[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.]

                                 [all]