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


             PATIENT RELIEF FROM COLLAPSING HEALTH MARKETS

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

                                 HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            FEBRUARY 2, 2017

                               __________

                            Serial No. 115-4
                            
 [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                           
                            


      Printed for the use of the Committee on Energy and Commerce
                        energycommerce.house.gov
                        
                        
                                __________
                               

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                    COMMITTEE ON ENERGY AND COMMERCE

                          GREG WALDEN, Oregon
                                 Chairman

JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
  Vice Chairman                        Ranking Member
FRED UPTON, Michigan                 BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
TIM MURPHY, Pennsylvania             ELIOT L. ENGEL, New York
MICHAEL C. BURGESS, Texas            GENE GREEN, Texas
MARSHA BLACKBURN, Tennessee          DIANA DeGETTE, Colorado
STEVE SCALISE, Louisiana             MICHAEL F. DOYLE, Pennsylvania
ROBERT E. LATTA, Ohio                JANICE D. SCHAKOWSKY, Illinois
CATHY McMORRIS RODGERS, Washington   G.K. BUTTERFIELD, North Carolina
GREGG HARPER, Mississippi            DORIS O. MATSUI, California
LEONARD LANCE, New Jersey            KATHY CASTOR, Florida
BRETT GUTHRIE, Kentucky              JOHN P. SARBANES, Maryland
PETE OLSON, Texas                    JERRY McNERNEY, California
DAVID B. McKINLEY, West Virginia     PETER WELCH, Vermont
ADAM KINZINGER, Illinois             BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia         PAUL TONKO, New York
GUS M. BILIRAKIS, Florida            YVETTE D. CLARKE, New York
BILL JOHNSON, Ohio                   DAVID LOEBSACK, Iowa
BILLY LONG, Missouri                 KURT SCHRADER, Oregon
LARRY BUCSHON, Indiana               JOSEPH P. KENNEDY, III, 
BILL FLORES, Texas                   Massachusetts
SUSAN W. BROOKS, Indiana             TONY CARDENAS, California
MARKWAYNE MULLIN, Oklahoma           RAUL RUIZ, California
RICHARD HUDSON, North Carolina       SCOTT H. PETERS, California
CHRIS COLLINS, New York              DEBBIE DINGELL, Michigan
KEVIN CRAMER, North Dakota
TIM WALBERG, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia

                         Subcommittee on Health


                       MICHAEL C. BURGESS, Texas
                                 Chairman
BRETT GUTHRIE, Kentucky              GENE GREEN, Texas
  Vice Chairman                        Ranking Member
JOE BARTON, Texas                    ELIOT L. ENGEL, New York
FRED UPTON, Michigan                 JANICE D. SCHAKOWSKY, Illinois
JOHN SHIMKUS, Illinois               G.K. BUTTERFIELD, North Carolina
TIM MURPHY, Pennsylvania             DORIS O. MATSUI, California
MARSHA BLACKBURN, Tennessee          KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington   JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey            BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia         KURT SCHRADER, Oregon
GUS M. BILIRAKIS, Florida            JOSEPH P. KENNEDY, III, 
BILLY LONG, Missouri                     Massachusetts
LARRY BUCSHON, Indiana               TONY CARDENAS, California
SUSAN W. BROOKS, Indiana             ANNA G. ESHOO, California
MARKWAYNE MULLIN, Oklahoma           DIANA DeGETTE, Colorado
RICHARD HUDSON, North Carolina       FRANK PALLONE, Jr., New Jersey (ex 
CHRIS COLLINS, New York                  officio)
EARL L. ``BUDDY'' CARTER, Georgia
GREG WALDEN, Oregon (ex officio)

                                  (ii)
                             
                             
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     2
    Prepared statement...........................................     3
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, opening statement.......................................     4
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................     6
    Prepared statement...........................................     7
Hon. Susan W. Brooks, a Representative in Congress from the State 
  of Indiana, prepared statement.................................     9
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................    10
    Prepared statement...........................................    11
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, prepared statement..............................   108

                               Witnesses

Douglas Holtz-Eakin, Ph.D., President, American Action Forum.....    14
    Prepared statement...........................................    17
    Answers to submitted questions \1\...........................   188
J.P. Wieske, Deputy Commissioner, Wisconsin Office of the 
  Commissioner of Insurance......................................    23
    Prepared statement...........................................    25
J. Leonard Lichtenfeld, M.D., Deputy Chief Medical Officer, 
  American Cancer Society........................................    39
    Prepared statement...........................................    40
    Answers to submitted questions...............................   190

                           Submitted Material

Discussion Draft, H.R. ___, the Preexisting Conditions Protection 
  and Continuous Coverage Incentive Act of 2017, submitted by Mr. 
  Burgess........................................................   109
Discussion Draft, H.R. ___, the State Age Rating Flexibility Act 
  of 2017, submitted by Mr. Burgess..............................   116
Discussion Draft, H.R. ___, the Plan Verification and Fairness 
  Act of 2017, submitted by Mr. Burgess..........................   118
Discussion Draft, H.R. ___, the Health Coverage State Flexibility 
  Act of 2017, submitted by Mr. Burgess..........................   123
Article of January 30, 2017, ``It Cost $2.5 Million to Keep My 
  Child Alive,'' by Virginia Sole-Smith, Slate, submitted by Ms. 
  Schakowsky.....................................................   125
Letter of February 1, 2017, from Joyce A. Rogers, Senior Vice 
  President, Government Affairs, AARP, to Mr. Burgess and Mr. 
  Green, submitted by Mr. Butterfield............................   128
Chart, ``Forecasters: Obamacare enrollment will hold steady,'' by 
  Sarah Kliff, Vox.com, January 24, 2017, submitted by Ms. 
  DeGette........................................................   131
Report of the Congressional Budget Office, ``How Repealing 
  Portions of the Affordable Care Act Would Affect Health 
  Insurance Coverage and Premiums,'' submitted by Ms. DeGette....   133

----------
\1\ Dr. Holtz-Eakin did not answer submitted questions for the record 
by the time of printing.
Report of the Henry J. Kaiser Family Foundation, ``High-Risk 
  Pools for Uninsurable Individuals,'' July 2016, submitted by 
  Mr. Lujan......................................................   137
Statement of the Asian & Pacific Islander American Health Forum, 
  February 2, 2017, submitted by Mr. Green.......................   148
Statement of the American Heart Association, February 2, 2017, 
  submitted by Mr. Green.........................................   152
Letter of February 2, 2017, from Rob Restuccia, Executive 
  Director, Community Catalyst, to Mr. Walden and Mr. Pallone, 
  submitted by Mr. Green.........................................   156
Letter of February 2, 2017, from Debra L. Ness, President, 
  National Partnership for Women & Families, to Mr. Walden and 
  Mr. Pallone, submitted by Mr. Green............................   158
Statement of the National Women's Law Center, February 2, 2017, 
  submitted by Mr. Green.........................................   160
State of Wisconsin Report, ``Fact Sheet on Mandated Benefits in 
  Health Insurance Policies,'' submitted by Mr. Tonko............   163
Statement of Bill Flores, a Representative in Congress from the 
  State of Texas, submitted by Mr. Burgess.......................   171
Statement of the Blue Cross and Blue Shield Association, February 
  1, 2017, submitted by Mr. Burgess..............................   172
Statement of the American Congress of Obstetricians and 
  Gynecologists, February 2, 2017, submitted by Mr. Burgess......   175
Letter of January 2, 2017, from Richard I. Fiesta, Executive 
  Director, Alliance for Retired Americans, to Mr. Burgess and 
  Mr. Green, submitted by Mr. Burgess............................   180
Letter of February 2, 2017, from Mary Grealy, President, 
  Healthcare Leadership Council, to Mr. Burgess, submitted by Mr. 
  Burgess........................................................   182
Statement of America's Health Insurance Plans, February 2, 2017, 
  submitted by Mr. Burgess.......................................   184

 
             PATIENT RELIEF FROM COLLAPSING HEALTH MARKETS

                              ----------                              


                       THURSDAY, FEBRUARY 2, 2017

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:39 a.m., in 
Room 2123, Rayburn House Office Building, Hon. Michael C. 
Burgess (chairman of the subcommittee) presiding.
    Members present: Representatives Burgess, Guthrie, Barton, 
Upton, Shimkus, Murphy, Blackburn, McMorris Rodgers, Lance, 
Griffith, Bilirakis, Long, Bucshon, Brooks, Mullin, Hudson, 
Collins, Carter, Walden (ex officio), Green, Engel, Schakowsky, 
Butterfield, Matsui, Castor, Sarbanes, Lujan, Schrader, 
Kennedy, Cardenas, Eshoo, DeGette, McNerney, Tonko, and Pallone 
(ex officio).
    Staff present: Michael D. Bloomquist, Deputy Staff 
Director; Adam Buckalew, Professional Staff Member, Health; 
Karen Christian, General Counsel; Jordan Davis, Director of 
Policy and External Affairs; Paige Decker, Executive Assistant 
and Committee Clerk; Paul Edattel, Chief Counsel, Health; Blair 
Ellis, Press Secretary/Digital Coordinator; Adam Fromm, 
Director of Outreach and Coalitions; Caleb Graff, Professional 
Staff Member, Health; Jay Gulshen, Legislative Clerk, Health; 
Zach Hunter, Communications Director; Peter Kielty, Deputy 
General Counsel; Katie McKeough, Press Assistant; Carly 
McWilliams, Professional Staff Member, Health; James 
Paluskiewicz, Professional Staff Member, Health; Kristen 
Shatynski, Professional Staff Member, Health; Jennifer Sherman, 
Press Secretary; Josh Trent, Deputy Chief Counsel, Health; 
Hamlin Wade, Special Advisor for External Affairs; Luke 
Wallwork, Staff Assistant; Jeff Carroll, Minority Staff 
Director; Tiffany Guarascio, Minority Deputy Staff Director and 
Chief Health Advisor; Jessica Martinez, Minority Outreach and 
Member Services Coordinator; Dan Miller, Minority Staff 
Assistant; Samantha Satchell, Minority Policy Analyst; Matt 
Schumacher, Minority Press Assistant; Andrew Souvall, Minority 
Director of Communications, Member Services, and Outreach; and 
Arielle Woronoff, Minority Health Counsel.
    Mr. Burgess. I want to thank our guests for being with us 
this morning. I thank everyone for their indulgence. The 
Subcommittee on Health will now come to order. I will recognize 
myself for 5 minutes.

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

    We are all here to help Americans, all Americans, insured, 
uninsured and functionally uninsured. We want people to get 
access to quality affordable health care. Our system is plagued 
with problems that impose the highest burden on individuals and 
consumers who have fewer choices, sometimes burdensome 
mandates, costs that continue to spike and--Americans who 
remain uninsured.
    Leading up to the 2016 elections, promises were made to 
voters that the healthcare system would get back on track. We 
laid out a step-by-step plan to prioritize access to quality 
affordable health care not just insurance. The new 
administration has taken steps to reduce the regulatory burden, 
and this hearing marks another step in that journey to 
stabilize and rebuild our healthcare system.
    I will be the first to admit we do not agree on everything, 
but members of this subcommittee, both sides of the dais, have 
a strong track record of advancing bipartisan legislation. I am 
confident we can continue to advance bills through an open and 
through an inclusive process to protect and empower patients.
    In today's hearing we will consider policies that bolster 
the health markets and reassure Americans that help is on the 
way. To start, we all agree that individuals should have the 
comfort of knowing that they will not be denied a health plan 
from an insurer based upon their health status.
    Chairman Walden has offered a bill that will maintain 
safeguards for patients with preexisting conditions following 
the repeal of the Affordable Care Act. In addition, 
Representative Brooks is working on a bill that will go beyond 
protections for preexisting conditions by creating incentives 
for continuous coverage.
    Currently, individuals moving from one job to another are 
protected from rate increases by existing law. Extending these 
protections to the individual market is a simple but important 
reform that will encourage Americans to enroll in coverage and 
to stay enrolled. Rather than forcing people to buy insurance 
that fails to meet their needs, this policy will reward people 
for making responsible decisions.
    Young, healthy adults have faced the highest rate hikes in 
premiums to account for the higher costs of covering older, 
less healthy individuals. Today we will discuss legislation 
offered by Representative Bucshon to modify age rating 
restrictions and bring younger, healthier individuals into the 
insurance market.
    Regulations have allowed individuals to keep coverage for a 
full 3 months without paying premiums. Dozens of statutory and 
regulatory instances allow individuals to enroll in a plan 
through a special enrollment period. To stabilize the market, 
Representative Flores and Representative Blackburn have offered 
legislation intended to end manipulation of health insurance 
rules.
    I look forward to hearing from our witnesses on the merits 
of setting the grace period to 30 days for nonpayment of 
premiums and requiring verification of eligibility for those 
special enrollment periods. I think it is important to note 
that all of these bills, all of these bills would allow States 
the flexibility to modify the requirements. After all, States 
understand what their residents need better than Washington.
    Good policy that will stand the test of time requires hard 
work. It requires compromise. It requires the scrutiny of the 
American people. As we learned with the Affordable Care Act, 
policy hastily built by folks behind closed doors results in 
devastating consequences. We are committed to large-scale 
reform. Real people are struggling as we speak, and we are not 
waiting to take action.
    These bills are an important example of the work we are 
doing right now, right now to advance Member-driven solutions 
that will improve health care for Americans. I am hopeful, 
hopeful that we can work together to reform our health system 
for the benefit of the American people.
    [The statement of Mr. Burgess follows:]

             Prepared statement of Hon. Michael C. Burgess

    We are here to help all Americans-insured, uninsured, and 
functionally uninsured-to get access to quality, affordable 
health care. Our healthcare system is plagued with problems 
that impose the highest burden on individuals-consumers have 
fewer choices and burdensome mandates, costs continue to spike, 
and as many as 30 million Americans remain uninsured.
    Leading up to the 2016 elections, we promised voters that 
we would get health care back on track. We laid out a step-by-
step plan to prioritize access to quality affordable health 
care, not just insurance. The new administration has taken 
steps to reduce regulatory burden, and this hearing marks 
another step in our journey to stabilize and rebuild our 
healthcare system.
    While we do not agree on everything, members of this 
subcommittee have a strong track-record of advancing bipartisan 
legislation. I am confident that we can continue to advance 
bills through an open and inclusive process to protect and 
empower patients.
    In today's hearing, we will consider policies to bolster 
our collapsing health markets and reassure Americans that help 
is on the way. To start, we all agree that individuals should 
have the comfort of knowing they will not be denied a plan from 
a health insurer based on their health status. Chairman Walden 
has offered a bill that will maintain safeguards for patients 
with preexisting conditions following repeal of the ACA.
    In addition, Representative Brooks is working on a bill 
that will go beyond protections for preexisting conditions by 
creating incentives for continuous coverage.
    Currently, individuals moving from one job to another are 
protected from rate increases by existing law. Extending these 
protections to the individual market is a simple but important 
reform that will encourage Americans to enroll in coverage and 
stay enrolled. Rather than forcing people to buy insurance that 
fails to meet their needs, this policy will reward people for 
making responsible decisions.
    Young, healthy adults have faced the highest rate hikes in 
premiums, to account for the higher costs of covering older, 
less healthy individuals. Today we will discuss legislation 
authored by Representative Bucshon to modify age rating 
restrictions and bring younger healthier individuals into the 
insurance market.
    Regulations have allowed individuals to keep coverage for 
three full months without paying premiums. Dozens of statutory 
and regulatory instances allow individuals to enroll in a plan 
through a special enrollment period. To stabilize the market, 
Representative Flores and Representative Blackburn have 
authored legislation intended to end gaming of health insurance 
rules.
    I look forward to hearing from our witnesses on the merits 
of setting the grace period to 30 days for nonpayment of 
premiums, and requiring verification of eligibility for special 
enrollment periods. I think it is important to note that all of 
these bills would allow States the flexibility to modify these 
requirements. After all, States understand what their residents 
want and need better than Washington.
    Good policy that will stand the test of time requires hard 
work, compromise, and the scrutiny of the American people. As 
we learned during the ACA, policy hastily crafted by Government 
bureaucrats behind closed doors results in devastating 
consequences.
    While we are committed to large-scale reform, real people 
are struggling as we speak and we are not waiting to take 
action. These bills are an important example of the work we are 
doing right now to advance Member-driven solutions that will 
improve health care for all Americans. I am hopeful that we can 
work together to reform our healthcare system for the benefit 
of the American people.

    Mr. Burgess. And I would now like to yield the remainder of 
my time to Dr. Larry Bucshon of Indiana.
    Mr. Bucshon. Thank you, Mr. Chairman. Currently the 
Affordable Care Act requires that the most generous plan costs 
no more than three times the least generous plan according to 
age. As a consequence, younger healthier individuals have been 
priced out of the health insurance market, destabilizing risk 
pools and driving premiums higher for everyone.
    H.R. 708, the State Age Rating Flexibility Act of 2017 
would set this ratio at 5:1 or also allow States to set their 
own age rating based on their unique patient population. For 
example, Indiana had no age rating prior to the ACA. This 
solution encourages more actuarially sound plans to enter the 
marketplace, providing more affordable options for younger, 
healthier individuals and bringing them back into the insurance 
market to more adequately balance the risk pools and drive down 
the premiums for almost everyone. I yield back.
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman, and the Chair recognizes the gentleman from 
Texas, Mr. Green, 5 minutes for the purpose of an opening 
statement, please.
    Mr. Green. Thank you, Mr. Chairman. Before I start, we have 
a member of our Energy and Commerce Committee but not a member 
of the subcommittee. I would like to ask to waive on Jerry 
McNerney, who will be here shortly, and I just wanted to give 
notice that----
    Mr. Burgess. Is the gentleman making a unanimous consent 
request?
    Mr. Green. Yes.
    Mr. Burgess. Without objection, so ordered.
    Mr. Green. OK, and Congressman Paul Tonko, also unanimous 
consent.
    Mr. Burgess. Again, without objection, so ordered.

   OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Green. Thank you, Mr. Chairman. Thanks to the 
Affordable Care Act, 20 million previously uninsured Americans 
now have health coverage. For the first time ever, less than 
nine percent of Americans are uninsured with the uninsured rate 
currently at 8.6 percent. Since the enactment of the ACA, for 
roughly 150,000 million Americans who have coverage through 
their employer, premium growth remains much lower than in the 
past and everyone benefits from consumer protections and 
provisions that improve and expand coverage.
    Unfortunately, my colleagues want to undo the progress we 
have made. There should be no repeal of healthcare reform 
without an immediate adequate replacement that achieves the 
same historical gains in coverage, ensures people with 
preexisting conditions aren't blocked or priced out of the 
market, and that health plans cover a basic set of benefits and 
consumer protections.
    Repealing the Affordable Care Act in whole or in part 
without an adequate replacement in place would cause chaos and 
is downright irresponsible. It has been 7 years, and, despite 
claims to have a better way, the bills we are considering today 
will only further sabotage the existing system and offer only 
unfinished, inadequate proposals that as written would leave 
Americans worse off and put insurance companies back in charge.
    It is truly fitting that today is Groundhog Day, except 
unlike Bill Murray it is not a comedy. For 7 years we have 
asked Republicans to work with us to strengthen the ACA and 
make health care more affordable and accessible, and for 7 
years they told us they would not. This is real and not an 
abstract intellectual debate, and the discussion draft my 
colleagues have put forward today is just indefensible.
    Thirty million people would stand to lose their health 
insurance if the ACA is repealed. The emergency room should not 
be the point of entry for our healthcare system. It is bad for 
patients, budgets and the healthcare system as a whole. Repeal 
and replace is a slogan not a meaningful policy and would 
likely put us on a path to catastrophe.
    The gravity of the situation is hard to overstate. There 
are real people with real concerns who deserve more than a half 
written bill and inadequate talking points. Proceeding with 
repeal with half-baked ideas for replacement is offensive and 
confusing and alarming. My colleagues across the aisle control 
the Congress and the White House. Millions of people are 
relying on them and looking to them for what they are going to 
do to protect them. We are well past talking points and the 
American people deserve answers.
    As always, I stand to work with my colleagues, with anyone, 
to amend and improve the Affordable Care Act. And thank you, 
Mr. Chairman. I yield the remaining balance of time to 
Congresswoman Schakowsky.
    Ms. Schakowsky. Thank you. It has been reported that some 
of our Republican colleagues have recently voiced important and 
specific concerns about repealing the ACA. And, for example, 
Congressman Tom McClintock of California, quote, said, ``We had 
better be sure that we are prepared to live with the market 
being created ... that's going to be called `Trumpcare.' 
Republicans will own it lock, stock, and barrel.'' And then 
Congressman Tom MAcArthur of New Jersey said, quote, ``We're 
telling those people that we're not going to pull the rug out 
from under them, and if we do this too fast, we are, in fact, 
going to pull the rug out from under them.''
    Mr. Cassidy pointed out that their plan to tax employer-
sponsored insurance will increase taxes on the middle class, 
and these serious concerns and unanswered questions show that 
Republicans are finally starting to realize what Democrats have 
known all along, that their plan to sabotage the ACA will leave 
millions of Americans without coverage, will reduce the quality 
of insurance, and will raise costs for everyone.
    And regardless of the rhetoric that we may hear today, we 
know that this half-written, half-baked bill put forth by 
Chairman Walden will allow insurance companies to charge people 
with preexisting conditions whatever they want and charge them 
whatever they want for their coverage. That is what the bill 
actually does.
    Now that Republicans have started to recognize the 
consequences of their plan to take away coverage from 30 
million Americans, I hope that they will finally actually work 
with us to make health care more affordable and more 
accessible. We are ready to sit down. We have been ready for 7, 
8 years to do exactly that. Let's do it.
    I do agree with the chairman of the subcommittee that we 
all agree that we want to provide quality, affordable health 
care. Those Republicans who have misgivings are right to have 
that. So let's sit down and do it together instead of these 
continual proposals that will hurt all of our constituents. And 
I yield back to the gentleman from Texas.
    Mr. Burgess. The gentlechair thanks the gentlelady. The 
gentlelady yields back. The Chair would like to recount the 
number of times it was rebuffed by the Obama administration on 
those very points, but I will reserve that until later. The 
Chair now recognizes the chairman of the full committee, Mr. 
Walden, 5 minutes for questions, please, for an opening 
statement, please.

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

    Mr. Walden. Yes, thank you. Thank you, Mr. Chairman, I 
appreciate it and I appreciate the concerns of my colleagues. I 
would note from the record there have been multiple pieces of 
legislation since Obamacare was enacted that have received 
Democrat and Republican votes and actually signed by the 
President to repeal problems in Obamacare. Those became law.
    So to argue that nothing has ever been done to try and 
straighten it out is false. I think Democrats combined cast 
4,775 votes to repeal, to reform, to change Obamacare, so check 
the facts. We are here today, we know on our side we are going 
to repeal Obamacare. It is not working. It has left a lot of 
wreckage around. We are here to clean it up. And in fact we are 
wide open to hearing from our colleagues on policy. That is 
what we are about.
    We know Obamacare has, what it has done to the healthcare 
system. It is why we are hard at work crafting reconciliation 
language to repeal it, and today we begin the important work of 
laying the foundation to rebuild America's healthcare markets 
as we dismantle Obamacare. We have to save this individual 
healthcare insurance market. It is collapsing. And if you want 
to walk away and just let it collapse, a pox on your side. That 
is not what I am about. I have always been a problem solver.
    You will hear us in a minute talk about bipartisan 
legislation, go after those who try and corner certain markets, 
drive up costs--things like EpiPen. I am happy to work with 
you, but it has to be something that can move this forward and 
take care of people. There is no shortage of evidence that 
patients and families are hurting under the overwhelming weight 
of Obamacare. Patients in 21 States have seen average premium 
increases of 25 percent or more this year. People in seven 
States will experience premium increases of 50 percent or more. 
That is not sustainable.
    In 2016 there were 225 counties across America that had 
just one insurance choice in the market, just one on the 
exchange. This year that number has climbed to a 1,022, 1,022 
counties with just one insurer. That is a third of the entire 
number of counties in the country, a third. Five entire States 
now, patients there have just one choice.
    And if you focus on what those plans are saying, they are 
evaluating right now whether they can even stay in these 
markets in the outlying years because of what is coming in 
existing law passed in a partisan manner by Democrats. Over 
five of the original 23 insurance co-ops remain in business, 
five of 23. They tried it, it didn't work. Two of those failed 
co-ops are sadly in my own State of Oregon and we are pretty 
progressive about trying new things and a lot of it has worked. 
These did not.
    We have the responsibility to prevent a real train wreck 
for millions of Americans. Not only can we solve this problem 
but we must solve this problem. It is time to end the partisan 
rhetoric and actually come to the table and solve these 
problems and I commend my colleagues on both sides of the aisle 
who are willing to do that.
    The proposals before us today close enrollment gaps, 
protect taxpayers and give patients cost relief. The first 
three bills should come as no surprise. They were introduced 
last Congress and were the topic of two hearings in this 
subcommittee. The other proposal is equally important to all of 
us. We will ensure patients with preexisting conditions will 
always have access to coverage and care, period.
    To take this a step further, we have included a placeholder 
as all of you have sort of referenced in your testimony, and I 
appreciate your testimony. Everybody has a different view of 
this. We want to get it right. That is why there is placeholder 
language. Our Better Way agenda envisions a new patient 
protection in the individual market for helping patients keep 
health coverage. HIPAA, Medicare Part B, Medicare Part D can 
serve as guidance for the Congress as we consider how best to 
achieve the goals of protecting America's sickest patients and 
maintaining market stability. We can do both without 
Obamacare's unpopular individual mandate where all these carve-
outs have occurred.
    We have got the best minds focused on helping us, including 
our witnesses today. We are going to get this right. We are 
going to take the time to get this right. That is why you see a 
placeholder language in the draft. And my colleague Susan 
Brooks is championing these efforts and I would actually like 
to yield her a few minutes for remarks at this time, and then I 
will conclude with one other announcement.
    [The statement of Mr. Walden follows:]

                 Prepared statement of Hon. Greg Walden

    We all know the damage Obamacare has wrought on our 
healthcare system, which is why this committee is hard at work 
crafting reconciliation language to repeal it. But today, we 
begin the important work of laying the foundation to rebuild 
America's healthcare markets as we dismantle Obamacare; 
especially, saving the individual market from total collapse-
which is where it is headed absent our intervention.
    Look, there's no shortage of evidence that patients and 
families are hurting under the overwhelming weight of 
Obamacare.
     Patients in 21 States have seen average premium 
increases of 25 percent or more this year.
     Folks in seven States will experience premium 
increases of 50 percent or more.
     In 2016, 225 counties had one insurer. This year, 
there are 1,022 counties with just one insurer--that's a third 
of the entire country.
     Five entire States just have one insurer offering 
coverage on the exchange.
     Only five of the original 23 health insurance co-
ops remain in business. In my home State of Oregon, we had not 
one, but two co-ops fail!
    We have the responsibility to prevent a real train wreck 
for millions of Americans. Not only can we solve this problem, 
but we must solve this problem.
    The proposals before us today close enrollment gaps, 
protect taxpayers, and give patients cost relief. The first 
three bills should come as no surprise--they were introduced 
last Congress, and were the topic of two hearings in this 
subcommittee.
    The other proposal is equally important to all of us. We 
will ensure patients with preexisting conditions will always 
have access to coverage and care. Period.
    To take this a step further, we've included a placeholder 
for a continuous coverage incentive. Our Better Way agenda 
envisions a new patient protection in the individual market for 
helping patients keep health coverage. HIPAA, Medicare Part B 
and Medicare Part D can serve as guidance for the Congress as 
we consider how to best achieve the goals of protecting 
America's sickest patients and maintaining market stability. We 
can do both without Obamacare's unpopular individual mandate.
    We've got the best minds focused on helping us, including 
our witnesses today. We are going to take time to get it right. 
That's why you see placeholder language in the draft, today. My 
colleague, Susan Brooks is championing these efforts, and I'd 
like to yield to her for a few remarks. Mrs. Brooks. ...
    Thank you, Susan.
    While I know our focus today is on insurance reforms, we 
are also working in other areas of health care to bring relief 
to patients. Next week, we will take up legislation sponsored 
by Rep. Gus Bilirakis and Rep. Kurt Schrader that would 
incentivize generic drug development and increase competition 
in the market. And for those in industry who think it's OK to 
corner a market, drive up prices and rip off consumers, know 
that your days are numbered.
    President Trump made it clear in the White House meeting I 
attended with him and Vice President Pence: He wants 
competition that will bring lower drug prices and that is 
precisely what this measure will accomplish. Patients are tired 
of waiting for relief. We are going to move forward in a 
bipartisan way to give them help. It's an important step 
forward. And it needs to happen now.
    Specifically, the bill would require FDA to prioritize and 
expedite the review of generic applications for drug products 
that are currently in shortage or where there are few 
manufacturers on the market, if any. We all remember recent 
situations where bad actors jacked up the price of older, off-
patent drugs because there was no competition. We want to make 
sure that doesn't happen again.
    This bill would also increase transparency around the 
current generic backlog at FDA. While progress has been made, 
there are still an unacceptably high number of generic drug 
applications sitting at FDA that, if and when approved, could 
bring additional lower cost alternatives to patients. Whether 
it's examples like daraprim or EpiPen, patients need solutions 
and this bipartisan bill gives us all a new tool to fight back 
on their behalf.

    Mrs. Brooks. Thank you, Mr. Chairman. Yes, I agree. We all 
agree we have to save the individual market, yet we all know 
current law requires individuals to buy Government-dictated 
insurance. Instead, we propose giving people freedom from this 
mandate, it is only fair. Continuous coverage isn't a new idea. 
It has been discussed by reputable public policy organizations 
like the economic and political freedom center at Hoover 
Institution, free enterprise-focused American Enterprise 
Institute and others.
    We don't pretend that this is the only solution, but we are 
confident that continuous coverage provides promise. That is 
why it is part of our Better Way Plan, a fairness agenda for 
helping patients get relief. And today this placeholder 
provides the clearest signal yet that we are working with 
patients and healthcare groups to draft language that balances 
important health status protections with necessary risk 
mitigation tools.
    I look forward to the panelists' expert feedback today on 
the value of how this idea might help patients get and keep 
health coverage, and with that I yield back.
    [The statement of Mrs. Brooks follows:]

               Prepared statement of Hon. Susan W. Brooks

    Thank you, Mr. Chairman.
    As we all know, current law requires individuals to buy 
Government-dictated insurance. Instead, we propose giving 
people freedom from this mandate--it's only fair.
    Continuous coverage isn't a new idea. It's been discussed 
by reputable public policy organizations like the economic and 
political freedom-centered Hoover Institution and the free 
enterprise-focused American Enterprise Institute. This coverage 
incentive has also been contemplated in publications by Rand 
Corporation, Urban Institute, and others.
    We don't pretend that this is the only solution. But we're 
confident that continuous coverage provides promise. This is 
why it's part of our Better Way plan--our fairness agenda for 
helping patients get relief. And today, this placeholder 
provides the clearest signal yet that we're working with 
patients and healthcare groups to draft language that balances 
important health status protections with necessary risk 
mitigation tools.
    I look forward to the panelists' expert feedback on the 
value of how this idea may help patients get--and keep--health 
coverage.

    Mr. Walden. Mr. Chairman, if I could just conclude. While I 
know our focus today is on insurance reforms, we are also 
working in other areas of health care to bring relief to 
patients. Next week we will take up legislation sponsored by 
Representatives Bilirakis and Schrader, bipartisan bill that 
would incentivize generic drug development and increased 
competition in the market.
    And for those in the industry who think it is OK to corner 
a market and drive up prices and rip off consumers, know that 
your days are numbered. President Trump made it clear in the 
White House meeting I attended with him and Vice President 
Pence, he wants competition that will bring lower drug prices 
and that is precisely what this measure will help accomplish.
    Patients are tired of waiting for relief. We are going to 
move forward in a bipartisan way to give them help. It is an 
important first step. It needs to happen now. Specifically, the 
bill would require FDA to prioritize and expedite the review of 
generic applications for drug products that are currently in 
shortage or where there are few manufacturers on the market.
    We all remember recent situations where bad actors jacked 
up the price of older, off-patent drugs because there was no 
competition. We want to make sure that does not happen again. 
This bill would also increase transparency around the current 
generic backlog at FDA, and while progress has been made there 
are still an unacceptably high number of generic drug 
applications sitting at the Food and Drug Administration that 
if and when approved could bring additional lower cost 
alternatives to patients.
    Whether it is examples like Daraprim or EpiPen, patients 
need solutions. I believe this bipartisan bill gives us a new 
tool to fight back on their behalf. I thank you for the 
indulgence of the committee and I yield back the balance of my 
time.
    Mr. Burgess. The Chair thanks the gentleman. The Chair 
recognizes the gentleman from New Jersey, Mr. Pallone, 5 
minutes for an opening statement, please.

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

    Mr. Pallone. Thank you, Mr. Chairman. I am trying not to 
blow up here today because I like Chairman Walden, he is a nice 
guy. I like the gentlewoman from Indiana, she is a lovely 
woman. But I just, the statements that are coming out from the 
two of you about what you think you are doing versus what is 
really happening here are very disturbing to me.
    No one has a problem with making improvements to the ACA, 
but you are not seeking to make improvements. You are seeking 
to repeal it without saying how you are going to replace it. 
And, you know, you can do a little, you know, if you really 
wanted to make some changes and do some things without 
repealing it, you know, we would be fine to work together, but 
there is no suggestion of that. And the idea that this is 
collapsing of its own weight is simply not true.
    The reason that the ACA is going to have problems here is 
because you and the President are purposely, in my opinion, 
making it collapse because of the policies that you are 
espousing. You know, the best example of that was when the 
White House last week announced that they weren't going to do 
anymore promotion. They were going to pull the ads, so that 
people wouldn't even be able to sign up or wouldn't even know 
what they were signing up for.
    So, you know, don't suggest to me that somehow this is 
going to collapse because of the bill, because of the ACA. It 
is going to collapse because of purposeful Republican policies. 
And, you know, the gentleman from Indiana mentioned the 
individual mandate. You know that without the individual 
mandate that the younger and healthier people are not going to 
sign up, and then the insurance pool becomes broken and then 
the insurance companies pull out and gradually the ACA 
collapses, again if you eliminate the individual mandate.
    So I just have to say, you know, Republicans have been 
rooting for the demise of the Affordable Care Act for 7 years, 
actively trying to sabotage the law. They have done this under 
the guise of having a better way, but today it is clear that 
this was never the case. Now that the time has come for them to 
actually show the public this better way they are in complete 
disarray and today it is clear that Republicans have no plan to 
replace the ACA. Every day their timeline changes and all they 
have successfully done so far is create chaos and uncertainty 
among patients and insurance companies. Chaos here with the 
ACA, chaos with immigration, chaos with foreign policy, the 
list goes on from this badly motivated person, in my opinion, 
who is in the White House.
    The bills we are discussing today are supposedly the first 
pieces of the Republicans' elusive plan, so essentially, after 
a 7-year smear campaign on the ACA, they intend to move forward 
three bills from last Congress that help insurance companies 
instead of people.
    And another bill, the only so-called replacement, is 
literally half-written. You know, I had to laugh--again I love 
you, Dr. Burgess, but I had to laugh when you said that the ACA 
was hastily built upon. I mean, the chairman's bill literally 
runs off the page. I mean, I took it this morning and I started 
to read it, and then I got to ``Title II 09 Continuous 
Coverage,'' it says, ``incentive [placeholder].'' Talk about 
hastily built, what is this, half-built? I mean, I just, I 
don't even know where to begin.
    [The statement of Mr. Pallone follows:]

             Prepared statement of Hon. Frank Pallone, Jr.

    Since 1965, the Medicaid program has been an invaluable 
resource to poor families, pregnant women, children, seniors, 
and now, thanks to the Affordable Care Act, low-income working 
adults. It is also the program that individuals with 
disabilities depend on to maintain independence in the 
community.
    In 2016, over 97 million Americans depended on Medicaid at 
some point during the year. Together, Medicaid and CHIP cover 1 
in 3 children in this country, and nearly half of all births. 
It is undeniable that Medicaid coverage pays us back as a 
society tenfold--that's why improving and strengthening 
Medicaid for generations to come continues to be one of my 
primary goals.
    Last Congress, this committee worked together on targeted 
policies that genuinely strengthened and improved the Medicaid 
program for beneficiaries. Unfortunately, the bills before us 
today do not share these priorities. In fact, one piece of 
legislation continues the Trump administration's assault 
against our legal permanent resident population and naturalized 
citizens.
    The Republican strategy to strengthen Medicaid is to remove 
or exclude certain people from the program and then apply those 
resources to another person. This is a meaningless approach to 
resource management. There is no evidence to suggest that some 
beneficiaries take away resources from others, or that 
excluding some beneficiaries will benefit others.
    In today's hearing we will discuss three bills that are 
based on this very falsehood, bills that target specific 
beneficiaries for exclusion. Bills that ultimately incentivize 
and reward those States that choose to operate waiting lists 
for Home and Community Based Services.
    In order to truly strengthen the Medicaid program, we 
should expand coverage, protect against fraud, and implement 
advanced delivery system reform. The Affordable Care Act did 
just that. Thanks to the Affordable Care Act, 31 States and the 
District of Columbia have adopted expansion and dramatically 
lowered the uninsured rate. All 50 States are testing 
innovative models of care, and Medicaid eligibility and data 
collection systems have been modernized.
    Medicaid has always been under attack by Republicans, but 
the threat to this program and to its beneficiaries is more 
dangerous than ever before. Republican policies to cap or turn 
the program into a block grant would result in the rug being 
pulled out from under millions of children, elderly, 
individuals with disabilities and low-income working adults. 
These policies are nothing but bad for our providers and our 
State economies. In fact, one analysis by the Kaiser Family 
Foundation found that block granting Medicaid would lead States 
to drop between 14.3 million and 20.5 million people from 
Medicaid, an enrollment decline of 25 to 35 percent, and would 
lead States to cut provider reimbursements by more than 30 
percent.
    Republicans keep saying that they have a plan--and that 
Americans will not lose their health coverage. It's clear 
today, that the Republicans only game plan right now is to 
sabotage health coverage for tens of millions of Americans.
    I yield back.

    Mr. Pallone. I am going to stop, because I have to give 
some time to Congressman Kennedy and then, if there is also 
time, to Representative Castor, so I will yield to the 
gentleman from Massachusetts initially.
    Mr. Kennedy. Thank you, and I thank the ranking member. I 
want to thank Chairman Burgess and Ranking Member Green for 
their leadership as we confront one of the most contentious 
debates this body will address in the coming year. All of us in 
the subcommittee can agree that there is room for improvement 
in our healthcare system from premium deductibles that should 
be lower, insurance options in rural and underserved areas that 
must be increased.
    But there are also areas where the law is working well. In 
Massachusetts we have a 2.8 percent unemployment rate and a 2.8 
percent uninsured rate. On this side of the dais we are happy 
to have the debate about fixing the Affordable Care Act, but 
repealing the ACA without a replacement, and the four half 
measures today before us are not a replacement, will only 
exacerbate those problems. More than that it will erode the 
very minor progress that we have made to reform our mental 
healthcare system in this very room last year with 21st Century 
Cures.
    For the roughly 43 million Americans suffering from mental 
illness, parity laws that currently guarantee coverage will 
crumble. For the 30 percent of patients with a mental health 
issue that is covered by the Medicaid expansion treatment will 
no longer be within reach. For constituents in all of our 
districts, red or blue, rural and urban, preventive screenings 
for behavioral health that can save lives will be unaffordable 
and inaccessible. Simply put, no matter where you live if you 
have coverage or you are uninsured, you are on an uncertain 
path that will lead to seismic, tragic shifts in our behavioral 
healthcare system. Today is an opportunity for all of our 
colleagues to commit to changing course. I yield back.
    Mr. Pallone. Mr. Chairman, Mr. Walden had like an extra 
minute and a half, and I would like Ms. Castor to have a minute 
if possible. I would ask unanimous consent.
    Mr. Burgess. Are you asking a unanimous consent request? So 
ordered.
    Ms. Castor. Well, thank you very much. Members, the fear 
across America is widespread about the Republican plan to 
withdraw this lifeline that is the Affordable Care Act. I 
wanted to tell you about a woman who approached me recently 
back in Tampa. Sixty-year-old Kathy Palmer is a single parent 
with a student in high school. She is doing everything right. 
She is working part-time at a small company. She is working 
towards her bachelor's degree in accounting. She is paying her 
fair share in taxes.
    She took personal responsibility--because her company is so 
small and doesn't provide health insurance--she took personal 
responsibility and went shopping out on healthcare.gov, and in 
our very robust market, far from collapsing in the Tampa Bay 
area, where we have 61 plans to choose from, she chose a plan 
and she has been paying her premiums.
    And thank goodness for that, because in December she wound 
up in the hospital with what she thought was a heart attack. 
When she got out of the hospital that bill for all the care she 
received was $70,000. Without the Affordable Care Act, she 
would be bankrupt. Her future and probably her child's future 
would have been very bleak.
    So I ask my Republican colleagues to listen to our 
constituents all across this country. Before you go and do the 
damage of repealing the Affordable Care Act, understand what it 
will mean for the families that we represent and their economic 
futures. I yield back.
    Mr. Burgess. Does the gentleman from New Jersey yield back?
    Mr. Pallone. Yes, Mr. Chairman.
    Mr. Burgess. The Chair thanks the gentleman. The gentleman 
yields back. We now conclude with Member opening statements. 
The Chair would remind Members that, pursuant to committee 
rules, all Members' opening statements will be made part of the 
record. We want to thank our witnesses for being here today, 
for taking time to testify before the subcommittee. Each 
witness will have the opportunity to give an opening statement 
followed by questions from our Members.
    We are pleased today to welcome Dr. Doug Holtz-Eakin, no 
stranger to this committee room, president of the American 
Action Forum; Mr. J.P. Wieske, deputy commissioner for 
insurance for the State of Wisconsin; and Dr. Leonard 
Lichtenfeld, deputy chief medical officer for the American 
Cancer Society.
    We appreciate each of you being here today. We will begin 
our panel with Dr. Holtz-Eakin, and you are recognized 5 
minutes for the purpose of an opening statement.
    Mr. Kennedy. Mr. Chairman, just before we begin the 
statements, I would like to raise a parliamentary inquiry.
    Mr. Burgess. The gentleman from Massachusetts, for what 
purpose does the gentleman from Massachusetts seek recognition?
    Mr. Kennedy. Mr. Chairman, I ask a parliamentary inquiry to 
try to understand from you, sir, given some of the hearing----
    Mr. Burgess. The gentleman will state his parliamentary 
inquiry.
    Mr. Kennedy. I would like assurance, Mr. Chairman, given 
what we have learned in the past several days about 
coordination between various House staffers and the 
administration and transition team and the signing of 
nondisclosure agreements----
    Mr. Burgess. The gentleman----
    Mr. Kennedy. Would like to understand if such agreements--
--
    Mr. Burgess. The gentleman has actually not stated a 
parliamentary inquiry, but I do want to accommodate your 
request. We are here of course to take testimony on bills 
before the committee. I think that can proceed, and I will 
defer to the chairman of the full committee for a discussion 
with you on your parliamentary inquiry.
    The gentleman, Dr. Holtz-Eakin, is recognized for 5 minutes 
for an opening statement, please.
    Mr. Kennedy. So Mr. Chairman, when--I appreciate your 
deference to the full committee chairman as to what is going to 
happen next. What, just so I understand given as you did 
indicate the challenge of hastily built----
    Mr. Burgess. The gentleman did not state a parliamentary 
inquiry.
    Mr. Kennedy. And so my question about----
    Mr. Pallone. He didn't finish his sentence.
    Mr. Kennedy [continuing]. The existence of nondisclosure 
agreements is unanswered, so it is unanswered.
    Mr. Burgess. The gentleman, Mr. Holtz-Eakin, is recognized 
5 minutes for the purpose of summarizing your opening 
statement.
    Mr. Griffith. Mr. Chairman. Mr. Chairman, parliamentary 
inquiry.
    Mr. Burgess. For what purpose does the gentleman from 
Virginia seek recognition?
    Mr. Griffith. Mr. Chairman, I inquire that if a Member asks 
a question that is not a parliamentary inquiry, is it not 
improper for the chairman to answer?
    Mr. Burgess. Yes.
    Mr. Griffith. So then you would actually be out of order if 
you attempted to answer Mr. Kennedy's question. Am I not 
correct?
    Mr. Burgess. Yes.
    Mr. Griffith. I yield.
    Mr. Pallone. Mr. Chairman.
    Mr. Burgess. For what purpose does the gentleman from New 
Jersey seek----
    Mr. Pallone. I just, I am not sure I understood what you 
were saying. You are saying you are going to get back to us 
about--I understand you are saying it is not a parliamentary 
inquiry, but did you say you are going to get back to Mr. 
Kennedy and respond to his question, or that Chairman Walden 
would? Is that what you said?
    Mr. Burgess. Well, the parliamentary inquiry was not about 
the proceeding with today's hearing on taking testimony from 
witnesses on the bill in front of us. I do respect the 
gentleman from Massachusetts a great deal, as he knows, and I 
do want to see his question answered for him, and I will seek 
the proper forum with the chairman of the full committee for 
him to do so.
    Mr. Pallone. So you will get back to us to respond to his 
question.
    Mr. Burgess. We will seek the appropriate forum.
    The gentleman, Dr. Holtz-Eakin is recognized.
    Mr. Butterfield. Mr. Chairman. Mr. Chairman.
    Mr. Burgess. For what purpose does the gentleman from North 
Carolina seek recognition?
    Mr. Butterfield. I have a unanimous consent request.
    Mr. Burgess. The gentleman will state his unanimous consent 
request.
    Mr. Butterfield. I would ask unanimous consent that the 
gentleman from Massachusetts be allowed to restate his 
parliamentary inquiry because I did not hear it. He was 
interrupted in the middle of the sentence.
    Mr. Griffith. I object.
    Mr. Burgess. Objection is heard.
    The Chair yields 5 minutes to Dr. Holtz-Eakin for the 
purpose of summarizing your opening statement.

 STATEMENTS OF DOUGLAS HOLTZ-EAKIN, PH.D., PRESIDENT, AMERICAN 
   ACTION FORUM; J.P. WIESKE, DEPUTY COMMISSIONER, WISCONSIN 
    OFFICE OF THE COMMISSIONER OF INSURANCE; AND J. LEONARD 
   LICHTENFELD, M.D., DEPUTY CHIEF MEDICAL OFFICER, AMERICAN 
                         CANCER SOCIETY

                STATEMENT OF DOUGLAS HOLTZ-EAKIN

    Dr. Holtz-Eakin. Thank you. Mr. Chairman, Ranking Member 
Green, members of the committee, I appreciate the chance to be 
here today to discuss these proposals to stabilize the ACA 
individual market. I am going to make three simple points. 
Point number one is that doing nothing is not an option. Under 
current law the trend in the individual market is quite bad in 
terms of premiums rising, insurers exiting and coverage 
ultimately declining.
    Second is that the proposals under consideration, reforms 
to grace periods, special enrollment periods, the age rating 
bands and continuous coverage provisions are all sensible 
policy that I would hope would garner bipartisan support. And 
then third that if indeed these measures were enacted there 
would still be much work left to do; that that would not be 
enough to stabilize them. Let me elaborate on each and then I 
look forward to your questions.
    Under current law the exchanges are headed in the wrong 
direction. In 2017, the benchmark Silver Plans rose at an 
average rate of 27 percent coming on the heels of ten percent 
rises in 2016, so the insurance is becoming increasingly 
expensive. As was noted by Mr. Walden, in five States and in 
one-third of U.S. counties there is only one insurer that is a 
choice for those participating in this market.
    Seventeen of 23 co-ops have failed and the insurance that 
is out there is not really equivalent to affordable care. 
Eighty-four percent of participants require taxpayer assistance 
to purchase these policies and when they do they face family 
deductibles that are about average $7,400 in the Silver Plans, 
average $12,300 in the Bronze Plans, which means in many cases 
they are never getting to the point where the insurance is 
paying anything even after they have purchased it. My 
expectation is that if current law were unchanged and things 
were left on autopilot we would see exchange enrollments 
decline, decline substantially perhaps as low as eight million 
or so by 2020.
    Clearly something needs to be done. In each case these 
measures would tend to improve the risk pools, lower the 
premiums and thus attract people in and stabilize the markets 
in that fashion. Grace periods in the Affordable Care Act are 
90 days. In all but two States, grace periods off the exchanges 
would be 30 or 31 days.
    So the playing field is not level in the individual market 
between off-exchange and on-exchange products. These long grace 
periods raise the prospect of an individual paying for 9 months 
and actually consuming a full year's worth of healthcare 
coverage. That leads to obvious problems for insurers and the 
costs have to be shifted.
    In some cases they will be shifted to the taxpayer and in 
some cases they will be shifted to other customers in the form 
of higher premiums and thus exacerbating the upward pressure on 
premiums. And in some cases insurers will be obligated to pay 
only 1 month of those costs and 2 months will be shifted to 
providers who will no longer want to participate in providing 
care to the people who need it in these markets. Moving the 
grace periods to match those off the exchange would be a very 
sensible way to take those pressures off.
    For the special enrollment periods the ACA has 30 
conditions in which individuals can enroll. By comparison, 
Medicare has seven and HIPAA provides for three. These special 
enrollment periods are a way for high cost patients, and all 
the evidence which is in my testimony suggests they are higher 
cost than the other enrollees, to enter into the market. Again 
insurers have to jack up premiums in anticipation of this and 
the result is that a large number, perhaps as many as a third 
of the participants in the individual market, have entered 
using this mechanism. Tightening them up would be a sensible 
way to stabilize the market and take pressure off premiums.
    The age ratings are 3:1. This relatively raises the cost of 
insurance for the young and healthy that is a group that has 
under-enrolled in the ACA exchanges. Getting them in is a key 
part of stabilizing it. Moving to 5:1 would match the data that 
is the ratio in costs and be a sensible thing for the committee 
to consider.
    And then lastly is the proposal for continuous coverage. 
Here I think it is simply the case that the individual mandate 
is not working as envisioned. There are about six and half 
million people in 2015 who simply paid the penalty. There are 
another 12.7 who are simply exempt. The continuous coverage 
provision would be a way to encourage the young to enter the 
market at the age of 26, buy coverage, remain covered, and 
because they remain covered they can never be medically 
underwritten and charged a special premium because of a 
preexisting condition. It is a way to stabilize the pools and 
to ensure that they do not continue to deteriorate.
    So I thank the committee for the chance to be hear today. I 
think these are sensible ideas which would be good steps 
towards stabilizing the individual markets, and I look forward 
to answering your questions.
    [The statement of Dr. Holtz-Eakin follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Burgess. The Chair thanks the gentleman. Mr. Wieske, 
you are recognized 5 minutes to summarize your opening 
statement, please.

                    STATEMENT OF J.P. WIESKE

    Mr. Wieske. Thank you, Chairman, and thank you, Ranking 
Member. I appreciate the time and the effort in discussing this 
important issue. As you know, as a regulator in the State of 
Wisconsin we have been on the front lines of having to deal 
with the issues surrounding the implementation of Obamacare. It 
has been frustrating to hear consistently that the folks don't 
seem to understand that States have an important role here and 
that States do have existing laws in place that have protected 
their consumers.
    I would like to just kind of flash back before the ACA and 
talk a little bit about the Wisconsin insurance market before 
the ACA, what happened with the ACA, and what we hope to see in 
the future. In short, prior to the ACA Wisconsin had an 
excellent uninsured rating and we continue to do so in 
Wisconsin. We could rate consistently in the top six for the 
least number of uninsured. We still rank in the top six for the 
number of uninsured in the last report.
    Wisconsin covered its folks who were vulnerable and were 
not eligible for the private market through a high-risk pool. 
And I know there has been a lot of talk about high-risk pools 
across the country. Wisconsin's high-risk pool works, worked 
while it existed. In fact, I got a call 2 weeks ago from a 
legislator who had constituents asking him to reinstate the 
Wisconsin high-risk pool because the coverage they had under 
Obamacare was inferior to what they had under the high-risk 
pool.
    They had numerous plan options. The coverage was obviously 
expensive. There is no question about that. Although if you see 
the numbers in my testimony with the Federal subsidy those 
rates went down considerably. And I think one of the most 
important features that Wisconsinites had in that high-risk 
pool was they could go to any doctor in the State. There is not 
a single plan in our exchange where you can go to any doctor in 
the State and get coverage without having really significant 
deductibles and having out-of-network costs.
    It was funded on assessments on the insurers as well as 
mandatory discounts for the providers, and the coverage, 
consumers had huge number of options inside that plan. And 
typically, I think what is interesting about the high-risk 
pools is that they stayed on those high-risk pools for about 3 
to 4 years and once they were there they moved into other group 
coverage later, so it was a great gap coverage.
    I will also note that we had relatively low premiums in 
Wisconsin compared to, and you can see in my testimony that the 
rates went up considerably. They went up much more on the young 
folks than they went up on the older folks because of the age 
band and that has caused an abandonment by and large of the 
market, individual market, by a lot of the folks in the younger 
age bands unless they have medical conditions.
    It has been very expensive for coverage. The fortunate 
thing in Wisconsin is we haven't seen the high increases. We 
had 16 percent increases this last year. We still have 15 
insurers in the State doing business. We still have a co-op 
doing business and that is in part because we recognize that 
our job as a regulator is to minimize the consumer disruption. 
However, I think one of the big issues going forward is if we 
don't look at the transition coverage and if we don't make 
changes going forward we are expecting to see the small group 
market start to implode and that is going to put folks, more 
folks in the individual market which is unaffordable And that 
will impact taxes. That will impact everything across the 
board.
    So we have serious concerns about not reforming the 
individual market impacting the small group market, not 
repealing Obamacare and ending up killing the small group 
market as well, which is on its way. About 80 percent of folks 
in the small group market are still in transition plans, so 
that is important to understand.
    Going forward I think it is important to understand that 
States have a number of laws on the books. We have preexisting 
condition laws in Wisconsin. We have mental health parity laws. 
We had the coverage to age 27, in fact, not 26, in the State 
prior to Obamacare passing. We did a number of consumer 
protections and we take consumer protections seriously in the 
State, and we do a lot of work and we deal with consumers 
directly, and we deal with insurers directly and we have 
discussions with insurers directly. We have done this for 
years. We have been regulating the health insurance market 
since the 1940s.
    And I will stop and indicate that we are ready to be here 
and help and be part of the solution as State regulators and 
that not all of these solutions need to be federally centric. 
Thank you.
    [The statement of Mr. Wieske follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman. Dr. Lichtenfeld, you are recognized 5 minutes to 
summarize your opening statement, please.

              STATEMENT OF J. LEONARD LICHTENFELD

    Dr. Lichtenfeld. Thank you, Mr. Chairman and Ranking Member 
Green, and members of the subcommittee. My name is Len 
Lichtenfeld. I am Deputy Chief Medical Officer for the American 
Cancer Society and I appreciate having the opportunity to be 
with you today.
    I am also pleased to be here on behalf of the nearly two 
million patients and people who will be diagnosed with cancer 
this year and the over 15 million cancer survivors that are 
living today as a result of successful treatment. These 
Americans who are your constituents, for them access to 
comprehensive, affordable health insurance coverage truly is a 
matter of life and death.
    Mr. Chairman, we appreciate your stated support for 
retaining two very important patient protections enacted as 
part of the ACA, the preex provision that bans discrimination 
against people based on their health condition; and secondly, 
guaranteed issue of coverage. And we look forward to working 
with you on the language in the legislation to make sure these 
provisions work to do just that. Providing patient access to 
coverage is obviously meaningful, but only insofar as the 
coverage itself is affordable and provides enough benefits to 
be meaningful for someone with cancer. And that is certainly 
the lens through which we view these particular pieces of 
proposed legislation.
    Prior to 2010 the insurance coverage was defined as just 
about anything marketed and sold by the industry and often 
contained exclusions, and hidden clauses resulted in denial of 
claims for all sorts of medically needed services. Current law 
requires that insurance provide major health coverage. When 
people buy insurance, especially when they are required to do 
so either by mandate or continuous coverage requirements, it is 
important to remember that insurance must cover a defined set 
of benefits to cover those individuals when they do become ill.
    My written statement goes into greater detail, but in the 
limited time I have with you today I want to focus on why 
cancer patients need access to health insurance and how we can 
improve the system to address their needs. Research shows that 
individuals who lack health insurance coverage are less likely 
to get screened for cancer, more likely to have their cancer 
diagnosed at a later stage when the chance of survival 
diminishes and the treatments are certainly much more 
complicated. I know from my days as a practicing oncologist 
that it is very difficult to tell someone they have cancer; it 
is even more difficult to guide them through what is hopefully 
successful treatment. What is worse than that is being told by 
a patient they can't afford the treatment because they lack 
health insurance coverage or because their health insurance 
doesn't provide coverage for the oncology and cancer related 
services necessary for their journey.
    Individuals with cancer including cancer survivors know how 
important it is to maintain health coverage. And unfortunately, 
before the patient protections provided under the ACA many were 
unable to obtain health insurance coverage because of the 
cancer diagnosis constituting a preexisting condition and 
others faced lifetime or annual limits on their coverage while 
others were still only able to purchase a health insurance 
coverage with limited benefits that provide inadequate 
reimbursement when they needed it most.
    Individuals with cancer want and need continuous access to 
comprehensive health insurance coverage. Unfortunately, the 
realities of life sometimes interfere with this goal. We have 
made great strides in cancer treatments over the years, but 
unfortunately many treatments still result in unimaginable 
fatigue and other symptoms that can be very debilitating such 
that the individual is unable to work.
    Research suggests that between 40 and 65 percent of cancer 
patients stop working while receiving cancer treatment with 
absence from work that ranges from 45 days to 6 months 
depending on the treatment, and sometimes these folks lose 
their jobs and their affordable employer-sponsored coverage.
    Imagine a diagnosis with cancer and undergoing treatments 
that make work impossible, repeated absences result in a loss 
of your livelihood, you have no income, yet you had a terrible 
disease and you need to get coverage for that illness. Cancer 
treatments have left you physically unable to even look for a 
new job. This is not only a hypothetical it is very real, and 
everyone in this room knows patients with cancer who have gone 
through such experience.
    So as you contemplate changes to the healthcare market, we 
urge you to give great consideration to how the various 
policies under consideration intersect and how an individual 
with cancer would be impacted. We are not saying the current 
market is perfect, more needs to be done to ensure 
affordability, but affordability cannot be judged on premium 
alone. We need to also consider out-of-pocket costs and the 
value of the benefits provided. Catastrophic plans will have 
lower premiums, but few cancer patients will be able to afford 
the deductibles, co-pays and other out-of-pocket costs 
associated with oncology treatment.
    In closing, I appreciate the opportunity to share our views 
from the American Cancer Society on how the healthcare system 
needs to ensure that individuals with cancer have access to the 
products and services necessary for their treatment, and I am 
glad to answer any questions from the committee. Thank you very 
much.
    [The statement of Dr. Lichtenfeld follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Burgess. And the Chair thanks the gentleman. The Chair 
thanks all of our witnesses for being here today and for your 
testimony. We will move into the question portion of the 
hearing. The Chair does note that he was delayed in arriving at 
the hearing, so in compensation for that I am going to defer my 
questions to the end and recognize the gentleman from Texas, 
Mr. Barton, for questions.
    Mr. Barton. It is rare that I am speechless, Mr. Chairman, 
but I am tempted to defer also because I had to go to a private 
meeting and missed--I was going to read my briefing book. I 
guess I am--but if you are recognizing me, I am going to try to 
go through it.
    I am tempted, but since you are Diet Coke man and not a 
Diet Dr. Pepper man I am a little skeptical.
    I do want to, first of all, commend the chairman for 
holding the hearing and commend our witnesses. I am going to 
ask a general question about the overall effectiveness or 
necessity of maintaining some sort of a health exchange option 
as we move away from the Affordable Care Act. Could each of you 
gentlemen comment on whether as we move to replace the 
Affordable Care Act we should give States the option to have 
something similar to a health exchange and also if we should 
have a national exchange in addition to that.
    Dr. Holtz-Eakin. I certainly think there is good reason to 
give the States such an option. I have always thought that the 
most important thing would be to have healthy competition in 
the individual market. Exchanges can provide the consumer 
information necessary to make that competition work better, and 
the place where I have reservations is only when the exchange 
becomes a means for excessive regulation.
    But the exchange, per se, is a marketplace where consumers 
can get information and purchase policies that they like. It is 
a very valuable concept.
    Mr. Barton. OK.
    Mr. Wieske. I think the concept of the exchange, it is good 
way to deliver subsidies but it is a three percent cost on top 
of the insurance. That is roughly what they are charging back 
the insurers for coverage to the exchange, and this is a 
website. I am not so sure three percent is the, I mean that may 
reflect the actual cost, so I think there is a value 
proposition there. I think prior to the ACA there were a number 
of websites that provided coverage as well.
    And again, depending on what the purpose of the exchange 
is, I think he is right, that it has become a means to add to 
the regulatory burden on insurers and consumers, so I am not so 
sure of the value in part because of the cost, but I don't 
think, you know, I think there is, there may some reason for 
it.
    Dr. Lichtenfeld. Mr. Barton, I appreciate your question. 
But speaking on behalf of the American Cancer Society, our 
major concern is that consumers have the opportunity to get 
affordable coverage that is going to meet their needs at their 
time of need, and the mechanism by which the committee decides 
going forward to achieve that must provide the information that 
people need to make that decision in a reasonable way.
    There obviously are folks here who are involved in the 
insurance community much more directly than I am or that we 
are, but it is a matter of information, affordability, and 
access, and that adequate coverages are available and that the 
consumer be aware of those options as they go forward with 
their insurance.
    Mr. Barton. Mr., is it ``Wee-ski'' or----
    Mr. Wieske. Wieske, yes, sir.
    Mr. Barton. Wieske, not ``wise guy,'' just Wieske. Your 
State has a high-risk pool, and another thing that we want to 
try to do as we move away from the ACA is guarantee that people 
with preexisting conditions get adequate access to insurance. 
The full committee chairman has put out kind of a placeholder 
bill dealing with high-risk pools. How would you envision based 
on your State's experience that working absent all the bells 
and whistles and mandates that we have currently under the ACA?
    Mr. Wieske. So sure, you know, I think the first thing is, 
is a high-risk pool isn't necessarily the solution for every 
State. I don't want to speak for other States. I will say that 
in the State of Wisconsin, while we had a high-risk pool, it 
was highly effective. It is still politically popular amongst 
both Republicans, Democrats, and especially amongst some 
subscribers of the high-risk pool. And they miss the coverage. 
It was a well-thought-out coverage. It was a well-thought-out 
program.
    So I think, you know, I think the key issue is always how 
you deal with the funding. And that has been one of the 
bugaboos, I think, in a number of States is when there is 
insufficient funding for a high-risk pool. You know, there was 
one State, California, had a waiting list for their high-risk 
pool. Florida closed their high-risk pool in the early 1990s, 
and it remained closed for a number of years. Other States had 
relatively low dollar caps.
    So there are issues in design, so the important piece is 
design. The other important piece is understanding how the 
funding works and having a stable funding source. I think it 
has been consistent that the insurance industry is required 
through the individual small group and large group market to 
contribute to the cost of the high-risk pool to make sure that 
it is affordable for consumers. I think as well having good 
medical discounts that attach to it are also important, but 
funding is sort of the key piece in making sure that it is 
maintained over time.
    Mr. Barton. You think it can be workable.
    Mr. Wieske. I think it worked incredibly well in Wisconsin 
and it provided great coverage and a lot of options for 
consumers, yes.
    Mr. Barton. My time has expired. Thank you, Mr. Chairman, 
for your----
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman. The Chair recognizes the gentleman from Texas, 
Mr. Green, 5 minutes for questions, please.
    Mr. Green. Thank you, Mr. Chairman. Last Congress our 
committee passed several important pieces of legislation on 
health care, a number of them fixing the SGR, extending FQHCs, 
and 21st Century Cures is probably the biggest one. Speaker 
Ryan once described the 21st Century Cures as the most 
important legislation to be passed in the 114th Congress.
    During the process of passing the Cures many members of our 
committee heard stories from patients and advocates across the 
country who were battling tough diseases and hoping for new 
treatments. Passing the Cures which contained new funding for 
research on diseases such as cancer we gave so many of them 
hope that one day they would get that treatment to be needed. 
Nationwide, the ACA is that delivery. It doesn't do us any good 
to invest in medical research if we don't have a physician or a 
facility--and I am from the Houston area, we are fortunate to 
have MD Anderson.
    Although up until the Affordable Care Act, MD Anderson 
being a State institution did not take a significant number of 
indigent persons even though they were Texans, and, but now 
they have something even if it is Medicaid. And, of course, 
Texas didn't expand Medicaid expansion, so we need to have this 
delivery system.
    And we can do things bipartisan, you know, I am hoping that 
is what we can do to fix the ACA, because there has never been 
a law passed by Congress that doesn't need to be looked at over 
a period of years. And, by the way, I served 20 years in the 
State legislature in Texas, and we wrestled with our high-risk 
pool. The problem is that we didn't fund it, and if you only 
have high-risk people, they can't afford the insurance.
    How does Wisconsin, Mr. Wieske, fund your high-risk pools? 
Is it premium? I thought I saw in your remarks it was premium 
taxes.
    Mr. Wieske. So there are number of funding mechanisms, so 
it was divided out equally. There was no actual State dollars 
that went into it. However, it was divided out between a 40/30/
30 share, so 40 percent was the cost for consumers, 30 percent 
was the cost for insurers, and 30 percent was the cost for the 
medical providers. They were required to have that level of 
contribution remain consistently over time which was true-upped 
every year in order to maintain the affordability. There was 
enough money there that it was private sourcing that actually 
provided the subsidy for folks under $34,000 of family income, 
so there was subsidies for folks under $34,000 of income as 
well.
    Mr. Green. Well, again and other States have tried that. I, 
like I said, worked as a State legislator doing work across 
State lines to see what we could do, but--and I have a district 
in Houston. It is very urban. Up until the Affordable Care Act 
44 percent of my constituents who worked did not get insurance 
through their employer.
    And so that is why the ACA is so important to an urban area 
and there are places all over the country. I would be 
interested sometime just to talk with you how Milwaukee, a very 
urban area, compares with most of the rest of Wisconsin, but, 
you know, that is my concern, that not every State is like 
Wisconsin.
    Dr. Lichtenfeld, thank you for being here. This bill 
requires insurers to cover preexisting conditions like cancer, 
but the bill doesn't say that insurers can't charge more for 
that cancer patient. That is one of the major issues, you know, 
the requirement that people have insurance so the insurance 
companies can spread that risk. Insurance is about spreading 
the risk, and if you only have cancer patients in the insurance 
plan nobody will be able to afford it. So that is why--and if 
they have to, you know, once you are diagnosed and you will 
have to spend it, tell me, is that one of the problems the 
American Cancer, your client has problems with?
    Dr. Lichtenfeld. I am part of the American Cancer Society 
and honored to be so. Of course it is a concern. You know, 
nobody goes out and says I want cancer or that I know I am 
going to get cancer, and that is what insurance is about, 
making sure that the benefits are adequate, that the cost is 
affordable and as I mentioned not only the premium cost but 
also the ancillary costs that inevitably come along. Making 
sure that patients and consumers have access to care is what 
this is all about.
    We are not here to in a sense solve all the problems in our 
testimony today. We are here today on behalf of cancer patients 
throughout this Nation and consumers to try to make sure that 
those principles are adhered to. That some of the fundamental 
protections in terms of affordability, limits on out-of-pocket 
expenses----
    Mr. Green. Before I run out of time, you don't see this 
proposed legislation is serving cancer patients?
    Dr. Lichtenfeld. What we believe is that this is a work in 
progress and we want to participate in that progress and help 
reach solutions in a manner that is acceptable for the people 
we serve.
    Mr. Green. Thank you. Thank you, Mr. Chairman.
    Mr. Burgess. The Chair thanks the gentleman. The gentleman 
yields back. The Chair now recognizes the gentleman from 
Kentucky, the vice chairman of the Health Subcommittee, 5 
minutes for questions, please.
    Mr. Guthrie. Thank you, Mr. Chairman. I have a chart. I 
would like to start by walking through a chart if we can have 
that posted.
    Now the chart we see here uses CBO data on where folks get 
their health insurance coverage in 2016. As you can see, 
roughly half of the country received coverage through their 
employer. That is 155 million people. Fifty seven million 
patients are enrolled in Medicare, another 57 million are 
Medicaid beneficiaries that were eligible before the Affordable 
Care Act.
    When it comes to the Affordable Care Act there are 11 
million recipients who were made Medicaid eligible by law, and 
a little under 11 million folks on exchange programs and 
roughly one million enrolled through basic health programs. 
What this chart illustrates is that we are talking about seven 
percent of the population all at the potential disruption of 
where 93 percent of people across the country receive their 
health coverage. Even more, the IRS said about eight million 
folks paid the mandate penalty and another 12 million claimed 
an exemption from the penalty.
    So of the 27 million uninsured Americans, 20 million chose 
to either to pay the individual mandate tax or claim an 
exemption. Look, we are going to hear a lot of numbers today 
and remember these. Seven percent of the country can be 
directly associate their coverage through the Affordable Care 
Act and all but seven million uninsured Americans paid the 
penalty or claimed an exemption.
    So instead about talking numbers let's talk about people 
behind the numbers. So Dr. Holtz-Eakin, can you tell me the 
national average of premium increases for on-exchange patients 
this year?
    Dr. Holtz-Eakin. For the benchmark Silver Plan it is 27 
percent.
    Mr. Guthrie. And Commissioner Wieske, what is the number 
for your home State of Wisconsin?
    Mr. Wieske. It was roughly 16 percent.
    Mr. Guthrie. Let's talk about ways to drive these costs 
down. Dr. Holtz-Eakin, as you point out in these reforms 
noticed today, taken individually or separately are good policy 
and should receive bipartisan support. If our immediate task is 
to stop the leaks before replacing the pipes, is this a good 
place to start with the bills before us today?
    Dr. Holtz-Eakin. I believe so. Yes, these are sensible 
reforms that will get part of the way.
    Mr. Guthrie. Thank you, and I agree with your written 
conclusion this will not fix everything but these are necessary 
changes. One of those longer term changes we strongly 
considered is continuous coverage. Would you please briefly 
describe the value of this incentive model and how it is aimed 
at patients keeping health care instead of simply getting 
coverage?
    Dr. Holtz-Eakin. So the basic concept is to deal with 
preexisting conditions in two ways. The first is for existing 
folks you go to a high-risk pool model like has been discussed. 
But for a young person, the minute they come off their parents' 
policy at age 26 they are young and cheap and if they buy a 
policy and keep coverage in any form throughout their life, 
regardless of whatever condition they develop, they cannot be 
medically underwritten and their premium cannot be raised based 
on their health condition.
    As a result, there is a huge incentive to get the young 
people in the pool and have insurance, because they are keeping 
the insurance over a lifetime insurers have a very different 
view of them than now. Now they are a 1-year snapshot, they 
should do everything they can to avoid costs. If you are 
looking at them over a lifetime you want to do the prevention, 
you want to do the wellness, you want to take care of them in 
very different ways. So this continuous coverage solves the 
problem of preexisting conditions by getting them in the pool 
to begin with and provides a better foundation for a different 
kind of medical model.
    Mr. Guthrie. OK, thank you. And Mr. Wieske, you answered 
some of these in your testimony, but I will just give you a 
couple minutes, a minute and a half here, to kind of drill down 
on some of the things that you said and just point it out 
again. Can you compare the market, what the market looked like 
in your State before and after the passage of the ACA?
    Mr. Wieske. Yes, I think roughly, I mean we actually did 
not see any gain in coverage if you look at the numbers, if you 
count our exchange folks, the current exchange folks, and then 
you look at the high-risk pool and you look at the market 
before. And so roughly we saw no gain in coverage as a result 
of Obamacare, at least the numbers don't bear that out.
    And it is important to note that the methodology to 
calculate the uninsured changed in 2013 so it is an apple to 
oranges comparison to a certain degree. But our market was much 
more affordable pre-ACA, there was access to coverage.
    Mr. Guthrie. What were the difference in options before and 
after?
    Mr. Wieske. Well, we had roughly 25 carriers operating in 
the individual market in Wisconsin and along with the high-risk 
pool and now we have about 15 in the exchange, but if you look 
at any particular region we have roughly five at the most, 
closer to three. There is only one region where we have one, 
and I think three counties where we have two.
    So there are fewer choices in our individual market. It is 
more costly and the plans are obviously centered, they are sort 
of Government-designed plans rather than having a lot of 
different options for----
    Mr. Guthrie. But not an increase in coverage?
    Mr. Wieske. Pardon me?
    Mr. Guthrie. You have fewer options, more costly and not an 
increase in coverage?
    Mr. Wieske. Correct.
    Mr. Guthrie. Thank you. I am out of time. I yield back.
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman. The Chair recognizes the gentleman from New 
Jersey, 5 minutes for questions, please.
    Mr. Pallone. Thank you, Mr. Chairman. The gentleman from 
Kentucky put up that chart and, you know, acting as if when you 
repeal the ACA the only thing you are impacting is people who 
bought individual policies on the marketplace. But the subject, 
certainly the Walden bill, the chairman's bill today is talking 
about standards. He is talking about, you know, preexisting 
conditions. That affects over a hundred million people.
    There is no reference in this half-baked bill we would 
assume because it doesn't put it back in that the essential 
benefit package is impacted, which is going to be my question 
to Mr. Lichtenfeld. So, you know, I don't understand how you 
are putting up that chart and acting as if what we are talking 
about here today is just the people in the marketplace. This 
affects everyone. The ACA guaranteed an essential benefit 
package. You start cutting back on that and offering skeletal 
or catastrophic plans, that is going to affect everybody on 
that chart including those who have, the majority that have 
employer-sponsored plans and the same thing with preexisting 
conditions.
    So, you know, I want everyone to understand. When you start 
talking about standards and repealing this bill, anti-
discriminatory practices, essential benefits, this isn't just 
the people in the marketplace.
    Now Mr. Lichtenfeld, my concern about the Walden draft is 
it would not limit in any way what insurers can charge for 
insurance. Before the ACA under HIPAA some people were 
guaranteed access to nongroup policies for which they could not 
be turned down nor have preexisting conditions excluded, but 
there was no limit on what they could be charged. And left with 
this only remaining option for discriminating based on health 
status, insurers charged very high rates for coverage 
effectively blocking access for a lot of cancer patients 
sometimes 2000 percent of standard rates.
    So roughly what percent of cancer patients do you think 
could afford to pay such highly surcharged premiums, and in 
your experience what happens to people who are diagnosed with 
cancer who can't afford health insurance? How is their access 
to treatment affected?
    Dr. Lichtenfeld. What we know at the American Cancer 
Society is that we did a considerable amount of research in the 
early 2000s to help support our views, shall we say, on the 
necessity of insurance. And what we found from that research, 
which we can certainly provide to the committee, is that 
patients were diagnosed at a later stage and did poorly 
compared to those who had insurance.
    So we do think that the legislation, the current policy has 
enabled patients in order to get access to care. Certainly 
there are issues. We recognize that there are imperfections 
that have to be worked on. One of our concerns with regard to 
the essential health benefits is the reality that we need to 
make sure that whatever we do here, whatever the committee in 
its wisdom decides, that we have adequate coverage to make sure 
that patients who have cancer can get the care they need 
without the limitations that might otherwise occur. And clearly 
affordability is a major issue.
    Most patients, it is no secret the majority of patients who 
would be impacted by this discussion today are people who are 
age 50 and older. And those folks would have, if they end up in 
a situation where there is a high premium and they couldn't 
afford it they would be put back in a situation where they 
would have difficulty getting the care they need for the 
illness that they have.
    So in response to your question, these are certainly 
concerns that we have and hopefully we will be able to work 
with the committee moving forward to address those issues.
    Mr. Pallone. Well, thank you, Doctor. You see, my concern 
is that when the GOP talk about replacement, what they really 
want is competition downward, skeletal, skimpy plans, you know, 
plans that--you know, before the ACA you could buy a plan that 
didn't cover prescription drugs or even hospitalization. And, 
you know, now we have these essential benefits, but Mr. 
Walden's draft assumes to repeal the entire ACA including 
essential health benefits. Sixty two percent of plans before we 
put the ACA in place lacked maternity coverage, I mean there 
was all kinds of exclusions.
    And, you know, just give me--I mean if the ACA benefit 
standards were to be repealed how would cancer patients be 
affected? I mean they might--limited doctor visits, much higher 
deductibles. I have only got a few seconds, but if you will 
just comment. I know you kind of mentioned it.
    Dr. Lichtenfeld. Mr. Pallone, I have lived through that 
experience as a physician and I am aware of what happened in 
the past and we at the American Cancer Society would be very 
concerned if we went back to that. We hope that there are 
solutions within the committee that will avoid that and 
provide--speaking with my colleague to my right, certainly some 
States have been excellent. Unfortunately others have not and 
we had huge problems in the past that we do not want to 
revisit. Cancer patients really need to know that they have 
insurance that works. Thank you.
    Mr. Pallone. Thank you, sir.
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman. The Chair recognizes the gentleman from 
Pennsylvania, Dr. Murphy, 5 minutes for your questions, please.
    Mr. Murphy. Thank you, Mr. Chairman. Dr. Lichtenfeld, 
thanks for your statement on the importance of maintaining 
preexisting conditions. We all agree with that. Those 
protections are important and guaranteeing issue is part of 
Chairman Walden's bill, too. We agree that these rating 
protections are important as well and really look forward to 
working with in your patient community and the broader chronic 
condition patient community.
    Can you talk about how Medicare Part D could serve as a 
role model, as a model for how we do this, how we approach 
this?
    Dr. Lichtenfeld. Well, as you are aware, Mr. Murphy, 
sometimes in some respects Medicare Part D works and in some 
places there have been some difficulties with how it has been 
applied. I am not sure that that is necessarily the model. I am 
not sure that there is any single model. I think that this is 
obviously a work in progress to be discussed and we look 
forward to participating in those discussions.
    At the end of the day we need to make certain that cancer 
patients can afford with regard to Part D, can afford their 
medications whether given in the doctor's office, whether they 
are bought over the counter or at a pharmacy. Those are 
critical. And it is also important to make sure that that 
coverage is uniform across the country. That is what we think 
is----
    Mr. Murphy. Dr. Holtz-Eakin, can you comment quickly on 
that too, just in a few seconds comment quickly on that 
question too about how Part D can serve as a role model on 
that?
    Dr. Holtz-Eakin. I think the Part D program has been 
enormously successful because it is built on very strong 
competitive pressures and on the ability to have very flexible 
plan design. And so we have seen that in the prescription drug 
plans competing with one another and offering products that 
seniors very much approve of.
    Mr. Murphy. Thank you. Mr. Wieske, did Wisconsin--let me 
talk about the high-risk pool. So does Wisconsin collect data 
on patients who are in these high-risk pools by medical 
condition, so cancer, certain chronic illnesses and infections, 
mental health?
    Mr. Wieske. We did. I served on the board of the high-risk 
pool. They had extensive information obviously on all the 
patients. It was--and some of them were there for an extended 
period of time, others were not. They had an intensive care 
management. So it was a very high number of high-risk 
conditions.
    Mr. Murphy. I am wondering how deep you could dive into 
that data. So Kaiser tells us about, in terms of the number of 
people who remain in the high-risk pool, about 45 percent are 
in their second year. Many have acute conditions and get 
better.
    And whether it is a chronic condition like cancer or, you 
know, the short term ones, maternity, and other complications 
like mental health, did you do a deeper dive when multiple 
illnesses occurred to see who were those people who were the 
big over utilizers by behaviors or high utilizers by medical 
conditions, so we can help analyze what are the differences 
there?
    Mr. Wieske. Yes. In short, yes. There weren't a lot of 
incentives. There were deductibles that attached. I think the 
lowest was $1,000 deductible. So there were specific efforts 
made to deal with high utilizers that were utilizing 
inappropriately in contacts from the administrator.
    But most of the folks on the high-risk pool were there 
about 3 to 4 years. They had specific medical conditions. 
Presumably they were covered or had group coverage at the end 
of their----
    Mr. Murphy. So here is an issue in where I think both sides 
of the aisle can agree that when you have a high deductible 
which is meant to discourage people from overutilizing the 
system that may work in some cases to keep people from running 
to the emergency room for every problem. On the other hand it 
hurts people from going to get medical care when they need it 
early on, which Dr. Lichtenfeld was describing the person for 
early stage cancer.
    I am particularly concerned here about such things as the 
mental health disorders. Generally a person with serious mental 
illness goes 60 to 80 weeks and adults longer between first 
symptoms and first treatment. And those complications were for 
example in Medicaid, five percent of Medicaid patients it is 55 
percent of Medicaid spending and virtually all of those have a 
concurrent mental health problem. Your State has gone above and 
beyond the numbers in terms of mental health parity.
    Mr. Wieske. Right.
    Mr. Murphy. Have you looked at that also as an issue in 
terms of having parity and making sure people are getting 
concurrent mental health services whether they start with a 
chronic illness or start with a mental illness that does 
something to help drive down costs?
    Mr. Wieske. Well, I think we have done a number of efforts 
I think both through the Medicaid program has done a fabulous 
job of working through that. I think we have new efforts 
related to the opioid issue which has gotten more attention and 
certainly in the opioid task force.
    There are a number of issues that we get to, but I think 
you are exactly right that there is this management in 
reflection of that this is an illness like any other illness 
and you need to treat it as such is sort of ingrained in 
Wisconsin.
    We have had mandates that attached mental health for 
decades, so while we have some mental health parity that 
applies we also have requirements that go back into the 1980s. 
We have had mental health coverage since the 1980s.
    Mr. Murphy. Well, I might take issue with you when you say 
Medicaid has done a fabulous job on that because we have had a 
lot of problems this committee has discussed. But I mentioned 
Wisconsin's data because we have seen from private markets and 
others that when private companies insure and they make sure 
their employees are covered with mental health benefits and 
concurrently looking at the impact, the cross pollenation here 
of chronic illness and mental illness, cancer is an example of 
that--high rate of depression, anxiety, panic--it drives people 
back to the emergency room versus if a doctor is working with 
them, so a lot of serious concerns there.
    If you are able to give us more data on that or if you and 
I could sit down and talk about that, the same with Dr. Holtz-
Eakin and Dr. Lichtenfeld, I would love to talk to you. This is 
an area where I have got to believe both sides of this 
committee can agree we can work on more effective health care 
and driving down costs.
    I realize I am out of time, Mr. Chairman. Thank you for 
indulging me.
    Mr. Burgess. The Chair thanks the gentleman. The gentleman 
yields back. The Chair recognizes the gentlelady from Illinois, 
Ms. Schakowsky, 5 minutes for questions, please.
    Ms. Schakowsky. Thank you, Mr. Chairman. My colleagues on 
the other side of the aisle claim to be concerned with, quote, 
protecting infant lives, unquote, which is what they called 
their panel last year that investigated Planned Parenthood and 
failed to prove any wrongdoing. But we know full well that that 
panel was created to attack women's health choices and not 
protect infant lives.
    But when it actually comes to protecting infant lives, 
Republicans are happy to put insurance companies back in 
charge, allow them to reinstate lifetime caps on coverage and 
medical underwriting. This would directly impact some of the 
most fragile and vulnerable patients in our country, including 
premature infants, infants with congenital abnormalities, and 
their families.
    So I would like to enter into the record an article 
featured on Slate called ``Our Insurance Paid $2.5 Million to 
Keep Our Child Alive.''
    Mr. Burgess. Would the gentlelady yield? Is that a 
unanimous consent request?
    Ms. Schakowsky. Yes.
    Mr. Burgess. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Ms. Schakowsky. The author explained that her child was 
born with congenital defects and their family accrued $2.5 
million in medical bills by the time that child was 3 years 
old. This, by the way, to make our Ranking Member Pallone's 
point, they had employer-based coverage, and the benefit 
package made sure that they were covered.
    And should Republicans have their way and reinstate 
lifetime caps on insurance coverage this child might already 
have reached her lifetime limit on coverage at the age of 3 and 
would be forced to pay all of her future care out-of-pocket if 
they could possibly afford it. Because of the ACA, more than 27 
million children have benefitted from the ban on lifetime caps 
and overall more than 105 million Americans have benefitted.
    Before the ACA, 89 percent of insurance plans included a 
lifetime limit on benefits. To add insult to injury, under 
Chairman Walden's bill this child may be subjected to an 
astronomical premium cost for the rest of her live based on her 
preexisting condition from birth.
    Let me ask you, Dr. Lichtenfeld, what does it mean for 
premature infants or children born with congenital 
abnormalities if these conditions are once again permitted to 
be medically underwritten?
    Dr. Lichtenfeld. Well, obviously, when speaking about that 
specific issue, those costs can rise rapidly and last for a 
lifetime, and we are concerned on behalf of cancer patients 
that lifetime caps or annual caps or whatever caps might in 
fact limit the treatment they receive.
    When you deal particularly in the cancer world with young 
people with cancer whether they be children, whether they be 
young adults, there is a very real issue about the cost of 
their care over time. And if in fact they become rated within 
the insurance market going forward as they age that would 
become obviously a very serious burden.
    Ms. Schakowsky. Have you seen that in your practice of 
young people who actually either have or live in fear of these 
lifetime caps?
    Dr. Lichtenfeld. Before the ACA it was a real problem and 
people even within organizations that I am familiar with would 
run up against, you know, and group insurance, would run up 
against caps and that would be a serious issue particularly 
patients for example with bone marrow transplants.
    When you talk about young people it is definitely, I can 
speak on information from the bone marrow transplant community, 
the financial toxicity of that care and the inability to work 
going forward for many of these young folks is a very real 
issue. And we do believe that that is something that needs 
attention as this again as this process moves forward.
    Ms. Schakowsky. And so once the ACA passed did you see then 
an improvement in those situations?
    Dr. Lichtenfeld. We do believe there was an improvement. It 
certainly removed the major concern that cancer patients have. 
We talk a lot these days about financial toxicity. We talk 
about the stress. We talk about mental health issues as was 
brought up----
    Ms. Schakowsky. What is your phrase, financial----
    Dr. Lichtenfeld. Financial toxicity.
    Ms. Schakowsky. That is what I thought.
    Dr. Lichtenfeld. It is a very real issue within the cancer 
community, the high cost of drugs, the high cost of care, the 
deductibles, the co-pays, whatever it may be, caps is clearly 
something that is part of that conversation.
    Ms. Schakowsky. Have you seen Chairman Walden's bill and 
how it would impact children or adults that have cancer?
    Dr. Lichtenfeld. Well, you know, to be honest with you 
again that is, there are things that are in the bill and things 
that are not in the bill so we still have a ways to go. So 
rather than supposing what is going to be offered, I would 
rather defer that until we have more information.
    Ms. Schakowsky. OK, thank you. And I yield back.
    Mr. Burgess. The gentlelady yields back. The Chair thanks 
the gentlelady. The Chair recognizes the gentleman from New 
Jersey, Mr. Lance, 5 minutes for your questions, please.
    Mr. Lance. Thank you very much, and good morning to the 
panel and I apologize for not being here for all of your 
testimony. We are shuttling back and forth between two 
subcommittees.
    To Mr. Holtz-Eakin, thank you for being here. In your 
testimony you mentioned that the individual mandate was an 
ineffective mechanism to encourage the enrollment of young 
people in the exchanges. In what ways is the continuous 
coverage concept a more effective tool to engage people to gain 
and maintain health insurance coverage?
    Dr. Holtz-Eakin. It is a natural and economic incentive and 
health incentive. You know, most of the replacement plans that 
have been offered that we have looked at would maintain the 
provision under current law where you can stay on your parents' 
policy until you are 26.
    At that point a young person who recognizes they are cheap 
to insure so it is easy for them to get insurance, they may 
develop, may not be medically underwritten so they aren't going 
to get their premiums jacked up because of their health, that 
is a real incentive to get in early. That broadens the risk 
pool and when people do develop conditions you have both the 
high risks and the low risks in the pool. That is always the 
goal in insurance.
    Mr. Lance. Would others on the panel like to comment on 
that?
    Dr. Lichtenfeld. I would, thank you.
    Mr. Lance. Certainly.
    Dr. Lichtenfeld. You know, the continuous coverage issue is 
one that is obviously again under discussion, but our concern 
at the American Cancer Society is and on behalf of our 
constituents, of our patients, is the details of what happens 
because the risk is very real.
    I mean what--you know, no one again expects to get cancer, 
and sometimes when it happens it happens very quickly and it 
absorbs people and they can lose their jobs and then they might 
lose their insurance and then they enter the market under the 
proposals and they may be rated at a premium they can't afford.
    So how the committee addresses this going forward again is 
a major concern of ours to get it right, to make sure that the 
rules are appropriate and that people who get a sudden illness 
may not be capable of dealing with a continuous coverage 
provision of 30 days, for example, are able to have some leeway 
and understanding that meets their needs at their particular 
time.
    Mr. Lance. I certainly agree that we want to get it right. 
It is just my concern that young people have not been involved 
to the extent we would like them to be involved. And we want to 
repair the ACA and I have never favored its repeal without a 
replacement. I think it needs to be repaired and we are trying 
to focus on repairing it and that is why we are conducting this 
hearing along with other hearings.
    To the commissioner, given your background as a State 
insurance commissioner, could you speak to some of the effects 
you have seen at the State level regarding the 3:1 age band, 
special enrollment periods and the 90-day grace period?
    Mr. Wieske. I think you can see in our testimony that the 
impact of cost, the increases have been borne by the young 
which has made it unaffordable, just caused the risk pool to 
deteriorate which has caused, you know, sort of a death spiral.
    We have seen consistent changes from the insurers in the 
areas that they are covering. There is a lot of chaos. We had 
37,000 folks that lost coverage from their particular insurer 
in Wisconsin last year which pales in comparison to the 100,000 
in Minnesota that lost their coverage last year. So there have 
been pronounced effects.
    You know, the problem with the SEP process is it is 
confusing for consumers, it doesn't make, you know, the current 
one it doesn't make any sense. It is harm to insurers. If you 
use magic words that go into the, with HHS you get your SEP. If 
you don't use the right magic words even if you deserve it you 
don't get an SEP. That has been a consistent problem when it is 
done at the Federal level, so there has been problems. We would 
like to see it go back to the companies to administer.
    Mr. Lance. Dr. Holtz-Eakin, would you care to comment on 
that, please?
    Dr. Holtz-Eakin. I think all the evidence that we have seen 
on it and summarized in my written testimony suggests that this 
is exactly right. It is not just a Wisconsin problem, this is a 
pervasive problem. It is worse in the risk pool and it has had 
the insurers unable to price things effectively.
    Mr. Lance. And I hope that the American people who are 
undoubtedly listening to our deliberations recognize that there 
has been this type of terrible situation across the country, 
not only in Wisconsin and Minnesota, but in other States, as 
well. And the goal of the ACA was a good goal, and the question 
is how to achieve that goal in the most effective and efficient 
manner recognizing that we want no one to be discriminated 
against, for example, based upon a preexisting condition. I 
yield back 5 seconds, Mr. Chairman.
    Mr. Burgess. The Chair thanks the gentleman. Before we go 
to our next question, the Chair would ask that Members on both 
sides of the dais who are engaged in conversations be mindful 
of the fact that I think Mr. Griffith of Virginia is hard of 
hearing and he is having difficulty in keeping up with the 
important discussions going on. So the Chair would ask that 
side conversations be taken off the dais or kept to a minimum.
    The Chair now recognizes the gentleman from North Carolina, 
Mr. Butterfield, 5 minutes for questions.
    Mr. Butterfield. Thank you very much, Mr. Chairman, for 
yielding time. Let me begin, Mr. Chairman, by just echoing some 
of the sentiments that were expressed by Ranking Member Pallone 
at the outset of this hearing. I share those concerns. This 
topic is very perplexing and very difficult for us to grapple.
    We hear different terminology as we have this debate. I 
hear Mr. Lance talk about repairing the ACA and I hear others 
talk about repealing the ACA, and so I am still trying to 
grapple with what we are talking about today. This appears to 
be another hearing to discuss Republican plans to change the 
healthcare system and reduce people's access to care and to 
make health care more expensive. That is the way it appears to 
me.
    You are trying to enact these changes that will actually 
make health care more expensive for low-income individuals and 
children and families and older Americans. After 7 years of 
complaining about the ACA and actively trying to disrupt by 
ripping it apart and causing it to fail, it is disheartening 
now to see a plan that is half written and incomplete. I expect 
more. I think the American people expect more.
    And I will say what my colleagues have said repeatedly, we 
are prepared and willing to work with you to improve the 
Affordable Care Act, make no mistake about it. This is the 
second day we have been in this room discussing ways to make it 
harder for people to access health care.
    I represent one of the poorest districts in the country in 
North Carolina where nearly one in four people live in poverty. 
Every day I hear from constituents about increasing access to 
health care, not decreasing it. Many of my constituents talk to 
me about expanding Medicaid and strengthening the ACA not 
making it harder to access health care.
    My constituents overwhelmingly, Mr. Chairman--maybe I spent 
too many years in a courtroom, Mr. Chairman. If the committee 
will come to order.
    Mr. Burgess. The gentleman from North Carolina is correct.
    Mr. Butterfield. Yes.
    Mr. Burgess. The committee does need to be respectful to 
the people who are speaking. Can I ask the committee to come to 
order?
    Mr. Butterfield. My constituents, Mr. Chairman----
    Mr. Burgess. The gentleman continues suspend.
    Mr. Butterfield. Thank you. I guess I was spoiled by being 
in the courtroom, Mr. Chairman.
    Mr. Burgess. The gentleman may proceed.
    Mr. Butterfield. My constituents, Mr. Chairman, 
overwhelmingly support our new Governor in North Carolina who 
is doing all that he can to expand Medicaid. In my district the 
uninsured rate has been cut by one-quarter. More than 35,000 
people have insurance as a result of the ACA. Across the 
country 20 million people have obtained health insurance since 
2010. The uninsured rate in our country is at an all-time low. 
That is a fact.
    I could talk for hours about the statistics that show North 
Carolinians and Americans are better off because of the ACA. 
Our healthcare system is better off because of it. It could be 
in an even better situation if detractors had not consistently 
fought it at every turn.
    Now Republicans want to turn back the clock. They want to 
put insurance companies back in charge of health care, make it 
more difficult to keep your healthcare plan and make it more 
expensive for many Americans to pay for health care.
    Chairman Burgess, I agree with your comments yesterday that 
seemed to indicate that this committee has gotten off on the 
wrong foot. I believe it has. Democrats will not stand idly by 
while we are forced to consider proposals that will restrict 
access to health care. Mr. Chairman, I have received a letter 
from AARP which supports the positions that I have just 
articulated. I would ask unanimous consent that it be included 
in the record.
    Mr. Burgess. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Butterfield. All right, I have 1 minute remaining. Dr. 
Lichtenfeld, thank you for your testimony in support of many of 
the improvements to our system made by the ACA. Many of my 
constituents in eastern North Carolina are from minority 
groups, racial minority groups.
    Can you discuss some of the cancer health disparities 
experienced by ethnic and African Americans and Hispanic 
Americans and would some of the potential changes to our 
healthcare system discussed today further exacerbate these 
disparities?
    Dr. Lichtenfeld. Well, Mr. Butterfield, thank you for your 
question. I mean there is no question that ethnicity plays a 
role in access to care and there is also no question that 
socioeconomic status plays a role in access to care. Making 
certain that all individuals have appropriate access to 
affordable care that meets their needs particularly for cancer 
patients is so important.
    I have lived in a rural area. I have experienced and seen 
the issue. I am in a State that did not expand Medicaid as have 
19 other States have not done so, and what the evidence is 
showing us is that access to care through insurance by whatever 
mechanism is important to reduce the burden of cancer.
    So we are aware of that. We are hopeful in the committee 
going forward will address that issue as well.
    Mr. Butterfield. Thank you, Doctor, and thank you, Mr. 
Chairman. I yield back.
    Mr. Burgess. The Chair thanks the gentleman. The gentleman 
yields back. The Chair now recognizes the gentleman from 
Oregon, the chairman of the full committee, Mr. Walden, 5 
minutes for your questions, please.
    Mr. Walden. Well, I thank the chairman. And I have been 
listening to the various comments and the testimony, and let me 
say again, this is a discussion draft. It is not a finalized 
bill. We are not coming here to cram something through that 
nobody has had a chance to have input on or read. I thought 
that is what you wanted. It is what I want.
    And so there are some opportunities to weigh in. That is 
what a--this may be unusual for some, but that is kind of what 
a legislative process is supposed to look like. And I will tell 
you what. I read all your testimony, and I appreciate it from a 
lot of levels. I have heard some of the things hurled my way. I 
don't want lifetime caps. I care pretty deeply about older 
people and younger people, including infants, very personal 
place.
    And I have seen markets that work and markets that don't. I 
fought on insurance companies when they were denying care and 
shouldn't. I fought to create high-risk pools when in my home 
State you didn't have the fix on a preexisting condition. I 
have seen cancer up close. My mother died of ovarian cancer, my 
sister-in-law, brain cancer. Like many of you, you or people in 
your families or in your communities deal with this. The notion 
that somehow because there is a break in the dais we don't care 
about getting this right is beyond the pale.
    So I hope going forward we can have a really constructive 
discussion here about how to make this bill work, how to make 
sure regardless of what we or some other Congress does going 
forward that if you had a preexisting condition you will always 
have access to care and that there won't be some artificial cap 
that says through no fault of your own you have a disease that 
keeps coming at you, but sorry, you are on your own and you are 
destitute. That is not the choice here. The choice is how do we 
get it right.
    The notion that this individual market is in a wonderful 
place is a fiction. All you have to do is listen to the experts 
that are out there and they will tell you this can't survive 
the way it is today. If Hillary Clinton were in the White House 
and Democrats controlled everything, I tell you, you would be 
back because just like we had to deal with other problems over 
the years, just like the laws that have been passed and voted 
on by Republicans and Democrats to deal with problems in 
Obamacare, we are going to repeal this and we are going to come 
back with a plan that will work for everybody.
    Now I want to ask the gentleman from Wisconsin, reading 
your testimony it was pretty evident you had a market that was 
working, not perfect but working. Tell me what happened when 
the ACA came down on top of what your State was doing, and tell 
me this, too: Is it possible for us here to pass this piece of 
legislation as appropriately written that will guarantee people 
have access to care of their preexisting conditions and that 
there won't be caps on lifetime coverage, and could you still 
put together a market with those two conditions?
    Mr. Wieske. We can in Wisconsin. I feel confident that--I 
mean we still have 15 insurers in the marketplace, in the 
market and selling insurance through the exchange. We have 
another six or seven that are selling off-exchange. We think 
that those will step up more to the plate if the rules reflect 
the actual costs.
    We have had a number of significant market exits. We think 
we can get them to return if the market rules are more 
reasonable across the country. It is not our rules that are the 
problem it is the Federal rules. They are losing money. We have 
seen significant, if you talk to our financial folks you have 
seen significant loss of capital inside the insurers that will 
never return under this environment and that is why they are 
leaving the individual market.
    The individual market is a residual market as was shown in 
the slides. It is roughly, you know, seven percent, five 
percent of any State's market. It is very small and it is 
leading the losses and that is why they are exiting the market. 
That is what is causing the issue.
    So I think a return to that if it returned to market 
principles with appropriate consumer protections that the 
market will return. It will take some time. Kentucky destroyed 
their market in the 1990s. It eventually came back. And so I 
think it will come back, yes.
    Mr. Walden. Mr. Holtz-Eakin, do you agree with that 
concept?
    Dr. Holtz-Eakin. I do agree with that. I think there is a 
lot of evidence that you can put in place sensible market rules 
and have vibrant individual markets. We don't right now, but it 
can be done.
    Mr. Walden. I know I have used up my time, Mr. Chairman, 
unless the doctor wants to respond. I would be happy to get his 
additional comments as well.
    Dr. Lichtenfeld. Thank you. Thank you, Mr. Chairman, I 
appreciate that.
    Mr. Burgess. Proceed.
    Dr. Lichtenfeld. You know, we sit here and we talk in 
certain words such as market principles, and I understand that. 
I accept that and that is not the problem. But when market 
principles get in the way with people having affordable care 
particularly the older people, then we run into difficulty.
    Mr. Walden. Right.
    Dr. Lichtenfeld. So as you said and I said earlier in my 
testimony or in my comments, this is a work in progress, 
understood, here to help try to meet a resolution.
    Mr. Walden. We appreciate that.
    Dr. Lichtenfeld. That is what we are aiming for so that we 
don't run into the problem where a principle becomes a barrier 
that then prevents people from getting access to care.
    Mr. Walden. Right, thank you. Thank you for your indulgence 
and your help.
    Mr. Burgess. The Chair thanks the gentleman. The gentleman 
yields back. The Chair now recognizes the gentlelady from 
California, Ms. Matsui, 5 minutes for your questions, please.
    Ms. Matsui. Thank you, Mr. Chairman. When we started 
writing the ACA over 7 years ago, I consulted with a full range 
of healthcare leaders in my community in Sacramento. We called 
together the hospitals, the health plans, the community health 
centers, the patients, and all those that contribute to our 
healthcare systems. Everything was fully constructed because we 
knew that each policy affected the next and the system as a 
whole.
    We all know that health care is complicated. You can't 
simply consider these changes in a vacuum. The Republicans have 
been saying for almost 7 years that they have a better way, but 
what we have seen today does not protect people. It really does 
take coverage away.
    One of the bills shortens grace periods to 30 days, which 
means that if someone misses just 1 month's premium payment 
they can be kicked off of their health plan. For many workers 
with fluctuating income they may need to forego a payment 1 
month in order to put food on the table and then pay it back 
the next when they receive their paycheck.
    Now, if getting kicked off your plan wasn't bad enough, the 
second policy kicks--which says, or we assume it will say, that 
you must maintain continuous coverage or else insurance 
companies will charge whatever they want the next time you sign 
up. If they know you are sick, they could offer you a plan, but 
only if you paid thousands of dollars a month, and what good is 
that? So now if a person ever misses even a single payment, 
they could be locked out of receiving health coverage for years 
or even for life.
    Now we talk here in statistics and charts and things like 
that, and that is very important. But I think we have to all 
understand that health care is very personal, to all of us here 
it is personal. Chairman Walden mentioned how personal it is to 
him with his mother having ovarian cancer. My mother had 
ovarian cancer. Many people here have had individuals with 
lymphoma, blood cancer. It is very personal. And I think to a 
certain degree we have to understand that there are certain 
diseases like cancer that may hit you with such a shock at the 
very beginning and you have to figure out what you are going to 
be doing next.
    So this is really a journey for most people with cancer, is 
that type of disease. So Dr. Lichtenfeld, in your experience, 
do cancer patients often spend a lot of time with their doctors 
and care teams to help get them well?
    Dr. Lichtenfeld. I am sorry. Can you rephrase the question 
again? I may have missed it.
    Ms. Matsui. Do your patients, cancer patients, often spend 
a lot of time with their doctors and their care teams to try to 
figure out what to do next, how to get them well?
    Dr. Lichtenfeld. Cancer is a complex disease and there is 
no question that the most important objective is to get the 
patient well and that takes time, it takes effort and it takes 
teams. There are, as I mentioned earlier there is increased 
attention to mental health issues with respect to cancer, 
financial toxicity issues, which are above and beyond the care 
discussion, and there are now requirements being put into place 
that expect that type of discussion.
    So yes, I mean it is not a simple process. It is complex. 
It is much more complex as time goes on. The drugs are more 
complex, the treatment, trying to help people get to the 
treatment, all of these are issues that have to be addressed as 
part of the cancer journey.
    Ms. Matsui. So during this process do cancer treatments 
like chemotherapy have side effects that make it hard for 
patients to accomplish daily tasks?
    Dr. Lichtenfeld. There is no question that the treatment is 
toxic for many situations and the fact that many patients are 
so impacted. I mean the fatigue issues are well known, the 
ability to work, whether someone, as I mentioned earlier the 
substantial number of people are not able to work. Meeting 
payment requirement is important, but yet perhaps the 30 days 
is not the right number that we should be talking about.
    Ms. Matsui. So cancer patients don't get a pass at all on 
taking care of the finances.
    Dr. Lichtenfeld. No, they don't get a pass. So I think we 
have to look through that cancer lens to understand the 
implications of what we do, and understanding it through that 
lens will give us guidance, we believe, in terms of how this 
should be constructed going forward.
    Ms. Matsui. So it is possible that a cancer patient has to 
deal with so much that even when a loved one is managing their 
affairs a month's payment can be overlooked?
    Dr. Lichtenfeld. It is incredibly complex. We have many 
life situations that are complex and cancer is certainly one of 
the most complex that we have to deal with.
    Ms. Matsui. So if that patient is kicked off their plan for 
missing one payment what happens to that patient?
    Dr. Lichtenfeld. Well, they end up, whether they could get 
the care the care would be interrupted, and then when they come 
back into the system so to speak their premiums under some 
discussions may be much higher than they would have been 
otherwise and that may last a lifetime.
    Ms. Matsui. OK. I yield back.
    Mr. Burgess. The gentlelady yields back. The Chair thanks 
the gentlelady. The Chair recognizes the gentleman from 
Virginia, Mr. Griffith, 5 minutes for your questions, please.
    Mr. Griffith. Thank you very much, Mr. Chairman. I have 
heard a lot of folks talk about things and what their 
constituents are telling them. And while I have constituents 
who certainly have liked the ACA, a vast majority of my 
constituents have had problems similar to Mark from Stuart, 
Virginia, who writes in part, talking about the increased 
premiums that he has had to pay, he says, ``It has cost my 
family around $21,000 over the last 3 years.''
    He goes on to say, ``I would like nothing more than to see 
this law repealed as fast as possible and relegated to the 
trash heap of history.'' He goes further, ``Please be 
responsible in what it is replaced with and make sure it 
consists of commonsense measures that will help, not hurt, 
middle-class families.''
    And I think that is why we are here. We are trying to 
figure out how we can do things that balance it out which is 
why, Mr. Wieske, I want to talk to you about the high-risk 
pools that were successful in your State. How many people did 
you all cover?
    Mr. Wieske. Roughly 25,000.
    Mr. Griffith. OK. And what rates were you able to offer 
these patients? I know you said they were affordable but just 
give me some idea of what they were.
    Mr. Wieske. They varied, so the deductibles varied from 
$1,000 deductible all the way up to a $7,500 deductible. I 
believe the rates for the typical, in my testimony I compared 
it to the rates that what a Silver Plan would be and it was a 
little bit lower than what the ACA plans are in Wisconsin 
currently.
    Mr. Griffith. OK.
    Mr. Wieske. So roughly about, depending on--it varied based 
on age--so between 200 and 500 dollars, roughly.
    Mr. Griffith. OK. And I thought it was interesting you said 
that 40 percent was paid by the insured, 30 percent by the 
insurers, 30 percent by the medical folks taking some 
discounts----
    Mr. Wieske. Correct.
    Mr. Griffith [continuing]. But then at one point I thought 
I heard you say there was also some private money?
    Mr. Wieske. There were subsidies that were also included as 
part of those assessments. So consumers who had, or members who 
had, incomes at or below $34,000 received subsidies, at the 
lowest end was up to a 43 percent subsidy on the premiums.
    Mr. Griffith. And the subsidy came from?
    Mr. Wieske. It came from the high-risk pool.
    Mr. Griffith. It came from the high-risk pool.
    Mr. Wieske. The high-risk pool funds, yes.
    Mr. Griffith. OK, so that would have been some State money?
    Mr. Wieske. No State money. There was no State money at 
that time.
    Mr. Griffith. Explain that to me. It came from the high-
risk, was that the insurers?
    Mr. Wieske. It was the insurers and the providers, the 
discounts. So they were able to provide----
    Mr. Griffith. So that was part of the 40/30/30 that you 
were talking about?
    Mr. Wieske. Correct, right.
    Mr. Griffith. All right. And I think you have already 
answered it was not a one size fits all? You could make some 
choices within the high-risk pool itself?
    Mr. Wieske. Yes, yes.
    Mr. Griffith. All right, so we are trying to figure out how 
to craft which is why, you know, it is interesting. I have 
heard some criticism that Chairman Walden's bill has a 
placeholder in it, but we are trying to figure out exactly, you 
know, what we can do to make this and get all the ideas, 
Democrat and Republican.
    So what in your opinion, if we are going to set up a high-
risk pool what are the most important factors to consider when 
States design these high-risk pools? When we say to the States 
if we decide that is where we want to go, what should the 
States be doing to make their high-risk pools work as yours 
did?
    Mr. Wieske. Yes, I think affordability is the key. I think 
having a good partnership between the providers and the 
insurers and having a strong board that is interested in 
governing, a long-term board. It was outside of the--it was a 
quasi-governmental entity that ran the high-risk pool. I think 
that was effective. They hired outside experts.
    They had, instead of taking the claims in-house they hired 
an administrator. They had a great administrator who did great 
work. So I think having a strong structure in place is the most 
important piece and then having the funding mechanism that is 
stable.
    Mr. Griffith. All right. And, you know, one of the things 
that I had thought we might have to do, but you all didn't have 
any State money, do you think we need to at least prime the 
pump, so to speak, and have some Federal money to help the 
States get their high-risk pools started, or do you think they 
can take your model and not have any Federal money?
    Mr. Wieske. I think you see if you look at the Federal, so 
early on the ACA did include funding for high-risk pools, and I 
think if you look at the premiums for that they dropped 
considerably. There was about a 150-$200 drop depending on the 
age in premiums. So I think Federal funding could certainly 
help make that coverage much more affordable.
    And, again, I will say that high-risk pools are not for 
every State so there may have to be other options like 
reinsurance schemes or, you know, maybe some States do want to 
do guaranteed issue, but we found high-risk pools effective.
    Mr. Griffith. OK, I really do appreciate that. You know, 
this is a tough nut to crack on all those bills that we are 
considering, not only the ones for today but other bills you 
see us considering. All three of the witnesses, if you would 
please let us know.
    I mean I am making suggestions to Chairman Walden's team to 
make some improvements on his bill that I think might need to 
be in there, but we encourage you to let us know what you see 
and what you think you can do because we are looking for 
constructive criticism. We want to take the time to get this 
right for the American people, and so as Mark from Stuart said 
to make that we are helping folks and not hurting middle class 
families in America. But thank you so much for being here 
today. I yield back.
    Mr. Burgess. The Chair thanks the gentleman. The gentleman 
yields back. The Chair now recognizes the gentlelady from 
Florida, Ms. Castor, 5 minutes for your questions, please.
    Ms. Castor. Well, thank you, Mr. Chairman, and thank you to 
the witnesses for being here. I wanted to make sure that we go 
back again to the point because we have the chart that was up 
on the screen and the impression that may have been left that 
repealing the ACA applies just to the healthcare.gov 
marketplace.
    And I think folks really need to understand that when you 
repeal the ACA as my Republicans are on track to do that 
affects all Americans, everyone. Medicare, Medicaid, or the 
folks, the 20 million Americans who did get coverage under 
healthcare.gov, the marketplace--and in Florida that was 1.7 
million, larger than the population of some States have 
enrolled in the marketplace in Florida--but the employer based 
insurers where most of our neighbors get their insurance.
    There are vital consumer protections that have improved the 
lives of our neighbors and you simply can't gloss over that or 
ignore it and people need to really understand what they have 
gained, and Florida is a great place to look. In Florida we 
have 8.8 million that have their insurance through their job 
that means that all of those folks can no longer be 
discriminated against if they have a preexisting condition like 
cancer, diabetes, asthma, heart disease--we estimate that that 
is about 7 million Floridians.
    Under the Affordable Care Act, under your private policy 
your kids can stay on your policy until they are 26 years old. 
Insurance companies cannot cancel your policy if you get sick 
and they can't impose lifetime limits or caps. All of that will 
be lost under the ACA Republican appeal plan. These consumer 
protections have been a godsend to our neighbors.
    And let's talk a little bit about cost because I am very, I 
am sensitive to the fact that the markets are different across 
the country, but you can't deny that before the ACA healthcare 
costs were out of control. And if you look just in my State, 
the ACA has generated significant savings for Florida families.
    And we have got to do more to control the cost. If we can 
really tackle pharmaceutical costs that would be a great help 
for families. I don't see any bills on the agenda today that do 
that but that would be very positive. Florida families with 
employer coverage saw their premiums grow only 1.3 percent from 
2010 to 2015 compared to 8.2 percent over the previous decade 
before the Affordable Care Act. That means, if you look at it 
in real dollars, a savings of about $7,600 per family.
    The ACA also requires, and this doesn't get a lot of play 
but it is very important. The ACA also requires health 
insurance companies to spend at least 80 percent of their 
premium dollars on actual health care, not administrative costs 
or profits, and if the insurance companies go over that 80 
percent they have to--consumers get a refund. HHS reports that 
Floridians with employer coverage have received $109 million in 
refunds since 2012. That really makes a difference for the 
working families I represent.
    So one of the bills that is on the agenda for discussion 
today is age rating. Boy, have you really hit a nerve back in 
Florida to ask that our older neighbors, and we are talking 
about those that are under 65, are going to pay a whole lot 
more for their insurance coverage.
    The thing about the Affordable Care Act, it is this very 
considered, thoughtful balance. Over time it is going to need 
rebalancing. Like I said, markets like mine are very 
competitive even in the individual market with 61 plans to 
choose from. Not all parts of the country are like that. But if 
you start tinkering here and asking my older neighbors to pay a 
whole lot more before they go into Medicare that is not smart. 
We want them to be as healthy as possible before they go into 
Medicare because we have our challenges there as well.
    So watch out for this age rating, and I go back to the 
woman that I mentioned during my opening remarks who is 60 
years old, working part-time in a small business, taking care 
of her youngster in high school, going to school. You ask her 
to pay five times the going rate instead of what is in the ACA 
now you probably price her out of this.
    So let's be thoughtful in what we do. We have got to turn 
back this repeal effort, though, and make more considered and 
thoughtful policy here in Washington, DC. I yield back my time.
    Mr. Burgess. The Chair thanks the gentlelady--the 
gentlelady yields back--and recognizes the gentleman from 
Florida, Mr. Bilirakis, 5 minutes for questions, please.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it 
very much, and I thank the panel for their testimony as well.
    Mr. Holtz-Eakin, I understand you run your, CBO, and you 
currently run a think tank?
    Dr. Holtz-Eakin. That is correct, sir.
    Mr. Bilirakis. Your organization recently did a review on 
the various replacement plans that conservatives had 
introduced. There is the Better Way by House Republican 
Conference, the Patient CARE Act, the Improving Health and 
Health Care Act, Empowering Patients First Act, the American 
Health Care Reform Act, the 2017 project in the World's 
Greatest Health Care Plan.
    When people say Republicans don't have a plan that is 
simply not true. There are many plans and competing ideas. 
However, it would be fair that there are certain common areas 
that are in most of these plans. Can you talk about the ACA 
provisions that in your expert opinion would most likely be 
kept? If you would elaborate, please.
    Dr. Holtz-Eakin. Yes, I mean one of the reasons we wrote 
the paper is that there is an enormous amount of overlap and so 
it seems to me to be sensible to expect those to be present in 
any replacement plan.
    So all of them allow children to stay on the parents' 
policy until age 26 as in current law, all prevent 
discrimination against those with preexisting conditions and 
guarantee the issuance of an insurance policy, all of them ban 
caps on annual or lifetime out-of-pockets for individuals, and 
then they all have subsidies for individuals, typically age 
based so the elderly, the older and more likely to be expensive 
patients get some help.
    All of them have some sort of risk pool for those who can't 
be managed in the normal pool and all have some sort of 
approach to the continuous coverage idea where the differences 
quite frankly are in how do you handle the gaps. Handling the 
gaps, I want to echo what was said, is a really important 
issue. All of them have some provision to cap the most exposure 
that an individual would face if somehow they did develop a 
coverage gap for reasons outside of their control. So there is 
always common elements in these replace plans.
    Mr. Bilirakis. Very good, thank you.
    Mr. Wieske, when the ACA was passed there were several 
promises made about it. The American people were promised it 
would bend and cost curve through increased competition the 
health insurance market. In Florida today 73 percent of the 
counties have only one health insurer and average premiums 
increased by 19 percent last year. I fear that what it will 
look like 2018.
    You mentioned that in Wisconsin you have an active 
insurance market pre-ACA----
    Mr. Wieske. Yes.
    Mr. Bilirakis [continuing]. And then how was the health 
market before ACA and now with the ACA? Can you discuss it?
    Mr. Wieske. Yes, I think we saw the highly competitive 
markets were fortunate. We still have a lot of choice in our 
market, but it is evaporating slowly but surely. And we see 
carriers consistently move their market around, move their 
coverage areas around, so there is a lot of instability. They 
have changed their networks. They have changed their networks 
around in order to deal with affordability and competition and 
issues, and the net result for a consumer is consumers don't 
have as many choices as they had before the ACA. They have 
fewer choices in coverage.
    Mr. Bilirakis. Thank you. Mr. Holtz-Eakin, again just in 
case members of the minority might not be familiar with our 
Better Way agenda, can you please detail that the Center for 
Health and Economy analysis finds the plan broadly what it 
accomplishes. Again, the impact on premiums would they increase 
or decrease? What about provider access? Would there be an 
impact on the Federal budget? Can you go ahead and discuss 
that?
    Dr. Holtz-Eakin. The Center for Health and Economy, of 
which I am a board member, did an analysis of the Better Way 
plan. I won't remember all the numbers right, but broadly 
speaking the insurance market deregulation lowers premiums 
something in the vicinity of 15 percent or so. Lower premiums 
improve private coverage in that plan and expand coverage. As a 
result of both the lower premiums and the subject structure 
there is less stress on taxpayers and there is budget savings 
in the Better Way Plan.
    And underneath the plans is important I identify what kind 
of networks and provider access are available, and access has 
improved. And there is an index of medical productivity, 
something to think about in terms an index for bending the cost 
curve, and there is improved medical productivity in the plan.
    Mr. Bilirakis. Thank you very much. I yield back, Mr. 
Chairman, appreciate it.
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman. The Chair recognizes the gentleman from Oregon, 
Dr. Schrader, 5 minutes for your questions, please.
    Mr. Schrader. Thank you very much, Mr. Chairman. I 
appreciate the panel for being here. I just want to put some 
emphasis on the goal of what we are trying to do here and that 
is not to just beef up an insurance market, but to provide good 
health care for Americans. That is really our goal.
    The vehicle we currently have is dealing with the insurance 
market, I get that. But I think when we are talking about you 
can't have the plans you want, et cetera, the goal here is to 
provide the essential benefits that basically provide health 
care for the scope of the people of this great country. And if 
everyone just pays in their little bit just like you do in any 
insurance program everyone benefits at the end of the day.
    I think we have to focus on the health care aspects here. I 
am a little concerned about the tenor of the hearing. I want to 
make sure we are talking apples to apples as we go forward.
    Mr. Holtz-Eakin, you talked about that some of these fixes 
could help stabilize the markets, so I assume you don't see 
these as replacement for the ACA but to stabilize the current 
market structure?
    Dr. Holtz-Eakin. Yes, the special enrollment periods, grace 
periods, those kinds, again these are what I think of as near 
term Band-Aids to make sure the current deterioration doesn't 
continue and it works----
    Mr. Schrader. I think that is fair. So they are not going 
to replace the ACA in and of themselves.
    Mr. Wieske, you talked a lot about the high-risk pools and 
you have a robust market in Wisconsin. Knock on wood we still 
do in Oregon, but some States don't, some counties don't, 
depending on the State they are in. I get that. You talked 
about the Federal subsidy driving down the cost of the program 
if you will making it more affordable for Wisconsinites.
    You know, if we get rid of the ACA in its entirety which 
has been proposed, and all the revenues, the 800 billion plus 
some of the other policy changes that make sure this is a 
deficit reduction, a piece of legislation, you know, what do 
you think? Don't we need some Federal revenues to make whatever 
system we have going forward affordable for Wisconsinites?
    Mr. Wieske. I mean I think Federal revenues obviously make 
it easier, but functionally, I mean I will say our market 
functioned pretty well. There was guaranteed issue available. 
Nobody could be turned down in most States, I think all States, 
because of a health condition once they were insured, so that 
didn't exist and that didn't exist in Wisconsin. People were 
not dropped off their coverage due to----
    Mr. Schrader. So I have to interrupt, I apologize. I don't 
have a lot of time. Yes, and I think there is different 
opinions about, you know, who should get, you know, well, 
apparently some different opinions about who should get 
covered. I think everyone should have coverage and that means 
making it affordable and maybe even giving some people more of 
a break than some people think they deserve, because it all 
costs us at the end of the day if they don't have health 
insurance and that is just not productive.
    I want to make a statement and I would like everyone to 
think about this both Democrat and Republican and you certified 
smart people over there on the dais. I am very worried these 
young people we are trying to get onto the individual 
marketplace they don't exist. I see no evidence that these 
people are out there no matter what we do--age bands, 
difference in premiums.
    The reason I say that is, and I would love to be proven 
wrong but no one has been able to give me the information, 
insurers, you know, providers, whatever is that a lot of young 
people are on their parents' plan, age 26. A lot of people have 
jobs, especially right now. They are working. The people that 
are on the individual market are, in my State and I think most 
States, adversely selected. They are 50 to 65 years old. They 
have got a bunch of medical conditions.
    And last but not least, with the Medicaid expansion that 
has been successful across the country and is part of the ACA--
I think we have to understand that the Medicaid expansion is 
part of the ACA--the biggest portion of that population that 
signed up, they are young. Well, younger than me, under 45 
years of age, eh. So that is good.
    I am worried that we are chasing a unicorn here, folks. I 
am worried we are chasing a unicorn. I don't care what plan I 
have heard from my Republican colleagues or as Democrats. So I 
think we need to put that into the mix as we think about how do 
we make sure this individual market is stabilized. It has been 
a boon for a lot of folks. It has worked very well for a lot of 
folks. It has some problems and maybe some of these fixes would 
get to them.
    And I would hope that the majority party would look at 
working with the minority party on some of these. The age bands 
don't have to be 5:1. The grace period doesn't have to be 3 
months, you know, there is accommodations that we have talked 
about in previous hearings.
    And I think we keep in mind that this is to stabilize the 
current ACA marketplace while my colleagues, trying to chase 
maybe a unicorn, maybe we have been chasing it and now it is 
their turn, but I hope we look at this and the goal again is to 
provide excellent health care to every single American in the 
greatest nation on earth. And I yield back.
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman. The Chair now recognizes the gentleman from 
Indiana, Dr. Bucshon, 5 minutes for your questions, please.
    Mr. Bucshon. Thank you, Mr. Chairman. Dr. Holtz-Eakin, your 
written testimony is packed with incredible statistics on age 
rating bands and I would like to read a few, just some facts. 
Average healthcare expenses for a 64-year-old are 4.8 times 
greater than that of a 21-year-old, and according to U.S. 
Census data, the insured rate for those age 19 to 34 is 4.6 
percent higher than the uninsured rate for those age 35 to 64.
    I raise this because you note that the administration 
predicted that the individual market would need about 40 
percent in the enrollee population to be made up of young, 
healthy patients. Today that number is 28 percent. So the 3:1 
age band in my view is just not an actuarially sound principle 
based on that. Would you agree that modifying the age variation 
in premiums would help balance risk and help stabilize the 
marketplace?
    Dr. Holtz-Eakin. Yes, it would help. It would allow 
insurers to offer relatively cheaper policies to the young and 
relatively inexpensive. It is true that they would be 
relatively more expensive for the older and sicker. That is a 
financial reality. But getting those into the pool helps 
everyone over the long term.
    Mr. Bucshon. So at the end of the day, do you think one of 
the biggest problems with what is happening in the exchange 
marketplace is mostly based on the fact that it is 28 percent 
young, healthy people versus 40 percent? Would you consider 
that the major factor or are there other reasons?
    Dr. Holtz-Eakin. There are probably some other reasons. I 
think this sort of grace period or the special enrollment 
periods or things like that have exacerbated the fundamental 
problem. But this is a core problem and because of the exits 
and the rising premiums it is getting worse not better.
    And we have discussed a little bit about the design of 
high-risk pools today, my basic theory is we have a high-risk 
pool, and it is called the exchange market, and it is just 
getting more and more like one every day.
    Mr. Bucshon. OK. Mr. Wieske, do you have any comments on 
that?
    Mr. Wieske. No, I think that is exactly right. And part of 
to understand is as you get more of the young folks in that 
drives the average rate down so that 5:1 may still be a 5:1, 
but it is not necessarily the same 5:1. It is a lower figure 
that you are starting with when you multiply it times 5.
    Mr. Bucshon. Correct. So the 1 will be a lower starting 
point.
    Mr. Wieske. Correct.
    Mr. Bucshon. And I think that is one of the concepts I 
think that people try to overlook. If you take changing the age 
rating band and the concept that the 1 will stay in the same 
place that it is today, you can make the argument yes, costs 
will be so high for the older, sicker patients that it might 
price them out of the marketplace.
    But my, you know, shifting the idea is to shift the whole 
marketplace back to a more actuarially sound position.So it is 
not just this, but there is some other actuarially unsound 
principles in the ACA that in my view have predictably resulted 
in where we are today.
    Do you have any other final comments, Dr. Holtz-Eakin, on 
that? Anything else that is what you consider nonactuarially 
sound other than the age bands that we might be addressing that 
we haven't addressed? Do you have any other thoughts?
    Dr. Holtz-Eakin. I think the more you delegate the sort of 
regulatory process and the review process to the State 
insurance commissioners, the better you are going to get this 
because the pools are different State by State, dramatically 
different.
    Mr. Bucshon. Very important concept.
    Dr. Holtz-Eakin. And so I think you should recognize that 
in going forward.
    Mr. Bucshon. OK. Mr. Wieske.
    Mr. Wieske. Obviously we agree. And I think, you know, I 
think the other piece here is that you can take a look at the 
testimony and you can see the disparate impact that the ACA had 
on rates when it was implemented. And in my testimony we have 
numbers that show that the increases were substantially higher 
on the younger folks than they were on the older folks, so it 
is a return back to where it was before.
    Mr. Bucshon. Dr. Lichtenfeld, I was a cardiac surgeon 
before I was in Congress, so I am going to ask and this is a 
serious question. Before the ACA, prior to the ACA, if you were 
referred a patient, you know, that has cancer for example, say, 
a GI doctor referred you someone that has a colon cancer and 
that person did not have medical coverage how did you handle 
that situation?
    Dr. Lichtenfeld. With difficulty, quite frankly.
    Mr. Bucshon. Yes. Did the patient get medical care?
    Dr. Lichtenfeld. Well, they may have gotten some medical 
care but they didn't get adequate medical care.
    Mr. Bucshon. So if they needed follow-up chemo from their 
colon cancer for example what, a 5FU or whatever you guys do 
these days, did they get that or they didn't get it?
    Dr. Lichtenfeld. 5FU is one question, the newer treatments 
we have today are entirely different, OK.
    Mr. Bucshon. OK, the newer treatments then, yes. OK.
    Dr. Lichtenfeld. And certainly, sir----
    Mr. Bucshon. I haven't done GI or colon stuff in 25 years 
so I am behind.
    Mr. Bucshon. I respect the work that you have done. In 
fact, one time in my life I wanted to be a cardiac surgeon and 
didn't make it, so----
    Mr. Bucshon. You made the right decision.
    Dr. Lichtenfeld. But the reality is, you know, we as 
physicians always want to do what we can to stabilize somebody 
in their time of need. That is very important.
    Mr. Bucshon. Yes.
    Dr. Lichtenfeld. Unfortunately cancer is a complex, long-
term disease.
    Mr. Bucshon. Understood.
    Dr. Lichtenfeld. And those folks will fall through the 
cracks. They did, and they are doing less so today.
    Mr. Bucshon. OK, thank you. I yield back.
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman. The Chair recognizes the gentleman from 
Massachusetts, Mr. Kennedy, 5 minutes for your questions, 
please.
    Mr. Kennedy. Thank you, Mr. Chairman, and I want to thank 
the witnesses for their testimony today, touch on a couple of 
issues.
    Mr. Wieske, you had testified and you spoke an awful lot 
today about the benefits of Wisconsin's high-risk pool, sir. I 
wanted to make sure we just fleshed that out a little bit. My 
understanding is that when you talk about the comprehensive 
coverage that was provided to consumers and that the cost 
coverage closely mirrored the cost of private coverage in the 
State, I believe though that the premiums for the Wisconsin 
high-risk pool were set at twice the individual marketplace; 
isn't that right?
    Mr. Wieske. No, that is not correct. They were set based on 
an actuarial basis, so the----
    Mr. Kennedy. So that is information coming from Kaiser 
Foundation.
    Mr. Wieske [continuing]. I am sorry.
    Mr. Kennedy. I am sorry. The information coming from the 
Kaiser Family Foundation indicated that those prices were twice 
the----
    Mr. Wieske. The numbers in my testimony were actually 
provided through the Legislative Audit Bureau, which did an 
audit of the State high-risk pool. I sat on the State high-risk 
pool board. The rates were set based on the actual contribution 
to costs by each of those that split the 40/30/30 that I talked 
about.
    So that was where it was. It was not set in an artificial 
200 percent of the Federal--I don't know where they got that 
number, unless it came from the Federal high-risk pool piece, 
which is separate, and they had their own separate rules of how 
they set their rates.
    Mr. Kennedy. So if it is not--I understand that you are 
saying they weren't pegged that way. Were the premiums though 
twice as high as they were for the high-risk pool as they were 
for the individual markets?
    Mr. Wieske. Yes. I don't think so, no.
    Mr. Kennedy. No, OK. Didn't Wisconsin's high-risk pool 
exclude coverage for 6 months for a preexisting condition that 
made patients actually eligible for that pool in the first 
place?
    Mr. Wieske. It depended on how you came into the pool. So 
folks who had continuous coverage it mirrored the preexisting 
condition piece so that is something that could certainly be 
fixed. But folks that came from no coverage similar to folks 
who were facing a grace period who have not signed up for the 
ACA and can't sign until the open enrollment period and have to 
wait until then to sign up if they don't have coverage, if they 
came from no coverage they did have a 6-month waiting period.
    Again it would be like an open enrollment period except you 
get to sign up anytime, but only for coverage of that 
condition. Now folks who came from other coverage that lost 
their coverage involuntarily did get preexisting condition 
credit and did not have a preexisting----
    Mr. Kennedy. So if I were, just to make sure I understand 
that if I did not have coverage before and came down with 
cancer I would have to wait 6 months for those cancer 
treatments to get covered?
    Mr. Wieske. Similar to if you did not have----
    Mr. Kennedy. Yes.
    Mr. Wieske [continuing]. Coverage right now you could not 
buy coverage in the individual market. You have to wait until 
open enrollment.
     Mr. Kennedy. Dr. Lichtenfeld, can you tell me what the 
impact of having a cancer patient wait 6 months for treatment 
might be?
    Dr. Lichtenfeld. We have actually been through that in the 
past where in fact some of the commercial plans in the group 
plans had exclusions of 9 months, so it is a pretty serious 
issue. And we have also had issues with regard to women who 
were screened for cancer, mammography for example, who did not 
get automatic coverage.
    So the question was, well, you have screening, you know you 
may have breast cancer but you can't get the care. So that has 
been addressed in some respect through the breast and cervical 
cancer early detection program. So it is a very real issue 
cancer doesn't wait, and there is acute conditions that really 
don't wait. So obviously the 6-month exclusionary period which 
has existed in the past in some places is something to be 
concerned about.
    Mr. Kennedy. So let me shift topics a little bit here, but 
I would appreciate your medical opinion on this. We have, as I 
mentioned in my opening comments a while ago now, this 
committee has dived into a partial examination of the failures 
of our mental health system across our country and some of the 
systemic failures with that marketplace.
    As you might be aware, the largest provider of mental 
health, or payer for mental health service in the country is 
Medicaid. And so the combination of mental health parity and 
the Medicaid expansion and some of the clauses in the 
Affordable Care Act themselves were a sea change in terms of 
access to care, understanding we still have an awfully long way 
to go.
    I was hoping you might be able to comment on what the 
impacts of either doing away with that Medicaid expansion or 
issues around preexisting conditions what that would mean for 
folks suffering from mental illness.
    Dr. Lichtenfeld. Mental health issues are serious and as I 
mentioned earlier they certainly impact patients with cancer 
and families of patients with cancer. Access to those services 
is very important. And clearly within the community and now 
with the opioid addiction epidemic that we have and the stress 
that that is putting on mental health services, we have to make 
certain that everyone has adequate access to mental health 
services just as we have talked about with respect to services 
for patients diagnosed with cancer.
    Mr. Kennedy. Thank you, sir. I yield back.
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman. The Chair recognizes the gentlelady from 
Indiana, Mrs. Brooks, 5 minutes for your questions, please.
    Mrs. Brooks. Thank you, Mr. Chairman. I just want to 
clarify, Dr. Lichtenfeld, under current law, current law, if a 
patient is diagnosed with cancer they also have to wait, do 
they not, to get into a market?
    Dr. Lichtenfeld. I am going to share with you that I can't 
respond to that directly. To my, you know, depending on the 
circumstances--I am trying as I think through this--they really 
are individual. If I may, they are individually specific to 
that person as to what happens to them, have they been engaged 
or not, and that is a very real----
    Mrs. Brooks. If they had not been engaged.
    Dr. Lichtenfeld. If they have not been then that could be 
problematic.
    Mrs. Brooks. OK, so that--and Commissioner Wieske, would 
you--and I am sorry. How do you say your last name?
    Mr. Wieske. Wieske.
    Mrs. Brooks. Wieske, I am sorry. Is that your 
understanding----
    Mr. Wieske. Yes.
    Mrs. Brooks [continuing]. That under current law if an 
individual had paid the penalty or had, you know, and was not 
insured right now, if they develop cancer they too have to wait 
for open enrollment?
    Mr. Wieske. Healthy or not they have to wait until open 
enrollment. They cannot enroll until January of the next year 
unless there is a special enrollment period.
    Mrs. Brooks. OK, thank you. I would like to talk about what 
we are trying to explore which has to do with continuous 
coverage and the importance of continuous coverage as a 
potential tool in incentivizing individuals to stay covered. 
And so some folks would suggest that this could lead to higher 
premiums based off of health status or preexisting conditions, 
but I believe that to be false.
    And because we want to prohibit rating based off of health 
status, we want to prohibit rating based off of preexisting 
conditions, critically important, but in order to accomplish 
this fairness goal we have to stabilize the markets, as I 
understand actuarially sound market stabilizers.
    And so, Commissioner Wieske, as Chair of the NAIC Health 
Care Reform how do both the State of Wisconsin and the 
association view the concept of continuous coverage?
    Mr. Wieske. Well, I think it is important. I mean I think a 
lot of the issues that surround the individual health insurance 
market are driven by the fact that again it is a residual 
market and the fact that folks jump in and out from carrier to 
carrier which has been exacerbated by the ACA.
    So I think insurers----
    Mrs. Brooks. Can you expand on that please?
    Mr. Wieske. Sure. That in the ACA that you have seen people 
typically jump from one carrier to another obviously based on 
price, based on their interest.
    Mrs. Brooks. And when you say they jump from one carrier to 
another what is the time period in which they have been doing 
that?
    Mr. Wieske. Every year they look to switch as to what their 
best options are. That is appropriate shopping. But I think if 
you can design a system that where their coverage is more 
continuous, I think that the interest of the insurers change in 
driving more long-term health and I think that is really where 
the issue is, is that if you have only got somebody for a year 
or 2, your investment in their long-term health never pays off. 
It pays off for the next insurer.
    So if you can have a long-term coverage with a single 
insurer you end up having a system where those further 
investments pay off for the insurer.
    Mrs. Brooks. And do we have some circumstances where people 
might be insured for 9 months and then drop out?
    Mr. Wieske. Yes, definitely we have heard that the--yes, 
consistently.
    Mrs. Brooks. Dr. Holtz-Eakin, I understand--what are your 
thoughts with respect to continuous coverage with respect to a 
mechanism for stabilizing the healthcare markets?
    Dr. Holtz-Eakin. As I said before, I think it is a very 
important concept. Obviously there are details that need to be 
worked out, but the incentives to get the young into the pool 
are very powerful. The issue of having a balanced pool gets 
taken care of organically because the young are always jumping 
in. Some will become more expensive as they get older; they are 
all in the pool.
    But the fundamental issue has always been how do you get 
quality care at lower costs, and this gives insurers the 
correct incentives to look over a lifetime, work with the 
providers not just for short-term purposes but for the long 
term and that would be beneficial. We don't have those 
incentives in the system right now. The closest place for that 
quite frankly is employers. Self-insured employers often have 
employees for an average of 7 years. That is a time period over 
which you can make a big difference.
    And I consider it no surprise that that is the place where 
we have seen the slowest cost growth in the U.S. health system.
    Mrs. Brooks. Can you share any actuarial cautions we should 
consider as we are shaping this process and what are some of 
the incentives that you believe could be really helpful?
    Dr. Holtz-Eakin. I think the most important thing is to 
separate what the system looks like from how we get there, and 
today's discussion is largely that sort of stabilizing it so 
that you can get something in place. The high-risk pools will 
be at a minimum a very important part of the transition 
mechanism. Figuring out who goes in and who comes out and gets 
back into the regular pool, I think, is going to be a really 
important part of this.
    Mrs. Brooks. Thank you. I yield back.
    Mr. Burgess. The gentlelady yields back. The Chair thanks 
the gentlelady. The Chair recognizes the gentlelady from 
California, Ms. Eshoo, 5 minutes for questions, please.
    Ms. Eshoo. Thank you, Mr. Chairman, and thank you to the 
witnesses for being here today. I guess it is an advantage to 
come early and hear what everyone has had to say and the 
questions that are asked and the answers that you have 
proposed.
    I want to start out by commenting on Chairman Walden's 
remarks. He is a good man, and I take him at his word in terms 
of what he believes in. But for each one of us, we are 
legislators. We are legislators. So while we can all talk about 
what we believe in what is actually written down in legislation 
which you are here to give testimony on, we came to a hearing 
where Title II Continuous Coverage Incentive is blank, blank. 
It is blank. So I can't help but comment on that first.
    There are so many things that have been said that I find 
either curious or really menacing. First of all, the Affordable 
Care Act in its promise which has been kept so far is that no 
one can take it away from you. That is not what the American 
people experienced before that legislation became law. Now 
today the only ones that can take it away from you are the 
Republicans. And that is what repeal is. Repeal is a heavy, 
heavy word. It is a wrecking ball.
    We are sitting in a hearing room that was recently 
remodeled. The entirety of the Rayburn Building was not taken 
down. It wasn't destroyed and then rebuilt simply because these 
daises needed to be adjusted or the room repainted. So when the 
word repeal is used, it is chilling and, you know what, it is 
chilling to markets. It is chilling to markets. And I don't 
think that has been taken into consideration by our witnesses 
today.
    Now this whole issue of insurance across State lines and 
what it is going to do, I can buy an insurance policy across 
State lines today. Maybe I pick Idaho, I don't know, Arizona, 
wherever. Terrific. Maybe it is lower cost than what I have 
now. The only problem is, when I get sick I have to travel to 
that State in order to take advantage of it. And within our 50 
States, there are many different standards. Some States are 
low-ball States. They have practically no protections for 
consumers, so if that is what is opened up, that is a disaster, 
in my view.
    Now what I want to ask each one of you is, do you support 
national insurance for people in our country, each one of you, 
yes or no? Quickly, because my time is running out.
    Dr. Holtz-Eakin. I don't know what national health 
insurance is.
    Ms. Eshoo. That everyone in this country is able to get 
health insurance.
    Dr. Holtz-Eakin. Everyone has an opportunity to buy a 
policy, sure.
    Mr. Wieske. Everybody should have access to affordable 
health insurance.
    Ms. Eshoo. Just access or be able to get it? I can go to 
Nieman's. I can have access at Nieman's.
    Mr. Wieske. I think access means that they can get it. If 
it is affordable, access means they can get it.
    Ms. Eshoo. Dr. Lichtenfeld.
    Dr. Lichtenfeld. Ms. Eshoo, and my personal thoughts are 
not relevant to my presentation today, I am here on behalf of--
--
    Ms. Eshoo. Well, you are here on behalf of--say yes or no.
    Dr. Lichtenfeld. I am here on behalf of the American Cancer 
Society and we are--just like everything else, we will 
certainly consider proposals if they are made. Our concern 
today is to make sure that----
    Ms. Eshoo. That is it. I am losing my time.
    Dr. Lichtenfeld [continuing]. Going forward that we----
    Ms. Eshoo. Do you support, you all say that you support the 
very good things that are in the ACA--no discrimination, 
preexisting conditions, women, up to 26 on their parents' 
policy--so you would support a mandate in whatever replaces the 
ACA to include those, because it is a mandate.
    Dr. Holtz-Eakin. I didn't say that. I said every 
replacement we have studied continued those----
    Ms. Eshoo. No, I am asking you do you support that? You 
accept that it is a mandate or is it voluntary? How are these 
things going to come about if they are not baked in as a 
mandate for an insurance policy?
    Dr. Holtz-Eakin. People are permitted to have their 
children on their policies up to age 26. They are not mandated 
to have them until 26.
    Ms. Eshoo. But there is a mandate to the insurance industry 
that those reforms which cover everyone----
    Dr. Holtz-Eakin. Yes, it is the current law.
    Ms. Eshoo [continuing]. So you accept that?
    Dr. Holtz-Eakin. Yes.
    Mr. Wieske. We had these reforms in place----
    Ms. Eshoo. Do you, Mr. Wieske?
    Mr. Wieske. We had these, we performed----
    Ms. Eshoo. No, I don't want to hear about that. I just want 
to know if you----
    Mr. Wieske. But Wisconsin believes that it has a good 
market and it doesn't need a Federal mandate to tell us what to 
do.
    Ms. Eshoo. But do you support those being mandated relative 
to the insurance industry in our country, those reforms?
    Mr. Wieske. We would look at it in State law, yes.
    Ms. Eshoo. Do you think that beyond your State it should 
be?
    Mr. Wieske. I can't speak for other States.
    Ms. Eshoo. Do you want it for your State?
    Mr. Wieske. We will work with our legislature and the 
legislature will figure out what is----
    Ms. Eshoo. Well, you know what, this is like nailing Jell-O 
to a wall because I don't think there is a commitment. I think 
you talk about these things and that they are good things, but 
unless these reforms are held onto that were made and have made 
an enormous difference in people's lives, including all the 
cancer patients in our country, then there isn't a commitment 
to them. And I think that this is part of the basics of what 
the integrity of what insurance plans need to have in the 
country. This has revolutionized people's lives.
    Mr. Burgess. The Chair thanks the gentlelady. The 
gentlelady's time has expired. The Chair recognizes the 
gentleman from Oklahoma, 5 minutes for questions, please.
    Mr. Mullin. I feel sorry for the panel. It is funny, 
because it seems like when I go after a panel like that they 
always get upset because I am badgering the witness or 
something. I understand everybody's opinions runs high on this, 
I get that. But I will be real frank with everybody. The 
Federal Government should get out of the people's way and we 
shouldn't be mandating anybody to do anything. That is not the 
role of the Federal Government. The Federal Government is to 
provide opportunities and resources for them to have access and 
affordable access, and that is what we are trying to do here: 
affordable access.
    Oklahoma, which I represent, is one of the States that only 
has one insurer carrier in there. We are one of the one of 
five. We saw premiums rise by 76 percent last year. It is not 
because the Blue Cross Blue Shield is trying to be greedy, it 
is because they are trying to stay in business. I understand 
that. The regulatory environment is such that they have to 
continue to change so they can afford to provide the health 
care.
    But because of the regulatory environment underneath, 
ironically, Affordable Health Care--which is anything but 
affordable--it is causing premiums to skyrocket, and then it 
causes less affordability, which means less access to our 
constituents. And all this committee is trying to do is find a 
way to bring those premiums down and allow access to be 
created.
    So Mr. Wieske--and I hope I pronounced that right.
    Mr. Wieske. You did.
    Mr. Mullin. OK. My first questions to you: Could you help 
explain why the regulatory environment that we are finding 
ourselves in right now is causing the premiums to literally 
skyrocket?
    Mr. Wieske. Sure. I think it starts with the risk pool. You 
know, you may have a large risk pool, but when you have loaded 
dice it is very difficult to get a representative, you know, 1 
through 6, a representative sample when the dice are loaded. In 
other words----
    Mr. Mullin. What do you mean by loaded dice?
    Mr. Wieske. What I mean is, is that the risk pool, the 
people who are purchasing coverage tend to need it and they 
tend to--that the folks who don't need coverage who are young 
and healthy are outside of the market. And so, when you are 
looking at the people that are buying coverage through the ACA, 
that they are tending to be sicker.
    And I think as Doug had indicated that it looks a lot like 
our high-risk pool looked from a risk perspective. It is a 
little bit better, but it looks a lot like that from that 
perspective. That is the concern. I think you need to lower the 
premiums for younger folks to get them into the marketplace.
    I think a lot of the burdens, you know, the SEP issue I 
think is one. There is a number of others where the Obama 
administration has set such stringent rules that make no sense. 
Their three Rs program has been a disaster as far as hearing 
out how you pay for the reinsurance and adequately price for 
the risk. The timelines are ridiculous. You are pricing a 
policy in March for something that starts in January. You know, 
it used to be a month, month in a half before, insurers don't 
have the data. There is a whole host of--I could go on probably 
for hours and bore everybody here.
    Mr. Mullin. Well, so if I am hearing you correctly, if we 
keep things the way they are right now are we going to create 
an environment for more access or is it going to drive more 
insurers out of the market?
    Mr. Wieske. I think there will be a few States like 
Wisconsin that will hang on by our nails for a while, but I 
think you can see in a number of States where the Tennessee 
commissioner who testified yesterday in front of Senate Health 
indicated that her market was near collapse, I think that is 
what you are going to be looking at over time in a number of 
States in the current environment.
    Mr. Mullin. Well, you know, what we have been hearing is 
that both people, my side of the aisle and the other side of 
the aisle, we are passionate about our constituents. What 
strikes me is that here we are actually holding hearings on 
trying to fix a problem. I just wonder how much input you guys 
got to have when this thing was jammed down you all's throat. 
At least now we are trying to open it up and allow you guys to 
comment on it. If it is really about our constituents, then why 
would the other side be so upset that we are actually having 
public hearings on trying to fix it and get it better? I don't 
understand that.
    So I appreciate, I appreciate that you guys are coming 
here, giving your perspective, the States' perspective, and we 
are getting input. And I appreciate the chairman, who has taken 
the time to listen and actually put up with some of the 
shenanigans that is going on on the other side, your patience, 
as you can tell, I wouldn't put up with. I appreciate you doing 
that, Chairman.
    But at the end of the day this is about getting it right 
and fixing it for our constituents. So thank you for your time, 
thank you for coming in here and giving your expert opinion and 
we look forward to working with you to bring down the premiums 
so it can be affordable and it can create access for our 
constituents to have healthcare coverage if they so choose to, 
not mandate to do. Thank you.
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman. The Chair would advise the subcommittee and the 
witnesses that a series of votes have been called on the floor. 
We are going to hear questions from Ms. DeGette for 5 minutes 
and then I am sure the panel would appreciate a break. We will 
have one and then we will reconvene back here immediately after 
the vote series is over. So Ms. DeGette, you are recognized 5 
minutes for questions, please.
    Ms. DeGette. Thank you, Mr. Chairman. I will just say 
before I start asking questions, my colleague from Oklahoma 
says, well, at least we are having hearings on legislation. But 
I would point out that we just learned today that we are going 
to have a markup of these bills that we are allegedly having 
the hearings today on, next Tuesday. And as my colleague from 
California said, Title II of the bill isn't even a title. It is 
Continuous Coverage Incentive, placeholder, and we are going to 
mark this up next Tuesday.
    Mr. Mullin. At least we are having an opportunity to read 
it.
    Ms. DeGette. I think we should work together on this. Now I 
want to welcome the panel here. I especially want to welcome 
you, Dr. Holtz-Eakin. I know when you were director of CBO you 
appeared in front of this committee many times and I am glad to 
welcome you back. I want to ask--I want to focus most of my 
questions on you. First of all, you State in your testimony 
that the ACA is in a downward spiral, correct?
    Dr. Holtz-Eakin. Correct.
    Ms. DeGette. And a downward spiral--well, you State in a 
downward spiral prices rise and insurers will continue to leave 
the market, correct?
    Dr. Holtz-Eakin. Yes.
    Ms. DeGette. And the result of that is because people are 
leaving plans and therefore the programs will not be 
sustainable; isn't that correct?
    Dr. Holtz-Eakin. And there will be less competition and it 
will affect prices.
    Ms. DeGette. Right. So declining enrollment would be one 
characteristic of a death spiral would it not?
    Dr. Holtz-Eakin. Yes.
    Ms. DeGette. Yes, it would. So I want to--my assistant is 
going to hand you actually a chart from the Congressional 
Budget Office, and it shows that Obamacare enrollment will hold 
steady from 2017 to 2027 and there won't be decreasing 
enrollment. Do you see that chart?
    Dr. Holtz-Eakin. I do.
    Ms. DeGette. Thank you very much. Now also, Dr. Holtz-
Eakin.
    Mr. Burgess. Will the gentlelady yield?
    Ms. DeGette. No, I will not. Also, Dr. Holtz-Eakin, the 
Congressional Budget Office, your former employer, issued a 
report in January 2017 called ``How Repealing Portions of the 
Affordable Care Act Would Affect Health Insurance Coverage and 
Premiums.'' Are you familiar with that report?
    Dr. Holtz-Eakin. I am not an expert on it, but I have read 
it.
    Ms. DeGette. OK. So what the report basically looked at was 
the plan President Obama vetoed before, but what that plan did 
was it eliminated in two steps the laws mandate penalties and 
subsidies, but it left the ACA's insurance market reforms in 
place like the preexisting condition and age 26 and all of that 
so it is pretty much like what we are talking about here today.
    And here is what the Congressional Budget Office found. It 
found that under a schematic like that, quote, the number of 
people who are uninsured would increase by 18 million in the 
first year following enactment of the plan. Later, after 
elimination of the ACA's expansion of Medicaid eligibility and 
the subsidies for insurance purchased through the marketplaces 
that number would increase to 27 million and then to 30 million 
in 2026. Are you aware of that finding?
    Dr. Holtz-Eakin. Yes, and I think it is wrong.
    Ms. DeGette. OK. OK, I appreciate that, but that was their 
finding.
    Dr. Holtz-Eakin. It is also out of date.
    Ms. DeGette. Now let me----
    Dr. Holtz-Eakin. You should, no, you should know before 
you----
    Ms. DeGette. No, no. Excuse me, sir. I am asking the 
questions.
    Dr. Holtz-Eakin. I am giving you some question advice.
    Ms. DeGette. The next finding that they made, on page 1 of 
their findings--and I do apologize, I only have 5 minutes. If 
you would like to supplement your testimony, I would welcome 
that, OK.
    The next finding was premiums in the nongroup market for 
the individual policies purchased through the marketplaces or 
direct from insurers would increase by 20 percent to 25 
percent. Are you familiar with that finding, sir?
    Dr. Holtz-Eakin. I don't remember that one.
    Ms. DeGette. You are not. OK, well, Mr. Chairman, I am 
going to ask unanimous consent to put both this chart from the 
CBO and also the report from January 2017 in the record.
    Mr. Burgess. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Ms. DeGette. Thank you. Now were you--so if you want to 
talk about a death spiral, it seems to me that a death spiral 
would be caused if you left all of the things, the requirements 
for the insurance companies, in place but then you eliminated 
the Medicaid expansion, you eliminated the exchanges and the 
subsidies, and people left the markets in droves.
    One more thing I just want to talk about, and that is 
premiums, because there have been a lot of allegations thrown 
around today that premiums have been skyrocketing. Are you 
aware of the CMS data that showed from 2000 to 2005 premiums 
were growing at 8 percent, from 2005 to 2010, 5.5 percent, and 
then under the ACA average premiums were growing at only 3.6 
percent, Mr. Holtz-Eakin?
    Dr. Holtz-Eakin. What premiums?
    Ms. DeGette. Private insurance premiums.
    Dr. Holtz-Eakin. Employer?
    Ms. DeGette. Yes.
    Dr. Holtz-Eakin. The ACA didn't touch employers.
    Ms. DeGette. Yes, it did.
    Dr. Holtz-Eakin. That is why it continued to perform well.
    Ms. DeGette. Yes, it did. Thank you very much, Mr. 
Chairman.
    Mr. Burgess. The gentlelady yields back. The Chair thanks 
the gentlelady. I do note the series of----
    Ms. DeGette. Mr. Chairman, may I just put this chart, ask 
unanimous consent to put this chart in the record, because it 
also talks about Medicare and Medicaid going down.
    Mr. Burgess. If the gentlelady is willing to share that 
with the committee, unanimous consent request is made, and 
without objection, so ordered.
    Mr. Burgess. We have 6 minutes left in our vote on the 
floor. The Chair advises that the committee will stand in 
recess until immediately after votes.
    [Recess.]
    Mr. Burgess. Call the subcommittee back to order, and to 
start I want to yield to Mr. Green for a point of personal 
privilege.
    Mr. Green. Thank you, Mr. Chairman, for the time and if I 
could have everybody's attention. I want to--there is a decorum 
requirement we do in this committee, and it was after we went 
to vote but our witnesses are here as guests and if you get up 
and insult, whether it is Republican or Democrat, that is not 
part of the decorum, no matter what. And I am just going to 
admonish that that is not acceptable.
    And so that is enough, Mr. Chairman. I just want to make 
sure that witnesses know they are here to answer questions and 
not to engage in arguments. Thank you.
    Mr. Burgess. The Chair thanks the gentleman and certainly 
once again thanks the witnesses for being here. And I know it 
has been a long day for all of us.
    At this time, the Chair would recognize the gentleman from 
New York, Mr. Collins, 5 minutes for questions, please.
    Mr. Collins. Thank you, Mr. Chairman. I am going to pretty 
much direct this to Dr. Holtz-Eakin. And I know we touched on 
the SEPs, the special enrollment periods. Representative 
Blackburn, who was chairing the Telecom, she is a sponsor of 
H.R. 706, I am a co-sponsor. It goes back to the last Congress, 
and to the two of us and I think to many, there is a lot of 
common sense in working on our special enrollment periods.
    And what we have noticed is, during the Obama 
administration, the enforcement seemed to be quite lax when it 
came to the SEPs and in effect giving individuals what I would 
call presumptive eligibility instead of verified eligibility, 
and in doing so there is always some costs that would come 
around.
    So, Dr. Holtz-Eakin, the last time that you testified 
before this subcommittee, you used the term, talking about the 
verification process, as being ``extremely generous.'' I think 
there was a little bit of tongue in cheek on that. Would you 
agree that that is still the case today, maybe if you want to 
expand on that at all?
    Dr. Holtz-Eakin. I think this is an important issue simply 
as a matter of the arithmetic as the risk pool. As many as up 
to a third of people in the pool entered through an SEP, and 
there are a lot of SEPs compared to other programs, like 
Medicare has seven.
    So, you know, that is a big part of it and in the data 
these are more expensive participants than other members of the 
pool. So in a system where the fundamental problem has been the 
cost and the inability of insurers to appropriately plan for 
costs and bake into their premiums those costs, this seems to 
me like a candidate for reform and a place that you should look 
right away.
    Mr. Collins. So in studying this how would you say it 
impacts the market?
    Dr. Holtz-Eakin. It does two things. It brings costs into 
the pool and those costs were unanticipated and that leads 
directly to insurer losses. The second thing it does is it 
makes insurers quite nervous about next year's unknowables and 
puts upward pressure on premiums just as a matter of caution to 
try to anticipate some of these people entering.
    Mr. Collins. So Commissioner, in your past life--and I know 
you are familiar with the SEPs as well. I think in your written 
testimony you actually say what we found up in Wisconsin was 
extremely problematic. Even more problematic, it was clear many 
consumers were using the process to receive costly medical care 
and then immediately dropping coverage.
    Mr. Wieske. That is correct. We actually did this on a 
national basis, looked at this on a national basis as well. We 
chair the Health Care Reform Alternatives Working Group at the 
NAIC and one of the plans indicated loss ratios on that 
business in excess of 180 percent, so significant losses and 
because of the dropping of coverage and they did not maintain 
it throughout the year.
    Mr. Collins. So I will ask somewhat of a rhetorical 
question, but when that happens who is stuck paying for that?
    Mr. Wieske. The whole pool is stuck paying, so the folks 
who are in the individual market because it is a single risk 
pool are paying higher premiums as a result.
    Mr. Collins. And I think it is also safe to say when--I 
will just call this out for what it is, cheating, and when 
someone is cheating the system they are also cheating the sick 
and the vulnerable patients and potentially driving up their 
costs. There is always a cost to someone and, you know, that is 
just kind of a point taken.
    So Mr. Chairman, I will yield back. I know there is some 
airplanes to catch and thank you all for your testimony.
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman, and the Chair recognizes the gentleman from New 
York, Mr. Engel, 5 minutes for your questions, please.
    Mr. Engel. Thank you very much, Mr. Chairman. We all know 
the phrase be careful what you wish for. It is a saying that I 
think my friends on the other side of the aisle are finding 
particularly poignant lately. I think our colleagues are on the 
other side of the aisle are finally realizing that it is easy 
to make promises, it is a lot harder to deliver progress as the 
Affordable Care Act has. You know, there is no such thing as a 
free lunch. If all the good things about the Affordable Care 
Act are going to be kept costs are going to go up and a lot of 
people will not be insured.
    And so I think it is leading us down a primrose path. We 
should have been working together all these years not to try to 
eliminate the Affordable Care Act 62 or 63 times, but to try to 
improve it.
    All major acts, all major bills, all major programs have to 
be implemented and then you see how it goes, what works, what 
doesn't and you tweak, you change it, you try to improve it. 
But all we have had here for the past several years is just 
ill-conceived votes to eliminate it entirely, and now that they 
apparently are they are going to be careful what they wish for.
    Mr. Green said this hearing is taking place on Groundhog 
Day. It is fitting because today Republicans are holding 
another hearing not on new ideas but the same ill-advised bills 
we have debated before in this committee. There is one 
exception, a half written draft that they claim would protect 
Americans living with preexisting conditions, but when you look 
closely we punish them instead.
    So I want to underscore how indefensible the situation is. 
My constituents are frightened. They are worried that their 
preventive services that the ACA guaranteed them free of charge 
are going to disappear. They are worried that insurance 
companies will again impose caps on their coverage. They are 
worried that without the ACA's protections they will be charged 
more for insurance. And my colleagues on the other side of the 
aisle are really doing nothing to allay their fears.
    Dr. Lichtenfeld, I would like to give you an opportunity to 
speak one more time on a matter you were asked about earlier. 
Speaking for the American Cancer Society, can you tell me 
whether you support every American having high quality health 
insurance?
    Dr. Lichtenfeld. Thank you, Mr. Engel, and let me clarify 
the answer to that particular question which I may have 
misheard previously was that yes, I personally am the American 
Cancer Society. I do support universal access to adequate and 
affordable healthcare coverage.
    Mr. Engel. Thank you. This draft would require insurance 
companies cover people with preexisting health conditions, 
however there is nothing in this text that prevents insurance 
companies from charging you more if you have a preexisting 
condition like asthma or diabetes.
    So is it fair to say, Dr. Lichtenfeld, that under 
legislation without a ban on medical underwriting Americans 
with preexisting conditions like cancer could be priced out of 
the care they need?
    Dr. Lichtenfeld. Once again thank you for the question. And 
it is our read and our concern that in fact that could happen.
    Mr. Engel. Before the Affordable Care Act I think you did 
say in your testimony that cancer patients who could get 
coverage which didn't always happen were still vulnerable to 
enormous costs; isn't that right?
    Dr. Lichtenfeld. Yes, sir.
    Mr. Engel. And that would happen again without the ACA. So 
I want to talk about that last point for a moment because 
lately we often hear Republicans use the phrase universal 
access as in they want everyone to have universal access to 
health care.
    They are careful to say universal access not coverage 
because this is what universal access is, a scheme in which 
insurers must cover you but can charge you whatever they want 
making it all but impossible for you to actually afford 
coverage. This is why they chose their words so carefully 
because the access they are promising isn't truly access at 
all.
    Democrats aren't making pie in the sky promises, they are 
showing progress. Thanks to the ACA 129 million Americans with 
preexisting conditions cannot be turned away or charged more 
because of their health status. Healthcare costs have been 
growing at the slowest rate in more than 50 years, and I could 
continue. Let me just say this.
    For 7 years Republicans have claimed to have a better way 
to reform America's healthcare system. If that were true then I 
believe that this hearing would have been the perfect 
opportunity to lay out that path forward. But instead after 7 
years we have the same old bills, tired bills and half of a 
draft. Our constituents have serious concerns. It is going to 
take a lot more than this to put those concerns to rest.
    So I just want to say that because I think there is nothing 
more important than people's health care, and I truly believe 
that if they destroy the ACA there is going to be a lot of 
people in this country that are going to be angry and scared. 
Thank you, I yield back.
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman. The Chair now recognizes the gentleman from 
Georgia, Mr. Carter, 5 minutes for your questions, please.
    Mr. Carter. Thank you very much, Mr. Chairman, and thank 
all of you for enduring this. We appreciate you being here and 
for seeing through this and for participating.
    I want to start with you, Mr. Holtz-Eakin. You pointed out 
throughout the hearing today that premiums are rising and that 
insurers are dropping out of certain markets and we know the 
horror stories of some States don't have but one insurance 
company that is participating now. And in full disclosure, 
before I became a Member of Congress I was a pharmacist and I 
owned three independent retail pharmacies at that time and I am 
a firsthand witness to what has happened to the free market in 
health care since the Affordable Care Act has taken, and I 
think that is the worst thing that has happened is that it has 
taken the free market out of health care.
    How do we get it back? How do we get back to where we are 
competing? I often tell the story that right now Adam Smith is 
rolling over in his grave to see what we have done to the free 
market in health care. And how do we get the competition back? 
That is what is going to drive prices down, competition.
    Dr. Holtz-Eakin. It is a hard question. I think in the 
hallmark of a good competitive system is some flexibility in 
the rules that surround competition. And I think the mistake of 
having something that is the same across all States where, you 
know, the market structures are very, very different is piece 
number one.
    And piece number two is you compete on whatever you pay 
for, and so if you pay for procedures people will compete by 
producing procedures that we want to pay for good outcomes. And 
that would be----
    Mr. Collins. You know, there are really three things that 
we want to do. We want to make health care accessible, we want 
to make it affordable and we want to cut out the red tape. We 
want to get the Federal Government out of the way of physicians 
and patients. And right now, there are so many, there is so 
much bureaucracy between the patients and the healthcare 
professionals, and that is what we are trying to do is to cut 
it out.
    Mr. Wieske, I want to ask you because you have obviously 
experience in this. One of the things that I am concerned about 
is the anti-trust laws as they pertain to the insurance 
companies, and I really feel like this is hindering the 
competition in a number of different ways.
    I am really big on trying to find exactly what is going on 
with prescription drug prices and particularly the role that 
PBMs play in that because I don't feel like they bring any 
value whatsoever to the healthcare system. They only raise 
prices and cause them to rise. And when you look at the PBMs, 
you have three PBMs that have 80 percent of the market. That is 
not competition yet they are protected by the anti-trust laws. 
I mean did you address that in Wisconsin at all?
    Mr. Wieske. So, you know, I think what is interesting about 
the ACA market from an anti-trust standpoint is actually that 
the insurers are competing not to get business, and I think 
that is where the problem is coming in. In fact, in one State 
they specifically wanted to get out of the cities and one 
company only wanted to do the rural areas so they would have 
less enrollment.
    And so, you know, I think that is what is interesting is 
they are actually not competing to get this business, they are 
competing to survive and just hope to live another day.
    Mr. Collins. OK. Let me ask you this, because you said 
something earlier that really tweaked my interest. And you said 
that in your high-risk pool that you had in the State of 
Wisconsin that all providers participated.
    Mr. Wieske. They did.
    Mr. Collins. Did you require them to?
    Mr. Wieske. It was required.
    Mr. Collins. How do you require them to?
    Mr. Wieske. So it was when they----
    Mr. Collins. Do you tie it in with licensing or something?
    Mr. Wieske. It was a requirement that they had to accept 
the high-risk pool patients and the rate that the high-risk 
pool set. They were part of the boards. They got the 
opportunity to work on setting those rates, but they were 
expected to contribute 30 percent to the surplus of the cost, 
30 percent of the cost----
    Mr. Collins. OK, you explained that. But what was the 
penalty if they didn't participate?
    Mr. Wieske. We never ran into that so we didn't have a 
penalty because they all participated. The patients went to the 
doctor, the doctor billed the high-risk pool for the services. 
I mean, ultimately, if they didn't participate, they just 
wouldn't get paid in the same rate, I guess, but, you know, 
functionally----
    Mr. Collins. You know, I find that hard to believe, 
especially if you have a favored nations clause in there and 
they are forced to accept that rate payment, and then they are 
forced to give it to another insurance company as well.
    Mr. Wieske. We had a--I mean, before and after, I mean, we 
do have an extremely competitive market. We don't have a 
dominant insurer that can get the most favored nation. The 
market share in Wisconsin, you know, the top about 18 comprise 
80 percent, so, and the top 10 only comprise roughly about 45 
percent or less of the market. So it is a different market.
    Mr. Collins. Well, again I just want to stress, and again 
thank all of you for being here. I want to stress again what we 
are trying to do here is to make health care accessible, to 
make it affordable and to cut out the red tape and to bring the 
free market back. Let competition drive prices down. That is 
what is going to do it. That is what we are trying to do. Thank 
you again, all of you, for being here. And I yield back, Mr. 
Chairman.
    Mr. Burgess. The Chair thanks the gentleman. The gentleman 
yields back. The Chair recognizes the gentleman from New 
Mexico, Mr. Lujan, 5 minutes for your questions, please.
    Mr. Lujan. Mr. Chairman, thank you very much. Before I 
begin, there was a line of questioning from Mr. Kennedy to Mr. 
Wieske pertaining to a Kaiser report titled ``High-Risk Pools 
for Uninsurable Individuals, Appendix Tables, 8903, the Henry 
J. Kaiser Family Foundation,'' which referenced the premium 
increases in the State of Wisconsin amongst other States. I 
would ask unanimous consent that that be submitted to the 
record.
    Mr. Burgess. If the gentleman is willing to share it with 
the Chair, without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Lujan. Just to note so that there is no question about 
this, what this report says is that the premiums were double in 
Wisconsin, so I know that we will get the chance to maybe go 
over that a little bit later.
    Mr. Chairman, if I could ask the staff to pull up the first 
slide upon our new smart screen, one thing that I wanted to go 
over was the question associated with where we are today with 
the bills that have been presented to this committee.
    President Trump recently said that he insists that everyone 
will have health insurance, insurance for everybody, he said. 
President Trump also said that there will be lower numbers, 
much lower deductibles. He went as far as to say that he is 
ready to reveal it alongside Senate Majority Leader Mitch 
McConnell and Speaker Paul Ryan. That was January 16th, 2017. 
And here is the important quote. It is a very much formulated 
down to the final strokes.
    So if we could go to the next slide, this is what we have 
today, down to the final strokes. So as we talk about these 
details I think it is just important that we keep an eye on 
what those final strokes really look like because that bracket 
sure is empty.
    If we could go to the next slide I wanted to answer a 
question that was brought up by one of my colleagues about this 
being shoved down people's throats. This is just a list of some 
of the hearings in the House and in the Senate that took place 
associated with the markup of the Affordable Care Act. I 
brought my copy in if anyone wants to take a look at it, which 
is coffee stained and marked up, highlighted up for everyone to 
see that we used not only to study this bill but to go and 
explain it to our constituents and answer questions from our 
constituents.
    And if we could just go to the next slide, the next slide 
shows what this committee alone did with different amendments 
that came up before this committee. So Mr. Lichtenfeld, I 
understand that you are--or Lichtenfeld, I understand that you 
are a physician. Have you read Chairman Walden's discussion 
draft?
    Dr. Lichtenfeld. I have read the paper that you have shown 
here to the committee.
    Mr. Lujan. Do you remember it saying anything about 
protecting young people and making sure they can stay on their 
parents' plans until they are 26?
    Dr. Lichtenfeld. My understanding is, Congressman, and so 
as I said before a work in progress and that there is obviously 
language that is still to be discussed and debated.
    Mr. Lujan. I will ask the question differently. Was it in 
the text that you read?
    Dr. Lichtenfeld. I am sorry, sir?
    Mr. Lujan. Was it in the text that you read?
    Dr. Lichtenfeld. No, sir.
    Mr. Lujan. Do you remember the text reading anything about 
establishing minimum standards of care to ensure Americans 
aren't sold a lemon health insurance plan?
    Dr. Lichtenfeld. I do not recall that, sir.
    Mr. Lujan. Do you remember it saying anything about making 
sure behavioral and mental health services are covered?
    Dr. Lichtenfeld. Again I don't recall seeing that.
    Mr. Lujan. Mr. Lichtenfeld, you are an oncologist, correct, 
sir?
    Dr. Lichtenfeld. Yes, sir.
    Mr. Lujan. I thank you for your work. My father sadly 
passed from a fight with stage 4 lung cancer a little more than 
4 years ago. We appreciate the experts that provided our loved 
one's care. Do you remember in Chairman Walden's bill saying 
anything about making sure individuals are not penalized by 
lifetime caps on their insurance coverage?
    Dr. Lichtenfeld. I do not recall seeing that, sir.
    Mr. Lujan. So the discussion that we are hearing today is 
that there be an environment set up so that individuals rather 
than having a 90-day grace period with their coverage would be 
shortened to a 30-day grace period if they had a preexisting 
condition. And if they missed a payment, and the text doesn't 
protect anyone that may be late with a payment, then they lose 
coverage. What I have heard today is the notion that people 
with preexisting conditions that would lose coverage would 
still be able to get coverage from somewhere else, right. But 
there is nothing saying that they will not pay a higher premium 
fee.
    And under the notion of, again if you could please bring up 
the first slide. Under the notion that our colleagues are 
saying that premiums will be lowered, deductibles will be 
lowered, care will be better, no one is going to be cut off, I 
just don't see it in anything that has been read to us.
    And then the last thing, after 7 years, if they bring the 
first slide up, please, the one with Fox News, we have not seen 
the Republican consensus plan before us. There was a lot of 
talk by one of our witnesses about a plan that was before us. 
There is no consensus plan before us. This is not a secret. For 
7 years, over 60 times my Republican colleagues have voted to 
repeal the Affordable Care Act. For 7 years we have not seen 
this text.
    I think it is important that when we are having these 
hearings about how to improve the Affordable Care Act it 
shouldn't be about repealing the Affordable Care Act. And I 
will just point that the text in Chairman Walden's discussion 
draft, in its title it says, ``upon repeal of the Affordable 
Care Act.'' So people can spin this all that they want, please 
look at the text and what is happening right now. And there is 
a willingness for us to work together to make things better to 
improve things, but not under the guise of repealing this. 
Let's find a way to really come together and do the right thing 
for the American people and not just the political thing.
    Mr. Burgess. The gentleman's time is expired. The Chair is 
advised that one of the witnesses needs to catch an airplane. 
Is this accurate? The Chair would ask unanimous consent that we 
allow the witness to make their--no, we don't allow the 
witness. OK, the Chair would advise that the witness who 
identified himself as having travel plans will actually be 
leaving at 2:15.
    And I do ask all Members to try to adhere to the 5-minute 
timeline. I have been lenient today because this is such an 
important topic.
    Mr. Green. Mr. Chairman, I ask unanimous consent to place 
into the record--if you want me to start the list--a statement 
from the Asian Pacific Islander American health care----
    Mr. Burgess. Without objection, so ordered. All of your----
    Mr. Green. All of it.
    Mr. Burgess [continuing]. Yes, consent requests will be 
honored. The Chair recognizes Mr. Sarbanes 5 minutes for 
questions.
    Mr. Sarbanes. Thank you, Mr. Chairman. I just got in here 
under the wire, so I want to thank the panel. I wanted to ask 
Dr. Holtz-Eakin, what are some of the pieces of the Affordable 
Care Act that you think we ought to keep in place?
    Dr. Holtz-Eakin. Well, I think that, you know, the ban on, 
caps on benefits for annual and lifetime, 26 staying on your 
parents' policy. I certainly think that you should have some 
sort of provisions for preexisting conditions and access to 
insurance.
    Mr. Sarbanes. What about the efforts to close the exposure 
in the so-called donut hole in terms of the prescription drug 
costs that our seniors had been facing, is that a piece we want 
to keep in place?
    Dr. Holtz-Eakin. I think there is, I would be happier if 
there was a more comprehensive approach to Medicare reform that 
sort of put together a more sensible insurance policy A, B and 
D, provided a broader coverage there.
    Mr. Sarbanes. But generally speaking this idea of trying to 
reduce the exposure that our seniors have to the prescription 
drug costs which the ACA addressed through this effort to close 
the donut hole, is that something you think we ought to hold 
onto?
    Dr. Holtz-Eakin. I guess the reason I am hesitating, my 
understanding is part of this is the private industry's 
agreement to cover 50 percent of costs in the donut hole. I 
honestly don't know how that works whether that has the force 
of law or if that is a voluntary action by them.
    Mr. Sarbanes. I think the industry's agreement to 
voluntarily address 50 percent of their costs in the donut hole 
was something that they were going to do transitionally as the 
donut hole was being closed through actually providing 
additional benefits under Part D.
    What about, you probably know that many seniors now as a 
result of the Affordable Care Act can have certain kinds of 
preventive screenings, annual wellness exams, other things 
where they used to have to come out of pocket for those 
expenses, those are now covered by the Affordable Care Act 
which is obviously a huge benefit for our seniors. Is that a 
piece of the Affordable Care Act that you think ought to stay 
in place?
    Dr. Holtz-Eakin. Truthfully I don't know. The question 
there is what has been the effectiveness versus the cost, and I 
would be happy to get back to you on that.
    Mr. Sarbanes. Well, I think the effectiveness has been 
significant in terms of enhancing care and there is actually 
savings as well, because if you catch some things earlier that 
then don't lead to acute care on the back end which have high 
costs associated with it, because you do the screenings and the 
preventive care service because you actually are reducing costs 
as well.
    So I guess I am asking the questions just to make the 
point, Mr. Chairman, that once you break--there is this kind of 
slogan of repeal the Affordable Care Act, you know, it hasn't 
delivered, et cetera. When you actually break it down into its 
component parts and look at the benefits that it is bringing, 
frankly, the public has a very positive view of a lot of these 
components to the plan.
    And as you just indicated in your answers, I think there is 
a recognition by the experts that there is many, many pieces of 
the Affordable Care Act that it would be regrettable to leave 
behind. So I think we need to start in an honest place of 
conversation when we are talking about this landmark healthcare 
reform and the benefits that it has brought to so many 
Americans and move forward from that point. With that I yield 
back.
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman. The gentleman recognizes the gentleman from New 
Jersey, Mr. Long, 5 minutes for questions, please.
    Mr. Long. Thank you, Mr. Chairman. Mr. Wieske, you 
mentioned in your testimony that a number of your insurers have 
lost significant capital because of Obamacare. How has that 
affected coverage options as well as provider network access 
for individuals?
    Mr. Wieske. So as I said just a few minutes ago, I think 
there are actually----
    Mr. Long. My apologies if you----
    Mr. Wieske. No, no, no. My apologies. My apologies.
    Mr. Long. I sat here all morning long for my turn to ask 
and we went to votes, so----
    Mr. Wieske. No, no, no. And they are competing not to get 
the business in a lot of cases and, you know, they want a 
limited number of coverage and they are losing money on that 
coverage and so they have dialed back their presence across the 
State. They have limited their networks. Most plans have gone 
to narrower and narrower networks. They have changed their 
networks. They have partnered with providers, provider groups 
to do it differently. They have done it under different 
insurance licenses. So they have taken a number of steps to 
sort of minimize their exposure to the market.
    Mr. Long. If nothing changes between now and next November, 
what would you see at that point?
    Mr. Wieske. I think we will see a number of carriers that--
I think we will see every year where we are sort of--my fear 
because we deal directly with the filings and I deal directly 
with the filings, my fear is that I am a little bit panicked 
that we are going to have counties that are uncovered.
    We have one county that has one right now. We have three 
counties that only had one for a number of years. I am deathly 
afraid that four or more of our counties will be left uncovered 
with no insurer offering coverage.
    Mr. Long. OK. And coming from an adverse State in terms of 
regions, have some areas of your State been hit harder by these 
changes?
    Mr. Wieske. Yes, there were big differences. I mean, you 
know, one of the issues is it almost feels like, and this is 
not insurance across State lines, but it narrowed the market 
considerably. So some of our plans that offered coverage that 
were near the border left those areas because of the rules and 
the way things work, and so that left those areas more exposed.
    So the areas near the borders have more problems than some 
of the other areas. Absolutely there has been winners and 
losers in the ACA.
    Mr. Long. And what has that meant for consumers? We call 
them consumers, I call them constituents, but what has that 
meant for consumers and our constituents in those areas?
    Mr. Wieske. We have seen, you know, rising costs over time, 
you know, more than doubling of the average premiums that most 
consumers pay over the course of, you know, from what they were 
paying pre-ACA, so there are significant increases. The 
deductibles have increased over time. They are higher than they 
were pre-ACA on average.
    And the networks are narrower. They are finding, you know, 
less choice in the type of providers they want to see because 
there are fewer, you know, they just want to offer narrower and 
narrower networks.
    Mr. Long. When you say they are higher, I remember back at 
Christmastime went to a Christmas party the Saturday, I think, 
before Christmas, and a local business owner came up talking 
about just his family's premium had gone up 360 percent since 
the advent of the Affordable Care Act. I would hate to think 
what it was like if it wasn't affordable, but these are the 
type of stories that we get from our constituents that 
everybody acts like everything is a panacea and everything is 
great out there.
    But these numbers, I mean health care, health insurance 
always was going up, and the other side will argue, I have 
constituents that like it and they say oh, you know, health 
care goes up anyway. But 360 percent in that short of time is a 
pretty healthy increase, isn't it?
    Mr. Wieske. It is. And I think what I am afraid of is 
States like Wisconsin that took advantage of the transition 
options, so-called grandmother plans, those plans will go the 
way at the end of '17 in the small group market. Roughly about 
180-190,000 of our 225-230,000 small group individuals are on 
those transition plans. They are going to get a significant 
increase when we roll from 2017 at the end of this year into 
'18.
    Mr. Long. That is kind of what I was----
    Mr. Wieske. On pre-ACA plans, yes.
    Mr. Long. That was kind of what I was getting to earlier 
when I asked you about November, what you foresaw for next 
November. And what are your projections and concerns of what 
the market is going to look like after that period in a few 
years if the current trajectory continues in your State?
    Mr. Wieske. We are expecting fewer carriers, probably 
regional. They happen to be regional in a lot of cases and 
probably only carriers, insurers that have a relationship, a 
contractual relationship with a health system. So you will have 
one health system and one insurer teamed up in a particular 
area and that will be the only coverage option. That is what we 
are afraid of in the future, no choice.
    Mr. Long. Do you view plan solvency in the market as a 
basic consumer protection?
    Mr. Wieske. Yes, we do. We do extensive work on solvency. 
Yes, sir.
    Mr. Long. What does that mean for consumers when their 
insurers exit the market like they have in droves in a lot of 
places?
    Mr. Wieske. It means that they obviously lose the coverage. 
They end up in what I would call ghost plans or phantom plans 
that don't exist anymore but they still have coverage, and then 
you have to deal with the issue of the guarantee funds and 
making sure the consumers are covered. And it ends up, it is 
for a consumer it is confusing and it is problematic and it is 
a little bit of a nightmare if their insurer--now we have been 
lucky. We haven't had any go insolvent in the State of 
Wisconsin. We have had carriers leave the market but we have 
not an insolvency in health that has had those problems so we 
have been lucky.
    Mr. Long. I have two daughters. One of them has a year and 
a half left in her residency program in pediatrics, so the 
future of health care is very concerning to her. And her 
younger sister just got a report out about 4 months ago from 
Hodgkin's lymphoma and she has been off chemo for 15 months, I 
guess.
    And so I know how important it is that people have coverage 
and stay covered because we had a little incident mid-chemo 
treatment when the Affordable Care Act told us she wasn't 
covered one day when we got over there for treatment. That was 
kind of hair raising. So there is no easy answers to any of 
this that we are doing today.
    And like I said, I was late because I was doing, to the 
first part of it because I had to do a telecom deal on rural 
broadband, so I wasn't here for the gavel, and then I was here 
by the time we voted.
    Mr. Burgess. The Chair accepts the gentleman's apology. The 
gentleman's time has expired. I do need to note it is past 
2:15. We have a witness that needs to leave. We will continue 
our--and will be excused. We will continue our hearing with the 
remaining witnesses. Of course, written questions may be 
submitted for Dr. Holtz-Eakin.
    And Dr. Holtz-Eakin, we appreciate you being here. You have 
always been a friend to this committee, and we appreciate your 
participation today. So you are excused.
    Dr. Holtz-Eakin. Thank you, Mr. Chairman.
    Mr. Burgess. And the Chair recognizes the gentleman from 
California, Mr. Cardenas, 5 minutes for your questions, please.
    Mr. Cardenas. Thank you, Mr. Chairman. I am glad we are 
discussing this incredibly critical and important issue that is 
critical to every American. I would like to read the following 
true story from a constituent from my city of Los Angeles, 
California.
    This is before the Affordable Care Act was made available 
to her and her family: ``In 2012 I was in between jobs and 
discovered that I was pregnant. My husband and I were thrilled 
to be expecting our baby. When I tried to sign up for insurance 
I was informed that my pregnancy was considered a precondition, 
preexisting condition, and no insurance company would cover me.
    ``My husband was working as a contract employee and was 
uninsured. I considered Medi-Cal and Medicaid program in 
California, but I was told that it could take months until I 
could actually visit a clinic. Fortunately, I was hired about a 
month later and I got back on a company's insurance. However, 
if I had not been hired, I don't know what I would have done. 
It was that we almost missed seeing a doctor until the second 
trimester.
    ``And as I experienced extreme daily stress worrying about 
whether I would be insured before I gave birth or be charged 
tens of thousands of dollars, such stress is never good for a 
baby. The fact that becoming pregnant prevented me from buying 
insurance was truly outrageous. I was so horrified that our 
system could do something like this.''
    True story, it happened, and unfortunately, before the 
Affordable Care Act, there were way too many stories like that. 
What I hope that we can prevent as Members of Congress, as 
legislators, as responsible elected officials, that we not go 
back to those days. This is America, and this true story goes 
to the heart of what we are all here to talk about.
    Why are we spending time analyzing a half-finished bill 
that doesn't take care of all the issues that were promised 
both by presidential candidates and people all over this United 
States Congress? Things like to ensure that a woman and a man 
pay the same price for their plans. This bill here that I have 
in my hand, which was introduced and what we are discussing 
today, does not guarantee coverage for a preexisting condition. 
A lot of Americans don't realize that if your 8-year-old 
daughter has asthma, that is considered a preexisting 
condition.
    Also to ensure coverage that we actually have access, this 
bill that I have before me talks about access, but it doesn't 
talk about ensuring coverage. The Affordable Care Act has 
stronger language such as ensuring coverage. This document 
speaks to access, but it doesn't spell out what we really 
should be talking about. Are people going to be denied coverage 
for a preexisting condition? Are women going to be allowed just 
like before to pay more for their health care than it is for a 
man at the same age, conceivably right next door?
    We have had nearly 8 years of talk about replace, but we 
have come up with nothing better in that time. Why aren't we 
talking about enhancing the Affordable Care Act instead of 
these ideas of just repealing it?
    I have a question for Dr. Lichtenfeld. I want to first 
thank you for coming today and for sharing your expertise with 
us and also for making sure that we can get some more 
information before the public. Under the half-written plan, 
could individuals with preexisting conditions like cancer, 
asthma, or diabetes be priced out of the care they desperately 
need?
    Dr. Lichtenfeld. Thank you, Mr. Cardenas. And our concern 
is that that could in fact happen unless it is absolutely laid 
out clearly what the plan is, that there could be problems down 
the line.
    Mr. Cardenas. And the bill as written today doesn't have 
any language guaranteeing that that would not happen, correct?
    Dr. Lichtenfeld. As I mentioned previously, that is 
correct. Yes, sir.
    Mr. Cardenas. OK. My next question is, Were the health 
insurance premiums across America in general going up year over 
year before the Affordable Care Act, or were they on their way 
down year over year before the Affordable Care Act?
    Dr. Lichtenfeld. Premiums were going up.
    Mr. Cardenas. OK. Now on those premiums going up, people 
were still denied coverage because of a preexisting condition, 
correct?
    Dr. Lichtenfeld. Yes, sir.
    Mr. Cardenas. But under the Affordable Care Act, that is 
not allowed in America today, correct?
    Dr. Lichtenfeld. That is correct.
    Mr. Cardenas. OK. So I just wanted to point out a few 
things in the short time that I get to speak on this committee 
and just wanted to make sure that everybody out there 
understands we are talking about you. We are talking about your 
health, your grandparents to your grandbabies and everybody in 
between. We need to get this right. And right now the bill that 
we have isn't even close. I yield back.
    Mr. Burgess. The Chair thanks the gentleman. The Chair 
would remind the gentleman he receives the same amount of time 
as every other member on the subcommittee and some who have 
waived on the subcommittee, and the chairman has been most 
generous with not hitting the gavel.
    The Chair would like to recognize the gentlelady from 
Tennessee, Mrs. Blackburn, 5 minutes for your questions, 
please.
    Mrs. Blackburn. Thank you, Mr. Chairman, and thank you all 
for being here. I want to go to the bill that we are looking at 
on the special enrollment plans, the special enrollment 
periods. This is legislation that I have drafted and the reason 
I did it was because of what we saw happening with lack of 
verification in the special enrollment periods.
    And I saw us going down a road that we traveled in 
Tennessee with TennCare which was back in the mid-90s. No 
verification, all of a sudden your plan is, your enrollees are 
being crowded out if you will, people that really need 
services. You begin to see networks narrow, reimbursements 
drop, the length of time you wait for reimbursements goes from 
30 days to 60 days to 90 days to 120, 180 days. And you all 
know the path. And my bill is just very straightforward and you 
need to prove why you need that special enrollment period, you 
need to prove that you are who you are and that you qualify. I 
think that is an important thing for us to be able to do.
    So the question, I have a couple of questions and I would 
like to hear you all weigh in on the need for verification for 
special enrollment periods. I think it is important for the 
integrity of any program and I think it is fair for the 
taxpayers who foot the bill.
    But shouldn't we simply be able to confirm if someone 
qualifies for special treatment that they self-attest that they 
are eligible that indeed they are, and especially if taxpayer 
subsidies are involved? Shouldn't we require that? And would a 
very small, but modest improvement to the plan be to move this 
verification from post-enrollment, which experience has told us 
very seldom gets done, to preenrollment? And I would like to 
hear what you all have to say on that.
    Mr. Wieske. Your bill is exactly right. I mean this is not 
actually that hard to get verification in my experience. This 
is something, special enrollment periods did not start with the 
ACA. Special enrollment periods existed with HIPAA and existed 
prior to that in the Newborn and Mothers Act and other pieces. 
Insurance companies were doing these verifications for years 
prior to the ACA.
    The problem that we have run into is when the Federal 
bureaucracy takes it over that that creates other problems and 
they don't have the time or the resources to verify. We had one 
person in our office who had spent months trying to solve the 
issue because he was not using the magic words that the 
customer service wanted them to use. So I think it shouldn't be 
that hard to get to a verification.
    Dr. Lichtenfeld. Well, Mrs. Blackburn, thank you for the 
question. And we are aware of some of the issues that have come 
up with regard to special enrollment. However, when we look at 
it through that cancer lens we also need to understand that 
there are some other issues that have to be looked at.
    So it may be someone who is working and loses their job and 
has to go get insurance and within the cancer focus how quickly 
that is going to be done, what is going to be required and will 
it be done expeditiously. Should it be done pre- with the 
presumption of correctness and then later, or should it be done 
later when there may be a gap in care? Those gaps in care can 
be significant.
    Also aware that how the one that administers it, whether it 
be Federal or whether it be insurance company, what the 
guidelines are that set around those requirements in terms of 
timeliness, all those are things that have to be considered.
    Mrs. Blackburn. I think you might have missed the point 
that I am trying to drive forward. I think that--I am not 
saying you don't need special enrollment periods.
    Dr. Lichtenfeld. No, I understand.
    Mrs. Blackburn. Just what you are inferring. I am saying 
that if we have a special enrollment period and one is 
necessary that it is out of fairness to the taxpayer and to the 
integrity of a program that an individual before they are 
admitted to a program that they prove that they need it and 
that they prove that they are who they attest to be. That those 
attestations that they have made to get that coverage that 
those are vetted before they are allowed into that program.
    Dr. Lichtenfeld. Mrs. Blackburn, I apologize if I wasn't 
clear on my statement. I didn't say we don't need special--I 
mean it wasn't my intent to say we don't need special 
enrollment.
    Mrs. Blackburn. OK, right.
    Dr. Lichtenfeld. I said it is the construct of how it is 
done that is important where we may have discussions about that 
issue.
    Mrs. Blackburn. OK, thank you. Yield back.
    Mr. Burgess. The gentlelady yields back. The Chair thanks 
the gentlelady. The Chair recognizes the gentleman from North 
Carolina, Mr. Hudson.
    Mr. Hudson. Thank you, Mr. Chairman, and I thank the panel 
for your time today. But since I arrived here directly from a 
dental procedure I will probably yield the balance of time, 
without objection from you, Mr. Chairman, to Mr. Griffith from 
Virginia.
    Mr. Burgess. The gentleman is recognized.
    Mr. Griffith. Thank you very much. I thank my colleague 
from North Carolina, so I think I ought to ask my North 
Carolina question first. My district shares a border with North 
Carolina. Mr. Wieske, you indicated earlier in answering one of 
the questions that there were some issues around the borders. 
Could you tell me what was going on there and how that affected 
you all?
    Mr. Wieske. Sure. I mean I think when you are dealing with 
the exchange and the subsidy market it sort of shut down the 
sort of, you know, moving between the borders that happen, that 
those borders became a little bit harder than they were before. 
And so because you are one exchange versus another exchange it 
wasn't just buying health insurance it was that became an 
issue.
    Mr. Griffith. And let me ask you if you ran into any of the 
problems in your State that I ran into with constituents when 
it first rolled out. I had folks who were going to medical 
facilities--because my district is the corner of Virginia so I 
border North Carolina, Tennessee, Kentucky and West Virginia. 
And so one of the things that popped up almost immediately was, 
and it was particularly a North Carolina situation, I had a 
constituent who was receiving cancer treatment in Winston-
Salem. It might have been Duke, but I am pretty sure it was 
Bowman-Gray.
    And all of a sudden found out when she, she had to go on 
the exchange. She went on the exchange and found out that she 
could not leave the Commonwealth of Virginia more than one 
county. Well, that created all kinds of problems because she 
couldn't keep with her cancer team. Did you have some of those 
issues as well?
    Mr. Wieske. A few of those, but more insurers withdrew from 
the neighboring counties. So Pierce, Polk and St. Croix County 
typically use, which is on the western part of our State, 
typically use providers in Minnesota, have Minnesota systems. 
All the Wisconsin systems essentially withdrew from that area 
and at least exchange wise, and so it was primarily a Minnesota 
company that provided coverage that was licensed in Wisconsin. 
So they just had fewer choices. They had to go, they had to go, 
across the border.
    Mr. Griffith. Right. And so it is kind of interesting 
because earlier one of the folks was making a statement on the 
other side of the aisle and seemed to indicate that whatever 
plans we were coming up with they wouldn't work because you 
couldn't go, you would have to go back to the other State, I 
believe she said, to see the doctors, and yet my experience in 
my district was that that problem exists with Obamacare.
    And it may be one of the things we need to take a look at 
it fixing, because that one county rule--and I described my 
district to you and I only had problems in North Carolina. But 
one of the hospitals in the area that specializes in children's 
care in Tennessee serves a big chunk of southwest Virginia but 
because independent cities, Bristol, Virginia is an independent 
city, Bristol, Tennessee, and the county surrounding it is the 
one county you could go to and the hospital is just over the 
line in the next county.
    So it was not just the problem in North Carolina with 
cancer treatment, it was also problems with people being able 
to go see the specialists in North Carolina, because I had 
Bristol, Virginia and Tennessee, where as you know from the 
GEICO commercial the line runs right down the middle of the 
main commercial street there. And then I also have Bluefield, 
Virginia, which also has Bluefield, West Virginia, and you have 
to figure out which side of the line you are on there. It is 
not quite as clear cut as Bristol, Virginia and Tennessee.
    So a lot of my constituents were impacted by that. And I 
know that it is--I assume that it is not a good idea to change, 
Dr. Lichtenfeld, it is not a good idea to change your doctors 
midstream particularly when you are satisfied with the cancer 
treatment you have been getting. And so it is not a good idea 
to switch even though Virginia has some very good medical 
schools as well; would that be correct?
    Dr. Lichtenfeld. Well, actually my son was just interviewed 
at University of Virginia so we respect the medical schools for 
sure.
    Mr. Griffith. Yes.
    Dr. Lichtenfeld. You know, yes, that is correct. I mean 
continuity of care is important, how it is constructed, what 
the rules are, whether, what hospitals are allowed in the 
network, the location of the network, all that is important.
    Mr. Griffith. Right, and closeness matters too. And in 
fact, big parts of my district they are a lot closer to other 
States' hospitals then they are to the University of Virginia 
which would be closest to my district. Not to negate MCV, also 
another fine institution and others.
    Let me switch gears, and I apologize, Mr. Wieske, you may 
not know the answer to this because it was a question for Dr. 
Holtz-Eakin about continuous coverage requirements. And he had 
said that that pushes providers and plans to invest in 
preventive and wellness programs to keep patients healthy, and 
the question would have been how does this impact the overall 
market, the overall risk pool? Are you in a position to answer 
that question? My team says you are but I don't know.
    Mr. Wieske. I think in general, I mean I think if you are 
able to keep people in the market and they stay in it and they 
stay with their insurer it provides better health, better 
health outcomes, and potentially over time it should lower, 
make the risk pool more representative and overall lower costs.
    Mr. Griffith. So similar to what I was talking about 
before. I see that Mr. Hudson's time is up and I yield back.
    Mr. Burgess. The Chair thanks the gentleman and now 
recognizes the gentleman from New York, Mr. Tonko, 5 minutes 
for questions, please.
    Mr. Tonko. Thank you, Mr. Chair. And Mr. Wieske, first let 
me thank you for your service to the people of Wisconsin and 
for your testimony today. In your written statement you refer 
numerous times to Wisconsin's well-functioning health insurance 
market pre-ACA and expressed a desire to see the ACA repealed 
and returned to a pre-ACA marketplace.
    So I would like to learn a little more about what 
Wisconsin's health insurance market looked like prior to the 
Affordable Care Act. I took and downloaded a publication from 
your office's website entitled ``Fact Sheet on Mandated 
Benefits in Health Insurance Policies,'' and with the 
permission of the Chair I would like to ask unanimous consent 
that this document be entered into the record.
    Mr. Burgess. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Tonko. Thank you. Now Mr. Wieske, prior to the 
Affordable Care Act did Wisconsin mandate that all health 
insurance plans serving the individual market cover hospital 
services or prescription drug coverage? Yes or no on that, by 
the way.
    Mr. Wieske. I don't believe----
    Mr. Tonko. Yes or no.
    Mr. Wieske. I don't believe it was mandated, but----
    Mr. Tonko. The answer is no. Pre-ACA, did Wisconsin mandate 
that all insurance plans serving the individual market cover 
mental health or substance use care, yes or no?
    Mr. Wieske. No.
    Mr. Tonko. The answer is no. Pre-ACA, did Wisconsin mandate 
that all insurance plans serving the individual market cover 
maternity care, yes or no?
    Mr. Wieske. No.
    Mr. Tonko. Would it be fair to assume that plans in 
Wisconsin that offered these fundamental healthcare services in 
the individual market pre-ACA would be more expensive than 
plans that didn't offer these services, yes or no?
    Sir, can we move----
    Mr. Wieske. Well, the problem is----
    Mr. Tonko. Yes or no, because I have got to move on with my 
time here.
    Mr. Wieske. I am sorry, I can't answer the question, 
because you have three there.
    Mr. Tonko. Well, fundamental healthcare services in the 
individual market pre-ACA, would it be more expensive than 
plans that didn't offer those services?
    Mr. Wieske. For maternity and for the mental health, the 
answer is yes.
    Mr. Tonko. So given your expressed support for the pre-ACA 
marketplace where plans that covered even the most basic 
healthcare services were astronomically expensive in the 
individual market pricing out anyone who might actually need 
care, you clearly support returning to a system where women and 
all people with preexisting conditions are charged higher 
prices for the care they need?
    Mr. Wieske. No. My assumption is that the States would be 
able to----
    Mr. Tonko. Yes or--so you are a no on that?
    Mr. Wieske. Yes, because the States will reform their laws 
and better reflect the market.
    Mr. Tonko. Well, we are looking at a Federal plan that 
would cover all States, so thank you, Mr. Wieske. To summarize 
what we just learned for all the folks watching on TV, health 
insurance in Wisconsin was less expensive before the Affordable 
Care Act unless you actually wanted to go to the hospital, fill 
a prescription, be covered for mental health services, or see a 
doctor. Women in Wisconsin were hit particularly hard, paying 
up to 42 percent more for their health insurance than men 
before the Affordable Care Act.
    So when my Republican colleagues talk about their supposed 
desire to protect people with preexisting conditions, it is 
important to remember that you can't address this problem with 
a half-baked bill that doesn't actually require insurance plans 
to offer benefits to those who are sick. Otherwise, insurance 
companies will deny care to those with preexisting conditions 
with restrictive benefit designs that fail to cover basic 
services like hospitalizations, prescription drugs or mental 
health care.
    I appreciate this hearing today because I think it is 
really critical to clarify the stakes of this healthcare debate 
for the American people. What Mr. Wieske and my Republican 
colleagues want to do is to rip health care away from millions 
and take us back to a healthcare system controlled by the big 
insurance companies, the system where your health insurance is 
worth less than the paper it is printed on, a system where you 
get charged through the nose if you need mental health care or 
are a woman, or God forbid, man or woman, if you get sick and 
have to go to the hospital.
    I don't want to go back. The American people don't deserve 
to go back. We should instead be moving forward and building on 
the promise of high quality, affordable health care for all. 
And with that Mr. Chair----
    Ms. DeGette. Will the gentleman yield?
    Mr. Tonko [continuing]. I yield back the balance of my 
time.
    Ms. DeGette. Will the gentleman yield? Will the gentleman 
yield me his 39 seconds remaining?
    Mr. Tonko. Yes, I will. I will yield.
    Ms. DeGette. Mr. Wieske, I thought that what Mr. Tonko was 
asking you was really important, which is with this bill that 
we are looking at today, there is no requirement that the 
States not charge people with preexisting conditions. That is 
just your hope that States wouldn't do that, right?
    Mr. Wieske. We had limits in place----
    Ms. DeGette. Yes, Wisconsin did, but maybe----
    Mr. Wieske. Correct.
    Ms. DeGette [continuing]. Utah or Colorado or Idaho didn't, 
right?
    Mr. Wieske. Right.
    Ms. DeGette. That is just your hope?
    Mr. Wieske. Correct.
    Ms. DeGette. Thank you.
    Mr. Burgess. The Chair thanks the gentleman. The gentleman 
yields back. The Chair once again observes that I have delayed 
my time for questions until the end because I was delayed 
arriving this morning, so I recognize myself for the balance of 
the time.
    No, and I do appreciate our witnesses being here. I am 
sorry Dr. Holtz-Eakin had to leave, because he always brings a 
lot to the discussion. Mr. Wieske, let me just ask you--and 
again I asked you while we were kind of in between on the 
votes--you have not testified before our committee before, have 
you?
    Mr. Wieske. I have not.
    Mr. Burgess. And so that graphic that one of our members 
put up of all the hearings that were held prior to the 
Affordable Care Act, you never participated in any of those 
hearings, did you?
    Mr. Wieske. Correct.
    Mr. Burgess. And I think that is a shame, because I think 
you would have added to the discussion and you would have added 
to the debate and maybe some of the problems that we are now 
encountering and trying to fix could have been avoided had we 
listened to sane, rational voices like yours.
    I will also point out our two members from Indiana have had 
to leave, but we didn't hear from Governor Mitch Daniels, and 
Mitch Daniels was reported in the Wall Street Journal, while 
all the discussion of the Affordable Care Act was going on 
during the 2008 election cycle and we were having hearings here 
in this very room, Mitch Daniels with his Healthy Indiana Plan 
had actually reduced costs by 11 percent over 2 years' time 
when every other HMO, PPO, Medicare, Medicaid was going up by 7 
or 8 percent across the country.
    Why would not we have asked people who were experts and who 
were performing well, why would not have asked their opinions 
before writing this big law that changed health care from soup 
to nuts in this country? And I--it is obviously a rhetorical 
question--I think we should have.
    Much was made at the beginning of this session about the 
fact that Republicans wouldn't help, and I have to tell you 
that is not true. I contacted the transition team in 2008 and I 
said, ``Look, I didn't give up a 25-year medical career to come 
sit on the sidelines while you guys do this. Talk to me. I am 
willing to talk to you.''
    Dr. Lichtenfeld, they could have put me in a tight spot, 
you know, because what if I had been offered to choose 
between--you talked about toxic financial situations, what 
about our medical liability in a lot of States? That is a toxic 
situation. What if they had said to me, Dr. Burgess, we know 
you care a lot about medical liability. We would like to help 
you, but we have got to have your help on the public option. I 
don't know what I would have done. That would have been a 
pretty tough spot to put me in.
    I don't know, maybe somebody who is familiar with making a 
deal might have, that might have occurred to them, but I was 
frozen out. I was frozen out by the then-chairman of this 
committee, Henry Waxman. I went to see him personally and said 
I didn't give up a career in health care to come sit on the 
sidelines. So the notion that we have simply dug our heels in 
and refused to help, it is offensive to me when I hear that 
espoused on the panel.
    Now let me just ask in particular with these bills that we 
have that we are considering, just on the issue of narrow 
networks now. Dr. Lichtenfeld, I mean you encountered narrow 
networks probably before the ACA was passed and after it was 
passed. Do you have a feeling? Is it better or worse? Are 
narrow networks less restrictive now than they were before?
    Dr. Lichtenfeld. Speaking personally, they are certainly 
more restrictive, and the testimony to that effect was made 
earlier. So the answer to that question is yes, they are more 
narrow.
    Mr. Burgess. You know, we all give our own experiences. And 
I will confess that there was a special deal set up for Members 
of Congress, the Grassley Amendment required us all to buy 
insurance under the Affordable Care Act and there was a special 
deal worked up between President Obama and then-Majority Leader 
Reid in the Senate that allowed us to receive a subsidy and 
walk it into the exchange. I didn't do that because my 
constituents back home would never understand that kind of a 
special deal.
    So I understand the difficulties that people felt in the 
individual market. My insurance was canceled at the end of 
2013. I was one of the 5.7 million people who lost their 
insurance. I liked my coverage. I liked my doctor. But I 
couldn't keep it because I was told I had junk insurance and I 
had to get rid of it. I had to do something else. I had to buy 
all of these other things. It was not something that I asked 
for.
    And when my constituents come to my town halls and say why 
did I have to do this, why did I have to make these changes, I 
wasn't asking for that--well, I felt their pain. And so I 
didn't have an answer for them but I could look them in the 
eyes and say, yes, I agree with you. I think it was bad policy. 
I hope we get a chance to rectify things someday.
    So when people ask me did you lose your doctor or did you 
go on a narrow network, to tell you the truth I don't even 
know, because unlike every other American I bought on price, 
show me the cheapest Bronze Plan out there and that is what I 
bought and I really have no earthly idea who the people are 
that I had available to me.
    On the issue of this 30 days, 90 days, I worried about that 
when the law was in the enactment phase in 2014 because, Dr. 
Lichtenfeld, now correct me if I am wrong here, but you have a 
90-day grace period. You know, the insurance companies actually 
were talking a lot to the Democrats in those days, they weren't 
talking to Republicans. But 30 days, the insurance company is 
on the hook for that coverage. What happens to the rest of 
those 60 days, Dr. Lichtenfeld? Who covers that bill if the 
patient doesn't pay their premium?
    Dr. Lichtenfeld. The answer to your question is that the 
person who provides the service ends up not getting paid under 
the current situation, if in fact the patient or the family 
doesn't pay that bill by 90 days.
    Mr. Burgess. And I do need to point out this is only for 
someone receiving a subsidy in healthcare.gov exchange, because 
I actually thought I had a 90-day grace period on my premium. 
It turns out, no, you only get 30 days because you are not 
receiving a subsidy, so that 90-day period does not cover you.
    But I did worry about that because I worried that former 
colleagues who practiced medicine would in fact be on the hook 
for those bills and it hasn't turned out to be the problem I 
thought it was going to be, but I think it is a problem that 
should be corrected. We shouldn't allow for the system to be 
manipulated where physicians and hospitals actually don't 
receive the compensation for the care that they provide.
    There are a lot of things that we could still talk about. I 
have some questions that I will submit for the record. We have 
been here a long time. I do appreciate both of you being here. 
This is not easy. This is complex. I don't know. I don't know 
at the end of the day where this all shakes up but I do know 
this. If it was working perfectly, if it was working perfectly 
we wouldn't be here today. It is not working perfectly. There 
are serious problems. There are serious fractures and we have 
been charged with fixing them.
    So that is what this subcommittee does. You have got some 
of the smartest Members of Congress on this subcommittee, and I 
appreciate each and every one of them, those that are here and 
those that have had to leave. This is a good subcommittee, a 
great subcommittee. We are up to the task, and we will deliver.
    So with that, I will yield back the balance of my time and 
then--oh my gosh, what have I got to do, all of these unanimous 
consent requests. Seeing there are no further Members wishing 
to ask questions, I would like thank all of our witnesses again 
for being here today.
    Before we conclude the hearing, I would like to submit the 
following items for the record: a statement from Representative 
Bill Flores, a statement from Blue Cross Blue Shield, a 
statement from the American College of Obstetricians and 
Gynecologists, a letter from the Alliance for Retired 
Americans, a letter from the Healthcare Leadership Council, and 
a statement from America's Health Insurance Plans.
    [The information appears at the conclusion of the hearing.]
    Mr. Burgess. Pursuant to committee rules I remind Members 
they have 10 business days to submit additional questions for 
the record. I ask the witnesses to submit their response within 
10 business days upon receipt of the questions. Without 
objection, the subcommittee is adjourned.
    [Whereupon, at 2:51 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]

                Prepared statement of Hon. Anna G. Eshoo

    Republicans have threatened to take health care away from 
30 million Americans through the repeal of the Affordable Care 
Act. My constituents are terrified that they will lose their 
health care. Hundreds have written and called me to express 
their fears. Republicans have said that they will protect them 
by passing something ``better'' than the ACA.
    The majority now has the White House, the Senate, and the 
House, and you've had seven years to come up with a plan. Yet 
today, you show up with a half-written bill that does not 
guarantee protections for Americans with preexisting 
conditions. Today is your first opportunity to show the 
American people that you will protect them, to assuage their 
fears about losing their health care, and to show the American 
people that you have a better plan.
    The plan we're discussing today is not better, and as it is 
written, it does not protect those with preexisting conditions 
from exorbitant premium increases, because it does not include 
medical underwriting for those with preexisting conditions, 
leading to higher premiums.
    This proposal is irresponsible and ignores the gravity of 
the situation for the millions of Americans who are afraid of 
what ``repeal and replacement'' of the ACA means for them.

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