thank you very much. Thanks very much. I
    yield back.
        Mr. Jordan. I thank the gentleman. I think it's a great
    line of questioning. We can't get an answer to the number of
    individuals who got payment inappropriately, fraudulent
    payments, but we can probably conclude that anyone who
    attempted, who applied fraudulently, probably did get paid. And
    who can we conclude that? Because you all ran the experiment:
    15 fictitious people, and you found that it wasn't one who got
    paid, it wasn't two, it wasn't 10, it wasn't 14; it was 15 out
    of 15. So Mr. Mitchell's question is entirely appropriate, and
    one we need to get--think about that. If everyone, based on the
    little experiment you all ran where you found it was--that
    we're batting 1,000, anyone who applied fraudulently may, in
    fact, have gotten money that they weren't entitled to. And that
    is a concern for the tech--not to mention all the other
    problems with the ACA that we've talked about, all of the
    misleading statements, all the false statements, all the lies
    told to the American people before this thing was passed. So
    we'd like to get that number as quickly as possible. And I
    appreciate the gentleman's questioning from Michigan.
        I now recognize the gentlelady from the District of
    Columbia.
        Ms. Norton. Thank you, Mr. Chairman. I guess it's been
    reported that this is the last day to sign up for the
    Affordable Healthcare Act, and people have been signing up in
    huge numbers. People are afraid of a big structural change and
    what effects it will have, not only on those who are part of
    the ACA, but, of course, we're talking about a sixth of the
    economy, and how fooling with this aspect of it could have an
    effect on the economy itself.
        And in my district, and I represent the District of
    Columbia, a lot of people already have health care because they
    work for the Federal Government, but 100,000 D.C. residents
    would lose their insurance if the Affordable Healthcare Act
    were repealed, and the estimated cost to D.C. would be $1.1
    billion. Now, that's a city of 700,000 people. Imagine what
    this means writ large across the country.
        I'm interested in, Mr. Siegel, because I think when most
    people think of the health care, of the Affordable Healthcare
    Act, they may not think of enrollees like Mr. Siegel, but the
    largest segment of enrollees in the non-group market is self-
    employed. So I'd be interested in your views on what effect
    guaranteed access to private insurance has had on the security
    of your business as a business.
        Mr. Siegel. I always had access. Affordable enrollment in
    coverage has made a huge difference, and the reason it makes--
    --
        Ms. Norton. To your business?
        Mr. Siegel. Yes.
        Ms. Norton. To your business itself?
        Mr. Siegel. Well, I buy it on the exchange, so the business
    doesn't buy it. But for the business, it makes a big
    difference, because it would not have me as a participant if it
    was not for the ACA. And we started out with three partners,
    and our youngest partner died after 6 months, and you cannot
    run a market research business with one person. So our business
    would probably not exist right now. That's my guess.
        Ms. Norton. Without the Affordable Healthcare Act.
        Mr. Siegel. That's my guess. It's counter-factual, right,
    so----
        Ms. Norton. So let's look at the potential effects of the
    repeal on your family's access, your business access, to
    affordable healthcare coverage.
        Mr. Siegel. New York is a State that will do something. I
    don't know what. I do know that in New York, before the ACA,
    they had--private insurers had to take anybody, and that made
    our costs--but they--but you didn't have to buy, so only people
    who needed it bought it, and so it made it expensive. My fear
    is we'll go back to that, and that would--if I can get
    insurance at all, it will probably now be, and I don't know,
    but I'm guessing $2,600, $2,700, $3,000 a month, because it was
    about $2,000 a month before the ACA, and so you're going to see
    a pop back. And at that level, I'm going to have to find a job
    working for an employer. And I'm 61 years old, and in market
    research, that is not easy. And in any case, I'm tired of being
    a boss and I'm tired of having bosses. I love running a
    business with a partner I admire, serving clients that I like,
    and taking care of my family that way, and I don't want to go
    back.
        Ms. Norton. Mr. Siegel, finally, let me ask you about a
    plan that I read about in the Republican Study Committee Guide
    that would replace this long-standing tax exclusion for
    employer-based coverage with a standard tax deduction. Now, we
    know that would put health care out of the reach of lower
    brackets of Americans, but I don't see how it would account for
    geography or age or health status. Do you have any view on such
    a replacement?
        Mr. Siegel. I don't have any view on the technical side of
    it. I can tell you now that health insurance and healthcare
    coverage, according to our accountant, are something I can
    deduct, but I also know that that is not as good as what----
        Ms. Norton. What about a standard tax deduction?
        Mr. Siegel. I imagine I'd benefit from it, but I don't know
    that my kids would. But what I was going to say is, you know,
    employer plans get a much better deal. And so just having a
    deduction for the private side, I don't know what it would be.
    You make it as good as employers, maybe it has an effect, I
    don't know, but if you don't, definitely not. I'm not an expert
    on the tax system. I'm sorry.
        Ms. Norton. Well, no one's an expert on how this would work
    out, I can tell you that much.
        Thank you very much, Mr. Chairman.
        Mr. Jordan. I thank the gentlelady. We'd now recognize the
    gentleman from Wisconsin.
        Mr. Grothman. Sure. Mr. Dicken, I notice in some of the
    information we have here and in your initial talk, you told us
    a little bit about the number of options Americans have as the
    number of insurance companies involved has dropped. Could you
    recite the numbers again for the last couple of years and the
    number of options?
        Mr. Dicken. Sure. For plan options, that would be on the
    different metal tiers that are offered through the exchanges,
    to be silver or gold, we found that most consumers had six or
    more plan options. In the most recent years, the number of
    issuers that are offering plans have declined, and so we've
    seen that. HHS has reported that this year, 21 percent of
    consumers have plan options, but only from one issuer, one
    insurance company.
        Mr. Grothman. Okay. So at 21, in essence, you have a
    monopoly, correct, 21 percent?
        Mr. Dicken. For the exchanges that there will be different
    silver or gold plans, but just from the same insurer.
        Mr. Grothman. And at this rate, how many, we don't know
    yet, but how many plans do you think will be out there for
    2018?
        Mr. Dicken. Yeah. I think there's a lot of uncertainty
    about what future years will bring. Certainly it's--insurance
    companies, it's been very concentrated, with many States having
    only one or two or three insurers having 80 percent of the
    market.
        Mr. Grothman. It shot up about--it shot up from, like, 5
    percent to 21 percent in one year, correct?
        Mr. Dicken. I don't have the early numbers, but it has
    increased that more----
        Mr. Grothman. Dramatically.
        Mr. Dicken. --areas have only one issuer.
        Mr. Grothman. Is there any concern that some areas will
    soon have no issuers?
        Mr. Dicken. Certainly, you know, it would be important to
    make sure that consumers under the current system with the
    exchanges have plans that are available. You know, certainly,
    that's a local decision--local decisions by the insurers in
    those areas.
        Mr. Grothman. Right. But if we've gone down from three or
    four or five options to one option, it stands to reason that
    it's entirely possible soon we're going to have no options,
    right?
        Mr. Dicken. That has not yet been experienced, but
    certainly a concern.
        Mr. Grothman. Okay. And what effect on premiums has that
    had as the number of--as the competition is disappearing?
        Mr. Dicken. Yeah. In general, you would expect that less
    competition would mean less pressure on keeping low premiums.
        Mr. Grothman. And is that true, right?
        Mr. Dicken. You know, we've not done a causal study looking
    at that, but that certainly would be the expectation.
        Mr. Grothman. Premiums have shot up in this past year,
    correct?
        Mr. Dicken. On average, about 25 percent increase.
        Mr. Grothman. 25 percent, which is--and I would say one of
    the reasons they shot up may be is there is no competition,
    right?
        Mr. Dicken. A range of issues for that as the experience of
    the exchanges has led some insurers to increase the premiums.
        Mr. Grothman. Right. And can you tell us why the number of
    insurance companies keeps disappearing?
        Mr. Dicken. I think there's a variety of reasons, a couple
    that have been mentioned today. Some of the plans that were
    available, such as co-op plans, have terminated operations,
    some large national insurers have changed the markets that
    they're operating in, or left the exchanges.
        Mr. Grothman. Can you let us know why they've left? I mean,
    there must be some reason. You know, a few years ago, they were
    apparently gung-ho and thought they could make a go of it, and
    now they can't. What happened?
        Mr. Dicken. Yeah. I think those are business decisions by
    the insurers as they decide what markets and what their
    experience has been.
        Mr. Grothman. Well, they are businesses, but could you
    speculate for us why companies keep leaving the current market
    that was originally envisioned?
        Mr. Dicken. Yes. Certainly, as they've learned more about
    the cost of individuals that they're covering and their
    relative premiums in that market, some have made business
    decisions that they're not going to compete in that market.
        Mr. Grothman. So it would seem that over time, given the
    current framework, insurance companies cannot operate, correct,
    or they wouldn't keep pulling out? And no new insurance
    companies are jumping in, are they, largely?
        Mr. Dicken. There have been--we did look at new entrants
    and exits. We found that most of the exits were among smaller
    insurers. There were--there have been some new entrants into
    the market as well.
        Mr. Grothman. Okay. Ms. Robinson, you looked at the grant
    funds, and reviews by the inspector general identified money
    that need to be refunded to the Federal Government, because
    it's not spent in accordance to your requirements. What's the
    status of your recommendations that money that was misspent be
    refunded to the Federal Government?
        Ms. Robinson. Thank you for your--that question. On the
    establishment grant funding, I believe most of those
    recommendations are still open and we are following up on that,
    but I think those are still open recommendations.
        Mr. Grothman. Are they refunding the money?
        Ms. Robinson. Not as far as I know.
        Mr. Grothman. What efforts are they making to refund the
    money, or is this just considered par for the course now?
        Ms. Robinson. So we worked with CMS to follow up on those
    recommendations. I don't have at my fingertips, but I'd be
    happy to follow up with you on any details about with respect
    to the specific amounts that we've identified.
        Mr. Grothman. Okay. And how many States does that include,
    do you know?
        Ms. Robinson. We looked at--if you just give me one moment.
    We looked at establishment grants at six States that we had--
    that we looked at.
        Mr. Grothman. Okay. Were there problems in all six or----
        Ms. Robinson. Yes. So we had problems in all six. We had
    one other that did not have any problems.
        Mr. Grothman. Okay. Well, six. One out of seven? Huh? Okay.
    Thank you.
        Mr. Jordan. I thank the gentleman.
        The former chairman of the committee, we're glad to
    welcome. The gentleman from California is recognized.
        Mr. Issa. Thank you, Mr. Chairman.
        Mr. Dixon--Dicken, you know, we're all watching the
    Affordable Care Act underperform, and we are all concerned that
    what it sought to achieve, one would say it at least partially
    achieved; there are millions of people on the plan, but let me
    go through a couple of comparisons, and they're a little
    outside your briefing, but I think they're well within your
    competence.
        You're personally under FEHBP, right?
        Mr. Dicken. That's correct.
        Mr. Issa. And you're familiar with the programs that are
    offered, the 250-plus different options?
        Mr. Dicken. Nationwide, there are many, yes.
        Mr. Issa. So if we were to contrast the 11 million-plus
    people that are in FEHBP, they're Federal employees, retirees,
    and their families, contrast the options between what you
    expect to have in 2017 in the Affordable Care Act as it is, and
    what half the number of people, but the Federal workers and
    their families have.
        Mr. Dicken. Right. About 8 million people covered through
    the Federal employees program, as you mentioned, nationwide,
    over 200 plans offered. That includes some national plan
    offerings, mostly PPOs as well as local HMOs, that are
    available in specific markets.
        Mr. Issa. Right. To include Kaiser, Blue Cross, all the
    major names?
        Mr. Dicken. That's correct. And so--and throughout those
    markets, Federal employees, retirees, and dependents can choose
    either from those national plans, the largest by far of which
    is the Blue Cross standard and basic options, which covers
    about two-thirds of enrollees.
        Mr. Issa. And under the plan, if you go onto a COBRA
    because you leave the Federal workforce, you pay to whichever
    healthcare program you were in as you continue, right?
        Mr. Dicken. COBRA would have continuation coverage with the
    individual paying the full premium, a smaller----
        Mr. Issa. Right. Which means at least in some cases, the
    healthcare providers accept a check from an individual?
        Mr. Dicken. In the COBRA cases, yeah. I don't know the
    actual transfer of money, but it would be coming from the
    individual.
        Mr. Issa. But in all cases, essentially these are private
    companies who have made a decision to provide a program to
    whatever amount of people, if you will, any and all from the
    Federal workforce current or, in the case of COBRA, COBRA, that
    choose their plan, correct?
        Mr. Dicken. They are private plans, yes.
        Mr. Issa. And just going through a couple of points,
    they're not gender discriminate, right?
        Mr. Dicken. It's available to all Federal employees that--
    --
        Mr. Issa. But, I mean, they change the same rate regardless
    of age?
        Mr. Dicken. Same premium nationwide.
        Mr. Issa. Right. So you take advantage of the pool, that
    you're not worrying about whether you're young or old, man or
    woman, the rate's the same?
        Mr. Dicken. It is one premium for all.
        Mr. Issa. Right. And your 26-year-old child can stay on it?
        Mr. Dicken. Up to age 26.
        Mr. Issa. Or 27th birthday, whatever.
        Mr. Dicken. It think it's 26th, but----
        Mr. Issa. 26th birthday. And there's no problem switching
    as a Federal worker from program to program on an annual basis,
    based on any preexisting conditions or any other
    discrimination?
        Mr. Dicken. Yeah. During the open enrollment period or for
    special reasons, they can change plans.
        Mr. Issa. Okay. So it's fair to say that FEHBP with 200 and
    some, my number is 250, but a great many plans more than the
    Affordable Care Act in most areas, in fact, offers all the same
    protections to the consumer that the ACA handles, right?
        Mr. Dicken. My understanding is that the plans meet the
    requirements of the Affordable Care Act.
        Mr. Issa. Okay. And they come in all levels, from
    relatively stripped down to essentially the equivalent, the
    very large plans like the Postal plan, which is a pretty good
    one, and so on, right?
        Mr. Dicken. They're all comprehensive medical. Some are
    high deductible offerings, and some are HMOs, yes.
        Mr. Issa. So I've taken you through this and taxed your
    expertise for a reason. Is there any reason that if the
    Affordable Care Act were to go away and a transition to
    enjoying the same programs offered to the Federal workforce to
    virtually everyone who now or has retired from the Federal
    workforce, is there any reason that that wouldn't be viable,
    considering these are insurance companies that want access to
    those 8 million-plus people they now insure, they bid for it
    every year, and if the number were increased, both for
    individuals and small or even not small businesses, is there
    any reason to believe that the program inherently wouldn't be
    able to serve the same purpose, especially considering at least
    a subset of FEHBP are, in fact, the same companies?
        Mr. Dicken. Yeah. We--GAO has not kind of evaluated
    expanding the Federal employees program to other plans or
    offerings. It is an employer-based plan based on the group of
    Federal employees, retirees, and that's kind of important for
    that risk pool, as there's not risk adjustment and other
    issues, and so----
        Mr. Issa. Well, there is risk adjustment, because they bid
    annually based on the risk, right?
        Mr. Dicken. It's based on their experience, yes, but not--
    if different plans end up with different risks, that's----
        Mr. Issa. Right. But if over time the Federal workforce
    gets older, sicker, whatever, they adjust?
        Mr. Dicken. Yes. So it would be placed based on that plan's
    experience.
        Mr. Issa. Okay. So last question, if I may, Chairman.
        You know, it was not considered originally, but they are
    private programs, there are more plans, it enjoys all the same
    protections of the Affordable Care Act. So when people, and I'm
    not trying to be partisan, I'm trying to be very open here
    against what do we do in the eventuality. There is no inherent
    reason that you couldn't have the Federal Government ensure
    through these national contracts with local and not local
    companies, there's no inherent reason that that couldn't be
    offered as a viable alternative, recognizing that there is a
    risk pool change, but these companies start off with an
    incredibly desirable 8-plus million people that they're not
    going to want to walk away from if others are allowed to join.
    Is that a fair question? And, again, we're taxing your
    expertise for an opinion.
        Mr. Dicken. It's certainly a fair question. We've not
    evaluated kind of what the effects could be, either for new
    entrants to that or for the Federal--existing Federal employees
    program; certainly a lot of considerations as to the risk
    pools, as to individuals involved. Some plans have left FEHBP
    over time as well. And so there would, again, be business
    decisions by the insurers whether or not to participate in
    that.
        Mr. Issa. Okay. Thank you, Mr. Chairman. I yield back.
        Mr. Jordan. I thank the gentleman. We can do maybe a quick
    question or two from--does the gentlelady from D.C. have
    additional questions?
        How about the gentleman from Wisconsin? You want another
    minute or minute and a half?
        Mr. Grothman. Oh, absolutely.
        Mr. Jordan. Yeah. You've got another minute and a half.
        Mr. Grothman. Minute and a half, that's what I need.
        Mr. Jordan. And then we'll come back to the D side and then
    we'll finish up here.
        Mr. Grothman. Sure. Maybe if I can, I'll even take 2
    minutes. If you give me one and a half, I'll take two.
        Mr. Jordan. All right.
        Mr. Grothman. Ms. Robinson, HHS, you've conducted several
    reviews of CMS' management of the health and insurance exchange
    programs and identified vulnerabilities related to Federal
    contracting and oversight in CMS's overall management and
    administration of the facilities.
        Through those case studies of the management and
    administration, what lessons have been gathered?
        Ms. Robinson. Well, thank you for the opportunity to talk
    about our case study work, where we did look across the
    management, and there were a number of lessons. Certainly the
    lesson around needing good acquisition strategies and good
    contract planning; lessons around needing clear leadership for
    projects; and a really important lesson that I think extends
    across, particularly for complex technological and policy
    projects, is really to integrate technology and policy staff
    and thinking and contractors and employed staff in working
    together without fragmentation and without silos. Certainly,
    when we saw that at CMS, it helped improve their management
    across the marketplace program.
        Mr. Grothman. Thank you.
        One more question for Mr. Siegel. I know there's some areas
    in which there's robust competition, but there are other areas
    that we just heard that only 20--you know, 26 percent of
    America, you've only got one choice under ObamaCare. And given
    that this has fallen over time, like, maybe a few years
    earlier, they had three or four, now they have one, does it
    concern you for your fellow Americans, as the number of
    companies drop off, that it's possible, maybe as early as next
    year, that there'll be no options at all? Does that concern you
    on behalf of your fellow Americans as you watch under the
    current----
        Mr. Siegel. Well, I only speak for myself. I don't pretend
    to speak for my fellow Americans, but of course it concerns me.
    I am not in the insurance industry, so I'm not going to
    speculate why there is only one company in some places. I can
    tell you that in New York, which has a long tradition of robust
    regulation of insurance markets, and a commitment, in many
    ways, to providing insurance to as many people as possible, we,
    by and large, have pretty robust choices. I had a choice this
    year. I'm trying to envision the thing they gave us. I had a
    choice, I would guess, of somewhere between 12 and 20 plans. I
    can't tell you exactly how many, because I can't remember the
    big, wide 8-1/2 by 11, 11-by-14 thing that I saw.
        Mr. Grothman. Okay. I'll come back to Mr. Dicken one more
    time. Again, there are some people, and I fought it and I think
    everybody else up here has fought it, who say we ought to let
    ObamaCare continue a few more years, because as companies
    continue to get out of these markets, the thing is going to
    collapse on its own. And when you already see 26 percent of the
    areas have one insurance company compared to where we were a
    couple of years ago, common sense will tell you that if we just
    let this thing go as it is, there might be some markets that
    have no plan at all, and others will just have one plan and
    they'll--and the rates will keep going up 25 or 26 percent, and
    we can just sit here and watch the train wreck and blame
    President Obama.
        I think almost every Republican has stepped forward and
    said, no, we cannot allow this train wreck to happen to the
    American people. But I'll ask you again, if you could
    speculate, given the disappearance of insurance firms from the
    market, how much of America is only going to have one company,
    or maybe no company if we don't act by 2019 or 2020?
        Mr. Dicken. Yeah. Thank you. And I cannot speculate, but I
    will note that, you know, this is the fourth year, it has been
    dynamic in the exchanges, we saw some increases up to 2015 and
    then a decline in insurers, as you've noted. That's a concern
    for the private health insurance market as a whole. As our
    work, required by the Affordable Care Act, indicated insurance
    markets are very concentrated, with often only one, two, or
    three large insurers having the predominance of the market. And
    so a competitive market, whether it is the exchanges or the
    insurance market overall, that is a challenging consideration
    going forward.
        Mr. Jordan. Mr. Dicken, I think the gentleman's point is
    the trend lines aren't good, the pattern isn't good. 2 years
    ago, 23 co-ops started, today there are 5; 18 of them went
    bankrupt. Three years ago, most exchange areas had five plans
    that you could choose from, today it's down to one. You look at
    patterns, you look at the pattern you all did, 15 fictitious
    people apply, they all get subsidies. So all the trends, all
    the patterns in this law are terrible, and that's our point,
    and I think that's Mr. Grothman's point. So I appreciate his
    questioning, even though it was his first hearing and it was
    sort of a filibuster there in the second round, but we have--
    I'm kidding you, Mr. Grothman. We appreciate that.
        Mr. Krishnamoorthi. Well, Mr. Chairman, can I have equal
    time, please?
        Mr. Jordan. Yes. You've got all the time you need.
        Mr. Krishnamoorthi. Great. Thank you so much.
        Are you aware, Mr. Siegel, that 11.5 million people, as of
    December 24, had enrolled in the ACA, and we are on record-
    breaking pace for the number of enrollees in the ACA in the
    coming year?
        Mr. Siegel. I was aware of that, yes.
        Mr. Krishnamoorthi. And in your opinion, do you think that
    the fact that there were almost 40 million uninsured folks
    before the ACA and now there--it's dramatically fallen is a
    positive trend line for America?
        Mr. Siegel. I think it's a wonderful trend line for
    America.
        Mr. Krishnamoorthi. And, sir, would you agree with me that
    there hasn't been any contrary evidence presented today about
    the amount of waste, fraud, and abuse that existed in the
    private insurance market prior to the ACA? Isn't that right?
        Mr. Siegel. I did not hear anything about private insurance
    fraud at all.
        Mr. Krishnamoorthi. And would you also agree with me, sir,
    that there hasn't been any contrary evidence presented that
    there would be millions of jobs lost if the ACA is repealed
    without a replacement, as my honorable colleagues on the other
    side propose to do?
        Mr. Siegel. I did not hear discussion of job loss at all.
        Mr. Krishnamoorthi. And would you surmise that people in
    the employer market, who have today protections from
    discrimination against preexisting conditions and other similar
    protections, would lose those protections once the ACA is
    repealed?
        Mr. Siegel. I don't know whether some States have
    protection, but if that was the end of Federal protection and
    your State didn't step up, yeah, I think you'd be screwed.
        Mr. Jordan. Term of art.
        Mr. Krishnamoorthi. Thank you for that colorful----
        Mr. Siegel. Sorry. I apologize if that's a violation of
    etiquette. I didn't mean that. I don't do this every day, so--
    --
        Mr. Krishnamoorthi. And that's why you're such a convincing
    witness.
        Mr. Siegel, what would you like to say to the chairman when
    he says it's clear that the ACA has got to go?
        Mr. Siegel. I would say that if you think about health
    insurance--Representative Cummings said it should be a right. I
    don't like ``rights'' talk, but I will tell you that I think it
    is a necessity in today's world for any person to have
    adequate, affordable health care available to them, and in our
    country, we do it through health insurance, and we must have
    that if you want people to be able to live lives where they
    reach their potential, and, therefore, contribute as much as
    they can as citizens, as taxpayers, as employees, as business
    owners to our society.
        Mr. Krishnamoorthi. The ACA has improved your life,
    correct?
        Mr. Siegel. The ACA made the life I have today possible,
    yes.
        Mr. Krishnamoorthi. Now, sir, I need to ask you a question
    about the creation of small businesses because of the ACA. Are
    you aware of others in your friend circle, family circle who
    similarly benefited from the ACA?
        Mr. Siegel. I don't--to be honest with you, I don't have a
    personal friend that I know of for sure started their business
    relying on the ACA for health insurance. I just don't know. I
    have some friends who get their health insurance through the
    ACA as well, but they are not necessarily in business.
        Mr. Krishnamoorthi. Got it.
        Mr. Siegel. So, you know, the honest answer to that is I
    don't know.
        Mr. Krishnamoorthi. Got it. Well, sir, I just want to thank
    you so much for your testimony today.
        Mr. Siegel. Okay. You're welcome.
        Mr. Jordan. I would just--just to close maybe say, look, I
    didn't say it wasn't a necessity. All I did was point out the
    facts. And the facts are there were all kinds of statements
    made to the American people 6 years ago about the Affordable
    Care Act that turned out to be false, turned out to be lies.
    And you don't have to take my word for it, you can take the
    architect of ObamaCare, Jonathan Gruber's word for it. He told
    us they misled the American people on all those statements,
    nine different statements.
        And now we have the ACA come along, it's the law, and we
    see where things are going, as evidenced by what Mr. Issa and
    Mr. Grothman pointed out. We started off with five choices for
    consumers, we're now down to one in lots and lots of places. We
    started out with 23 co-ops, we're now down to five, because 18
    of them went bankrupt. These guys didn't look at the private
    market, they looked at taxpayer dollars because, that's what's
    involved here. These guys took taxpayer money and lost it. And
    we have all kinds of fraud going on, as evidenced by the study
    that they undertook where it was 15 for 15.
        Now, think about this: If you're down to one insurer in an
    area, that obviously is going to drive up costs, so that's a
    monopoly situation, and if you have fraud going on up there,
    that's even more cost to the taxpayers. That's the story of the
    ACA, not to mention the increased premiums, increased
    deductibles for families all across this country. And that's
    why we're looking to repeal this law, just like we told the
    voters we were going to do, just like we promised them that we
    would do, and just like they sent us here to do, and we need to
    do that. After all, there was an election where that was one of
    the most important issues.
        So with that, I want to thank our witnesses for being here,
    thank our members for participating. And we are adjourned.
        [Whereupon, at 3:30 p.m., the subcommittee was adjourned.]

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