    [Senate Hearing 115-377]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 115-377

                     GRAHAM-CASSIDY-HELLER-JOHNSON PROPOSAL

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

                                    HEARING

                                   before the

                              COMMITTEE ON FINANCE
                              UNITED STATES SENATE

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                               SEPTEMBER 25, 2017

                                   __________

      [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                Printed for the use of the Committee on Finance

                                   _________

                        U.S. GOVERNMENT PUBLISHING OFFICE

     32-664 PDF                  WASHINGTON : 2018

                              COMMITTEE ON FINANCE

                         ORRIN G. HATCH, Utah, Chairman

    CHUCK GRASSLEY, Iowa                 RON WYDEN, Oregon
    MIKE CRAPO, Idaho                    DEBBIE STABENOW, Michigan
    PAT ROBERTS, Kansas                  MARIA CANTWELL, Washington
    MICHAEL B. ENZI, Wyoming             BILL NELSON, Florida
    JOHN CORNYN, Texas                   ROBERT MENENDEZ, New Jersey
    JOHN THUNE, South Dakota             THOMAS R. CARPER, Delaware
    RICHARD BURR, North Carolina         BENJAMIN L. CARDIN, Maryland
    JOHNNY ISAKSON, Georgia              SHERROD BROWN, Ohio
    ROB PORTMAN, Ohio                    MICHAEL F. BENNET, Colorado
    PATRICK J. TOOMEY, Pennsylvania      ROBERT P. CASEY, Jr., Pennsylvania
    DEAN HELLER, Nevada                  MARK R. WARNER, Virginia
    TIM SCOTT, South Carolina            CLAIRE McCASKILL, Missouri
    BILL CASSIDY, Louisiana

                         A. Jay Khosla, Staff Director

                  Joshua Sheinkman, Democratic Staff Director

                                      (ii)

                                C O N T E N T S

                                  ----------

                               OPENING STATEMENTS

                                                                       Page
    Hatch, Hon. Orrin G., a U.S. Senator from Utah, chairman,
      Committee on Finance...........................................     1
    Wyden, Hon. Ron, a U.S. Senator from Oregon......................     4

                            CONGRESSIONAL WITNESSES

    Graham, Hon. Lindsey, a U.S. Senator from South Carolina.........     7
    Hirono, Hon. Mazie K., a U.S. Senator from Hawaii................    10

                                   WITNESSES

    Cassidy, Hon. Bill, M.D., a U.S. Senator from Louisiana..........    13
    Santorum, Hon. Rick, a former U.S. Senator from Pennsylvania.....    15
    Smith, Dennis G., Senior Advisor for Medicaid and Health Care
      Reform, Arkansas Department of Human Services, Little Rock, AR.    17
    Miller, Teresa, Acting Secretary, Department of Human Services,
      Commonwealth of Pennsylvania, Harrisburg, PA...................    19
    Mann, Cindy, former Deputy Administrator and Director of the
      Center for Medicaid and CHIP Services, Centers for Medicare and
      Medicaid Services, Department of Health and Human Services,
      Washington, DC.................................................    21
    Woodruff, Dick, senior vice president of Federal advocacy,
      American Cancer Society Cancer Action Network, Washington, DC..    23

                   ALPHABETICAL LISTING AND APPENDIX MATERIAL

    Bennet, Hon. Michael F.:
        Kaiser Family Foundation study projections for Colorado under
          the
          Graham-Cassidy proposal....................................    91
    Cassidy, Hon. Bill, M.D.:
        Testimony....................................................    13
        Prepared statement...........................................    93
        Responses to questions from committee members................    94
    Graham, Hon. Lindsey:
        Testimony....................................................     7
        Prepared statement...........................................    99
    Hatch, Hon. Orrin G.:
        Opening statement............................................     1
        Prepared statement...........................................   100
    Hirono, Hon. Mazie K.:
        Testimony....................................................    10
        Prepared statement...........................................   101
    Mann, Cindy:
        Testimony....................................................    21
        Prepared statement...........................................   101
        Responses to questions from committee members................   115
    Miller, Teresa:
        Testimony....................................................    19
        Prepared statement...........................................   127
        Responses to questions from committee members................   131
    Santorum, Hon. Rick:
        Testimony....................................................    15
        Prepared statement...........................................   136
        Response to a question from Senator Brown....................   138
    Smith, Dennis G.:
        Testimony....................................................    17
        Prepared statement...........................................   138
    Woodruff, Dick:
        Testimony....................................................    23
        Prepared statement...........................................   142
        Responses to questions from committee members................   145
    Wyden, Hon. Ron:
        Opening statement............................................     4
        Prepared statement with attachments..........................   147

                                 Communications

    Adams, Marilyn...................................................   153
    Alliance of Community Health Plans (ACHP)........................   153
    The ALS Association..............................................   154
    ALS Association et al............................................   155
    American Academy of Family Physicians (AAFP).....................   156
    American Cancer Society Cancer Action Network (ACS CAN)..........   159
    American Civil Liberties Union (ACLU)............................   160
    American College of Emergency Physicians (ACEP)..................   162
    American College of Physicians (ACP).............................   162
    American Diabetes Association....................................   166
    American Heart Association.......................................   167
    American Hospital Association (AHA)..............................   170
    American Lung Association........................................   172
    American Nurses Association (ANA)................................   177
    American Thoracic Society (ATS)..................................   181
    America's Health Insurance Plans (AHIP) and Blue Cross Blue
      Shield Association (BCBSA).....................................   182
    The Arc of Colorado..............................................   188
    The Arc of Massachusetts.........................................   189
    The Arc of New Jersey............................................   190
    The Arc of Pennsylvania..........................................   191
    The Arc Tennessee................................................   193
    The Arc of the United States.....................................   194
    The Arc Wisconsin................................................   195
    Arthritis Foundation.............................................   197
    Association of Maternal and Child Health Programs................   198
    Beck, Kristine...................................................   199
    Blue Shield of California........................................   199
    Blue Cross Blue Shield of Massachusetts (BCBSMA).................   200
    Brain Injury Association of America..............................   202
    Brininger, Ruth Hong.............................................   203
    Bruner, Charles, Ph.D............................................   203
    Cahill, Anne.....................................................   204
    Center for Fiscal Equity.........................................   205
    Children's Hospital Association..................................   206
    Consortium for Citizens With Disabilities........................   207
    Crawford, Arlene J...............................................   210
    Cystic Fibrosis Foundation.......................................   211
    Disability Rights California (DRC)...............................   213
    Disability Rights Ohio (DRO).....................................   215
    Disability Rights Wisconsin (DRW)................................   217
    Doctors Organized for Healthcare Solutions.......................   220
    Family Voices....................................................   241
    Feminist Majority................................................   242
    Fox, Sarah, Ph.D.................................................   246
    Friday Health Plans..............................................   248
    Giroux, Anne Morgan..............................................   249
    Guttmacher Institute.............................................   250
    Hadden, Sue Matthes, R.N.........................................   253
    Holland, Carolyn.................................................   253
    Holmberg, Marion.................................................   254
    Jaber, Samir S...................................................   254
    The Jewish Federations of North America (JFNA)...................   256
    LeadingAge.......................................................   258
    Little Lobbyists.................................................   261
    Lusk, Don and Laurine............................................   267
    March of Dimes Foundation........................................   269
    The Michael J. Fox Foundation for Parkinson's Research...........   271
    Michigan Developmental Disabilities Council......................   273
    NARAL Pro-Choice America.........................................   275
    National Association of School Nurses (NASN).....................   276
    National Council for Behavioral Health...........................   277
    National Disability Rights Network (NDRN)........................   278
    National Health Council (NHC)....................................   280
    National Health Law Program......................................   282
    National Multiple Sclerosis Society..............................   288
    National Partnership for Women and Families......................   289
    National Women's Law Center......................................   290
    Oklahoma Council of the Blind (OCB)..............................   295
    Papadopoulos, Lecia..............................................   296
    The Partnership for Medicaid.....................................   300
    Prevent Blindness................................................   301
    Prochnow, Brenda.................................................   302
    Resource Center for Accessible Living, Inc. (RCAL)...............   303
    Shiffrin, Eva....................................................   304
    Sorensen, Barbara Burke..........................................   305
    Statewide Parent Advocacy Network (SPAN) and Family Voices-New
      Jersey.........................................................   306
    Steen, Shawn M...................................................   308
    Thomas, Earline..................................................   309
    Todebush, Emily..................................................   310
    Trust for America's Health.......................................   311
    UnidosUS.........................................................   320
    Wallace, Laura...................................................   324
    Wisconsin Board for People With Developmental Disabilities.......   325
    Wisconsin Family Ties............................................   327
    Wurzbach, Deanna.................................................   328
    Zaremski, Miles J., Esq..........................................   329
    Zarske, Ginger...................................................   330
    Zusman, Miriam and Neil..........................................   330

                     GRAHAM-CASSIDY-HELLER-JOHNSON PROPOSAL

                                  ----------

                           MONDAY, SEPTEMBER 25, 2017

                                           U.S. Senate,
                                          Committee on Finance,
                                                        Washington, DC.
        The hearing was convened, pursuant to notice, at 2 p.m., in
    room SD-215, Dirksen Senate Office Building, Hon. Orrin G.
    Hatch (chairman of the committee) presiding.
        Present: Senators Grassley, Roberts, Enzi, Thune, Isakson,
    Portman, Toomey, Heller, Scott, Cassidy, Wyden, Stabenow,
    Cantwell, Nelson, Carper, Cardin, Brown, Bennet, Casey, Warner,
    and McCaskill.
        Also Present: Republican Staff: Jay Khosla, Staff Director;
    Jennifer Kuskowski, Chief Health Policy Director; Preston
    Rutledge, Senior Tax and Benefits Counsel; Jeff Wrase, Chief
    Economist; and Martin Pippins, Detailee. Democratic Staff:
    Joshua Sheinkman, Staff Director; Anne Dwyer, Senior Health
    Counsel; Michael Evans, General Counsel; Elizabeth Jurinka,
    Chief Health Policy Advisor; and Arielle Woronoff, Senior
    Health Counsel.

     OPENING STATEMENT OF HON. ORRIN G. HATCH, A U.S. SENATOR FROM
                  UTAH, CHAIRMAN, COMMITTEE ON FINANCE

        The Chairman. The committee will come to order. I would
    like to welcome everyone, and I do mean everyone.
        [Interruption from the audience.]
        The Chairman. If you want a hearing--if you want a hearing,
    you had better shut up.
        Okay, let us get----
        Senator Grassley. Let the police take care of it. Just let
    the police take care of it.
        The Chairman. Oh, I will. I will.
        All right.
        [Interruption from the audience.]
        The Chairman. Get the police in here.
        [Interruption from the audience.]
        Senator Grassley. Do you want to stand in recess until they
    get them out of here?
        The Chairman. Let us give them a little more time. Let us
    let them get it out of their system.
        [Interruption from the audience.]
        The Chairman. I think I had better recess here for a few
    minutes. Is that okay with you?
        Senator Wyden. It is your call.
        The Chairman. I do not see sitting through this much
    longer.
        Okay, the committee is in recess. The committee will be in
    recess until we get order.
        [Whereupon, the committee was recessed at 2:09 p.m.,
    reconvening at 2:17 p.m.]
        The Chairman. Let us have order. And let us show some
    respect here. Look, a lot of us are on your side, so let us
    have some order. If you cannot be in order, then get the heck
    out of here.
        Okay, the committee will come to order.
        I would like to welcome everyone to this afternoon's
    hearing where we will discuss and examine the Graham-Cassidy-
    Johnson-Heller health-care proposal.
        Given the relatively unique circumstances we are facing
    with regard to health care generally, and this proposal in
    particular, the Senate Republican leadership as well as members
    of the conference have asked for a hearing on this proposal so
    that we can all get a better sense of how it is intended to
    work.
        Toward that end, we have two distinguished panels of
    witnesses before us today. The first panel will feature
    statements from two of our distinguished Senate colleagues.
        [Interruption from the audience.]
        The Chairman. If the police would please remove that
    person, we would appreciate it. And keep the doors shut.
        Okay. The second panel will feature another one of our
    colleagues who is also a member of this committee. We will hear
    from a friend and former Senate colleague on the second panel
    as well.
        Joining them at the table will be experts and stakeholders
    who are here to share their views on the proposal from Senators
    Graham, Cassidy, Heller, and Johnson.
        The purpose of the hearing is to respectfully discuss ideas
    and become better informed on particular issues.
        [Interruption from the audience.]
        The Chairman. The purpose of the hearing, as I have said,
    is to respectfully discuss ideas and become better informed on
    particular issues. It does not mean that everyone shares the
    same views and opinions. In fact, I expect that quite a few
    disagreements will be expressed today, and that is okay with
    me. I have been in the Senate for 4 decades now and in that
    time have been a part of some very difficult and contentious
    debates.
        Early on, I was part of a fierce debate over labor law
    reform. Over the years, I have participated in some of the most
    heated Supreme Court hearings in our Nation's history. I was
    here to take part in drafting, debating, and passing the
    Americans with Disabilities Act, one of my proudest
    accomplishments.
        I was around when the debate over the war in Iraq became
    extremely combative. And of course, I was here when we debated
    Obamacare before it passed. And I have been here for every
    debate we have had about it since that time.
        So I have been through an awful lot of this. And it is
    nothing new to me. So I understand that there are some strong
    opinions about this issue. And more importantly, I understand
    why opinions are so strong.
        When we talk about health-care policy, we are not just
    talking about a theoretical concept or legislation that impacts
    a single isolated industry. This topic has a significant impact
    on the lives of every person in this country in ways that can
    make or break both their health and their livelihoods.
        Frankly, because this issue is so personal, everyone has
    strong feelings on all sides of these issues.
        [Interruption from the audience.]
        The Chairman. If we could shut that door and keep it shut,
    I would appreciate it.
        To members of the committee, to those in the audience
    today, and to any person who may watch or read about today's
    hearing at some point in the future, let me say this: I respect
    your opinions on these issues, but, while I wish that
    expressions of good will could on their own fix our Nation's
    problems, that is just not the case. We have to do the work.
    And on these issues, the work is particularly hard.
        Today we are here to discuss the most recent health-care
    proposal drafted by some of our colleagues. And I commend them
    for their efforts and their willingness to put forward ideas to
    address these very difficult problems.
        My hope is that we can spend our time today questioning our
    witnesses about substance and policy, not on scoring political
    points, particularly when we have distinguished colleagues and
    a former colleague at the witness table.
        I know that for both sides of this debate, passionate
    demonstrations and righteous indignation, particularly when
    there are cameras in the room, make good fodder for Twitter and
    TV commercials, especially when the subject is health care.
        Our committee is generally regarded as being above such
    shenanigans, though we have not been entirely immune to these
    types of theatrics in the past.
        For today, let me just say this: if the hearing is going to
    devolve into a sideshow or a forum simply for putting partisan
    points on the board, there is absolutely no reason for us to be
    here.
        I will not hesitate to adjourn the hearing if it gets to
    that point. It has not gotten there yet, but it is close. I am
    saying this for the benefit of my colleagues on the committee
    and everyone in the audience. Let us have a civil discussion.
        I have no objection to having a spirited debate on these
    issues. My gosh, I was the author of the Americans with
    Disabilities Act, so I have very deep feelings about these
    issues, and I think most here on this committee have deep
    feelings as well.
        My hope is that, in the end, our efforts will generate more
    light and less heat than we have seen in the most recent
    episodes of the health-care debate. If we cannot have that, we
    should all be spending our time on something more productive.
        So with that and those few remarks, I now turn to our
    ranking member, Senator Wyden, for his remarks.
        [The prepared statement of Chairman Hatch appears in the
    appendix.]

                 OPENING STATEMENT OF HON. RON WYDEN,
                       A U.S. SENATOR FROM OREGON

        Senator Wyden. Thank you very much, Mr. Chairman.
        Mr. Chairman, I have an opening statement, and then at the
    conclusion of that, I would like to bring up several points
    about the process. And I understand we have agreed to that.
        The Chairman. That would be fine.
        Senator Wyden. Colleagues, nobody has to buy a lemon just
    because it is the last car on the lot. This Trumpcare bill is a
    health-care lemon, a disaster in the making. The fact that it
    is the last Republican repeal bill standing does not make it
    okay. It is going to be a nightmare for tens of millions of
    Americans, and it makes a mockery of the President's promise of
    better insurance for everybody at lower costs.
        The bill's sponsors are not even waiting for the official
    facts and figures from the independent scorekeepers. Version
    after version of this bill is floating around, and the pork
    parade is up and running. The process that has brought this
    Trumpcare bill to the brink of passage would be laughable if
    the well-being of tens of millions of Americans was not in the
    balance.
        Now, I want to blow the whistle on a few key points at the
    outset. First off, the American people do not want this bill.
    In the last few days, the committee has received more than
    25,000 comments from people who want it stopped. As with every
    other version of Trumpcare, this proposal is about as popular
    as prolonged root canal work.
        There is one group cheering the bill on: the right-wing
    Republican donor class. The big donors want the entire
    Affordable Care Act thrown in the trash, and they have wanted
    it from the beginning. But it did not work, since it turns out
    that it is bad policy to take health coverage away from tens of
    millions of Americans and raise costs for virtually everybody
    else.
        So the new strategy is essentially repeal by a thousand
    cuts. It would be national repeal, and it would be State-by-
    State repeal. The heart of this bill is a scheme that punishes
    the States that have worked hard to build strong private
    markets and make health care more affordable. It rewards the
    States where lawmakers have sat on their hands, where they have
    spent years loudly rejecting the opportunity to improve the
    lives of millions of the people they serve.
        But that is not a proposition that gets much support. So
    instead, the committee today is going to hear a lot of hocus-
    pocus about the word ``flexibility.''
        The story goes, it is flexibility for the States, more
    control at the local level, and somehow everybody by osmosis is
    going to be better off.
        But let's be up-front about what it means in practice. The
    real flexibility created by the bill is the option for States
    to do worse so that Americans are forced to pay more for less
    care.
        Now, off the top, this version of Trumpcare guts funding
    for health care in the new block grants. Then Governors and
    State legislators build new health insurance systems, and they
    are basically going to have to make ``Hunger Games'' choices,
    deciding which vulnerable people get care and which do not.
        The iron-clad, loophole-free, guaranteed protection for
    those with preexisting conditions will be gone. The bill's
    sponsors will tell you otherwise, but, colleagues, the facts
    are the facts. The guaranteed protection that nobody will be
    gouged due to a catastrophic illness, like cancer, will be
    done. That is because the bill reopens the door to annual and
    lifetime limits on care.
        The guarantee of essential benefits--gone. That means
    prescription drug coverage is on the chopping block. Maternity
    care, on the chopping block. Mental health and substance abuse
    treatment, on the chopping block. And a whole lot more. The
    guarantee that nobody could be charged higher premiums because
    of their health status or their job, also gone.
        Bottom line: this bill is an all-out assault on vital
    consumer protection. It revives some of the worst insurance
    company abuses that were banned under the Affordable Care Act,
    and it is going to make the health care that many people need
    unaffordable. No, it does not adequately protect people with
    preexisting conditions.
        What the bill does include are a few toothless lines about
    affordability and access. That is supposed to be protection,
    real protection for people with preexisting conditions. But
    there is no enforcement mechanism, no tough standards, no real
    definitions. And the
    watered-down protection States put together for new insurance
    systems then can get a rubber stamp from team Trump.
        Once again, in the Trumpcare bill there is an attack on
    women's health. Hundreds of thousands of women are going to
    lose the right to see the doctor of their choice. That is what
    you get when you defund Planned Parenthood.
        The traditional Medicaid program, a lifeline for people
    with disabilities, seniors, kids, and pregnant women--draconian
    cuts.
        An aging baby boomer who suffered a stroke might not get
    the help they need. The guarantee of nursing home care will not
    be there. The community-based program that offers care to
    people at home where they are most comfortable could disappear.
    Special education programs funded by Medicaid for vulnerable
    kids could be put in jeopardy.
        A few closing points, Mr. Chairman.
        The process that has led to this moment has been an
    abomination. And we have just seen, colleagues, some of the
    frustration that our people have at closed-door government that
    locks Americans out of the democratic process. This just is not
    serious--it is really a talking point today. It is a scheme to
    let Senators go home to fearful constituents and offer
    assurances, false assurances, that this bill got a fair
    examination and went through the regular order. It is not true.
        Senate Republicans have not gotten answers to the most
    basic questions about the real-world effects of the bill. How
    many people are going to lose coverage? By how much are
    premiums going to increase? Will the health-care market survive
    next year?
        The independent scorekeepers at the Budget Office say it is
    going to be several weeks before they can put forward estimates
    of coverage and cost. And their job gets tougher because this
    bill just changes by the hour as the majority throws around in
    the scramble for votes.
        Why the rush job? It is because the coach turns back into a
    pumpkin at the end of the month. That is when the
    reconciliation fast-track to pass the partisan bill expires.
        Now, we want to be clear. On this side, we think we ought
    to be working on bipartisan priorities. We have a good bill for
    kids, the Children's Health Insurance Plan, which covers 9
    million kids. The funding for that program, colleagues, runs
    out in just a few days at the end of the month. We would like
    to be working on that in a bipartisan way.
        And we would like to be working on stabilizing the private
    insurance markets. I heard about that this weekend in town hall
    meetings in central Oregon. That is what we want to work on. We
    want to do it in a bipartisan way with our sister Senate
    committee.
        Instead, what is on offer is this Trumpcare bill that is
    going to trigger a health-care disaster, a death spiral in the
    insurance markets as tax credits and cost-sharing payments go
    away, healthy people flee, and costs go into the stratosphere.
        Democrats on this side of the dais want to continue to do
    everything, (1) to stop this dreadful proposal from becoming
    law, and (2) to get down to the serious heavy lifting of
    passing bipartisan legislation for kids, number one, and for
    adults in the individual insurance market.
        Now, with that, Mr. Chairman, I would like to just wrap up
    with a few quick points about procedure for this hearing. This
    is per our agreement.
        First, Mr. Chairman, I think you know that we are very
    disappointed in the response to our request to hold this
    hearing in a larger room that could accommodate more members of
    the public.
        I would ask unanimous consent that a letter outlining this
    request be included in the record.
        The Chairman. Without objection.
        [The letter appears in the appendix on p. 149.]
        Senator Wyden. This is the first and only hearing that will
    be held regarding a bill affecting more than 320 million
    Americans and one-sixth of our economy. As we just saw, there
    is enormous public interest.
        We have seen hundreds of people today, many in wheelchairs,
    lined up in the hall hoping to get into the hearing. However,
    after you take account of the committee members, staff,
    witnesses, and members of the press, the room we are in only
    has space for about 30 members of the public--30 for a hearing
    of this import.
        Normally when Congress holds hearings that attract such
    enormous public attention, we have our hearings in the largest
    hearing rooms to accommodate hundreds of audience members. My
    understanding is, those rooms are available today. So the
    question I really have is, why not move the hearing there,
    somewhere people can attend? Otherwise, it sends yet one more
    signal that the majority wants to keep the bill under wraps
    rather than opening up the process to the American people.
        Finally, Mr. Chairman, I understand that Senator Cassidy
    wants to participate in this hearing both as a witness
    providing testimony and as a member of the committee asking
    questions of the same witness panel he is part of.
        I expect we are going to hear a lot today from Senator
    Cassidy about flexibility. I gather he is a big fan of
    flexibility. He appreciates flexibility so much, he wants to
    apply it to himself.
        However, to my mind, dashing back and forth between the
    witness table and the dais is not proper decorum for a hearing.
    So I would just like to make that clear, Mr. Chairman, because
    my understanding with respect to the rules is, I have to leave
    it at that.
        I sure think it is more appropriate that Senator Cassidy
    wears one hat during this hearing rather than two.
        Thank you.
        [The prepared statement of Senator Wyden appears in the
    appendix.]
        The Chairman. Well, thank you, Senator. I think Senator
    Cassidy ought to be able to do what he wants to do. But I will
    make sure he does not ask questions of himself. [Laughter.]
        Senator Wyden. Interesting.
        The Chairman. Well, maybe I had better withdraw that.
    [Laughter.]
        I appreciate your kind and good remarks.
        Now, because of the high interest and the importance of
    this hearing, an overflow room has already been secured, not to
    mention it will be televised on C-SPAN and available for live
    streaming on the Senate Finance Committee website.
        To my colleagues' complaints about the process for setting
    up this hearing, I will just say that many Senators have
    expressed a desire to examine details of the proposal we are
    discussing today. Today's hearing is being held to allow
    members on both sides to delve deeper into the policy and gain
    a better understanding of what our colleague's proposal hopes
    to achieve. I do not expect this hearing to go on forever, but
    we will get, certainly, good opportunity.
        Now, I would like to welcome each of our witnesses to our
    hearing today.
        To start off, on the first panel we will hear from our good
    friends and fellow Senators, the senior Senator from South
    Carolina, Lindsey Graham, who is the coauthor of this bill, and
    the junior Senator from Hawaii, Mazie Hirono, for opening
    remarks.
        We are grateful to have such passionate and wonderful
    Senators join us today to share their views.
        Senator Graham, will you please share with us your remarks,
    and then we will go to Senator Hirono?

                   STATEMENT OF HON. LINDSEY GRAHAM,
                   A U.S. SENATOR FROM SOUTH CAROLINA

        Senator Graham. Thank you, Mr. Chairman.
        The first remark I would like to share with you is why I am
    here. I am here because Obamacare is a disaster in my State. It
    is not your job to take care of South Carolina; it is mine, and
    I intend to do that. Maybe we will find a common way forward, I
    do not know, but I am not going to be deterred.
        The Chairman. But I intend to help--put it that way.
        Senator Graham. Thank you. In 2014, there were five
    insurers offering plans to South Carolina customers under the
    exchange. Today we are down to one with a 31-percent increase
    announced Friday. If you expect me to walk away from that, you
    are sadly mistaken.
        I do not know how it is working in your State, but in my
    State it is a disaster.
        Why are we in Finance? Because health care really does
    affect Federal finances. Most of you know that by 2042 that the
    entire revenue stream will be consumed by Medicare and Medicaid
    spending unless somebody does something about it. There will be
    no money for the military, the Department of Education, NIH, or
    anything else.
        So what do I do? I deal with two problems. Nationally,
    Obamacare premiums are going up 13 percent in the individual
    market, 45 percent of the counties in America are down to one
    choice, and 45 counties in this country have no choice under
    the plan you designed.
        The bottom line is, I do not doubt your intention to help
    people; I do question whether or not it is working as intended.
    And you can question my motives, and, quite frankly, I do not
    care, because I know why I am here.
        The Chairman. You are saying who designed it? It was not
    mine, I will tell you that.
        Senator Graham. Well, I know, Mr. Chairman, it was not. So
    we have two problems. If somebody does not fix Obamacare soon,
    the majority of counties in this country are going to be down
    to one provider. It is collapsing as I speak.
        Medicaid--Medicaid is on an unsustainable path. By 2027, we
    are going to be spending more on Medicaid than the military. By
    2042, Medicare and Medicaid combined take all the money that is
    going to be sent to Washington in taxes. And what do we do?
        In Year 8 of the block grant, we give flexibility and
    control to the States over the Medicaid program like they have
    not had before, but they have to spend it on the population in
    question. We begin to slow the growth down to make it more
    sustainable. But the flexibility we give will allow us to get
    better outcomes. Medicaid spending and Medicaid outcomes are
    not matched up where anybody should want them to be.
        When it comes to Obamacare, if you do not find a way to
    stop the bleeding, then it is going to basically collapse
    before our eyes.
        And here is what we do. I am getting a lot of pushback from
    my Republican colleagues because I leave the taxes in place.
    Here is the idea of Graham-Cassidy-Heller-Johnson. We repeal
    the individual mandate and the employer mandate, but you can
    reimpose it in your State if you like.
        If you want to go to single-payer health care, you can do
    it in Oregon, but you are not going to drag me with you.
        So here is the deal. We leave the taxes in place, that is
    $1.2 trillion, and we block-grant it out to the States in a
    formula that I think is fair. Under Obamacare, between 2020 and
    2026, four States get 35.4 percent of the money. They are
    Maryland, Massachusetts, New York, and California, and they are
    22 percent of the population. Good deal for them; not so much
    for the rest of us. Under this block grant, they get 29
    percent, not 35--still more than the population.
        What have I learned? Hawaii is a very expensive place to
    provide Medicaid. It is a very expensive place to provide
    health care. It is just a very expensive place to live.
        Alaska has 750,000 people and is 2\1/2\ times the size of
    Texas. Under this bill, we look at you. Rather than some
    bureaucrat in Washington who has all the money and the power,
    we are going to turn it back to you, your State legislature and
    your Governor.
        And I asked the following question at a lunch not long ago.
    How many of you know your State House member? Almost everybody
    raised their hands. How many of you know the Governor of South
    Carolina? Everybody raised their hand. I asked the question,
    how many of you know who is in charge of Obamacare in South
    Carolina? Nobody raised their hand. And that is the problem.
        We are going to send this money back to the States. You
    cannot spend it on roads and bridges; you have to spend it on
    health care. You are going to have flexibility, but you are
    also going to have accountability. And for the first time in
    health care, somebody is going to listen to you. Because if you
    do not like the health care you have, you can complain to
    somebody you vote for: ``The model you have created is never
    going to work.''
        As to the opposition to this bill, to the ranking member,
    every major insurance company opposes our bill. Why? Because we
    take hundreds of billions of dollars away from them, that were
    going to them from the Federal Government, and give it to the
    States. Guess what? They do not like that.
        If I were a major insurance company, I would hate my bill,
    because I take money and power away from you and I give it to
    the States.
        Washington is wired when it comes to health care. Everybody
    opposing this bill is a big winner of Obamacare. And my goal is
    to get the money and power out of Washington, closer to where
    people live so they will have a voice about the most important
    thing in their life.
        I do not need a lecture from anybody about health care, but
    what you have created is not working. It is time to try
    something new. And I believe with all my heart and soul, Mr.
    Chairman, that if we took the money and power out of Washington
    and we got it closer to the patient, we put it in the hands of
    somebody you would have a relationship with and you could
    actually vote for if you do not like the product, we are going
    to get a better outcome. And this is not the last chance, this
    is the best chance.
        And to my friends to the left, I will do everything I can
    to stop and put a stake in the heart of single-payer health
    care. You do not like Obamacare, you do not think it is big-
    government enough; I am here to stop you. You care as much as I
    do about health care, but going beyond Obamacare is a nightmare
    for this country. It will ruin health care and bankrupt the
    American people.
        And this is a debate worth having. Thank you very much. God
    bless you all.
        The Chairman. Well, thank you, Senator Graham.
        [The prepared statement of Senator Graham appears in the
    appendix.]
        The Chairman. Senator Hirono, please proceed with your
    statement now.

                  STATEMENT OF HON. MAZIE K. HIRONO,
                       A U.S. SENATOR FROM HAWAII

        Senator Hirono. Thank you, Mr. Chairman, Ranking Member
    Wyden, and all of the members of the committee. Thank you for
    inviting me to testify.
        When I was diagnosed with stage 4 kidney cancer about 5
    months ago--two things. The first was the diagnosis came as a
    total shock to me. It came about incidental to a physical
    checkup that involved an entirely different procedure that I
    was facing. This is how a lot of people learn about a serious
    illness or condition, out of the blue, bang. You cannot plan
    for it.
        Second, I received letters, cards, and notes when people
    found out. I was touched by the hands reaching out to me, the
    show of compassion, including from so many of my colleagues,
    including members of this committee on both sides of the aisle.
    Every day now, people come up to me at airports, grocery
    stores, restaurants to tell me that they too are cancer
    survivors. There is a connection there.
        It is never a good time to have cancer. But what I am
    experiencing through my cancer is the care and concern
    expressed by total strangers. This is compassion. It helps me a
    lot.
        What we do as leaders affecting everyone's lives should
    reflect compassion. Sadly, that is not in this bill. In the
    greatest, richest country in the world, compassion for our
    fellow men and women should not be so elusive or indeed
    missing.
        After all the compassion and care that I received from my
    colleagues after I disclosed my diagnosis, the Graham-Cassidy
    proposal reflects neither care nor compassion for millions
    across the country.
        Health care is a right. It is a right. It is not a
    privilege reserved for those who can afford it. But Graham-
    Cassidy treats health care like a commodity that can be bought
    and sold. This is fundamentally wrong.
        Although nearly all of us will face a serious illness
    during our lifetimes, it is almost impossible to budget and
    plan for the costs associated with treating it. And once you
    are diagnosed, you cannot just put off treatment because you
    cannot afford it.
        Before the Affordable Care Act, catastrophic health-care
    costs were the largest driver of personal bankruptcies in the
    country. And since the law went into effect, we have seen a
    huge reduction in personal bankruptcies. There is a causal
    relationship when people get health care.
        If you dig into the details and numbers, it is clear this
    bill is much worse than the bill we defeated in July. Under the
    thin veneer of States' rights and local control, the Graham-
    Cassidy bill imposes a radical overhaul on one-sixth of the
    American economy.
        According to the Brookings Institution, 32 million people
    will lose their health coverage under it. There is so much
    wrong with this bill that it is difficult to confine my remarks
    to only the short time I have been allowed to testify.
        Contrary to promises made by the bill's authors, this
    proposal undermines protections for the close to 600,000 people
    in Hawaii and 134 million people all across the country living
    with preexisting conditions. This bill seriously undermines
    consumer protections that require coverage for preexisting
    conditions and prohibit insurance companies from charging sick
    people more for care, which is exactly what they will do,
    believe me, if this bill passes.
        The process requires a pro forma explanation of how a State
    would maintain coverage for those with preexisting conditions.
    But it is really a box that they just check off. There is
    nothing here that ensures the level of protection that the
    Affordable Care Act does.
        Sure, the Federal Government can deny a State's waiver
    application, but the very people who would be making this
    decision at the Federal level are longtime opponents of the
    Affordable Care Act. Sadly, the American people cannot trust
    this administration to do the right thing regarding their
    health care.
        We do not have to look back far to see what the result
    would be of a State-granted waiver. Insurance companies could
    use age, health status, and other factors to determine what
    premiums to charge. They could set annual and lifetime limits
    on care and could refuse treatments because of how much they
    cost.
        Believe me, I have a complicated illness, and I would reach
    lifetime limits in practically a nanosecond. I intend to live a
    lot longer before that day comes. Under this bill, coverage
    might be available, but it would be prohibitively expensive and
    able to be taken away in someone's moment of greatest need.
        This bill dismantles Medicaid as we know it. The bill
    converts Medicaid into a block grant to States and cuts its
    funding by hundreds of billions of dollars by 2026. It punishes
    States like Hawaii that expanded Medicaid by cutting Federal
    funding and redistributing it to those States that did not
    expand Medicaid; and therefore, hundreds of thousands of people
    in those States do not even have the kind of coverage that
    Hawaii provided.
        For Hawaii, we are looking at around $4 billion in cuts and
    91,000 fewer Hawaii residents having health care because of
    this bill.
        Because States would receive so much less money, they will
    no longer be able to provide quality, adequate care for as many
    people as possible. Instead, they will face the impossible task
    of choosing who should lose insurance and which services to
    cut. Even then, the most vulnerable members of our society, the
    elderly and the disabled and children, will not receive the
    care and services they need.
        Mr. Chairman, we are all one diagnosis away from a major
    illness. I have certainly found that out. With so much
    uncertainty right now in our country, the one thing that people
    should be able to count on in the richest country in the world
    is getting the care they need when they need it.
        Health care is a right, not a privilege for those who can
    afford it. Health care is personal to every single one of us.
        I would like to conclude with a call to action. This bill
    would be devastating for millions of people across the country
    facing dire health consequences. Millions of lives are at
    stake. Let us return to the bipartisan negotiations led by
    Senators Alexander and Murray to stabilize the health insurance
    marketplace. This is something they are doing together in a
    bipartisan way.
        This is exactly how we should approach health care in our
    country. Focus on the people we are elected to serve. Focus on
    the people we are elected to serve. Show them the compassion
    that they are expecting from their leaders. They expect us to
    work together and come up with a bill that we can get behind.
        Thank you, Mr. Chairman.
        The Chairman. Well, thank you, Senator Hirono. We
    appreciate your remarks.
        [The prepared statement of Senator Hirono appears in the
    appendix.]
        The Chairman. Thanks to both of you for sharing your
    remarks to the committee today.
        I think I speak for all of my colleagues when I say that we
    are hopeful and praying, Senator Hirono, for your quick and
    total recovery from cancer.
        We do appreciate both of you for taking the time to be with
    us today. You are both welcome to stay for as long as you wish.
        Now we are going to turn to panel two. Next, we will hear
    from the six witnesses that sit before the committee today. I
    will introduce witnesses briefly and then have each of you
    provide your testimony in the order you are introduced.
        First, we will hear from a good friend, colleague, and
    fellow committee member, the Honorable Dr. Bill Cassidy. Prior
    to his coming to the Hill in 2015, Senator Cassidy provided
    care for uninsured and underinsured patients for nearly 30
    years.
        He is a co-founder of the Greater Baton Rouge Community
    Clinic, created a private/public partnership to vaccinate
    children against Hepatitis B, and in the wake of Hurricane
    Katrina he led a group of health-care volunteers to convert an
    abandoned K-Mart building into an emergency health-care
    facility.
        Senator Cassidy has also taught at the LSU medical school
    and is a former member of both the Louisiana State Senate and
    the U.S. House of Representatives. Senator Cassidy attended the
    Louisiana State University for both his undergraduate and
    medical degrees.
        Secondly, we will hear from our good friend and former
    colleague Senator Rick Santorum. Former Senator Santorum served
    in the U.S. Senate from 1995 to 2007, prior to which he also
    served in the U.S. House of Representatives from 1991 to 1995.
        Senator Santorum and his wife, Karen, are also coauthors of
    the bestselling book ``Bella's Gift: How One Little Girl
    Transformed Our Family and Inspired a Nation.''
        Senator Santorum received his bachelor's degree from Penn
    State University, his M.B.A. from the University of Pittsburgh,
    and his law degree from Dickinson School of Law.
        Next we will hear from Mr. Dennis G. Smith, the Senior
    Adviser for Medicaid and Health Care Reform at the Arkansas
    Department of Human Services and a visiting professor at the
    University of Arkansas Medical Sciences College of Public
    Health.
        Mr. Smith has spent most of his career in public service.
    At the Federal level, he has worked in both the executive and
    legislative branches, including 10 years on Capitol Hill and 10
    more years at the U.S. Department of Health and Human Services.
    In fact, Mr. Smith headed the Medicaid agency for nearly 7
    years, the longest tenure of any Medicaid Director at the
    Federal level.
        Mr. Smith also worked in both the U.S. Senate and the U.S.
    House of Representatives from 1989 to 1998.
        Our fourth witness will be Ms. Teresa Miller, the Acting
    Secretary of the Commonwealth of Pennsylvania's Department of
    Human Services. Previously, Ms. Miller served as the
    Pennsylvania Insurance Commissioner from January 2015 through
    June 2017. Additionally, she chairs the Senior Issues Task
    Force and its Long-Term Care Innovations Subgroup at the
    National Association of Insurance Commissioners, or NAIC.
        Prior to her work in Pennsylvania, Ms. Miller served as
    Acting Director of the State Exchanges Group, the Oversight
    Group, and the Insurance Programs Group in the Centers for
    Medicare and Medicaid Services at the U.S. Department of Health
    and Human Services. She also served as the Administrator of the
    Oregon Insurance Division.
        Ms. Miller received her J.D. from Willamette University
    College of Law and her B.A. from Pacific Lutheran University.
        Next we will hear from Ms. Cindy Mann, the former Deputy
    Administrator and Director of the Center for Medicaid and CHIP
    Services at CMS. Prior to her appointment at CMS, Ms. Mann was
    a research professor at the Georgetown University Health Policy
    Institute. There she was the founder and director of the Center
    for Children and Families.
        Ms. Mann also previously worked as a senior adviser at the
    Kaiser Commission on Medicaid and the Uninsured. Ms. Mann is
    now a partner with Manatt Health.
        She received her J.D. from New York University School of
    Law and her B.S. from Cornell University.
        And last but not least will be Mr. Dick Woodruff, senior
    vice president of Federal advocacy for the American Cancer
    Society Cancer Action Network. Altogether, Mr. Woodruff has
    more than 35 years of experience in Congress, the executive
    branch, and the not-for-profit world, including serving as a
    Chief of Staff and Legislative Director for members in the U.S.
    House of Representatives as well as the Senate.
        He also served as the Director of Congressional Affairs at
    the National Endowment for the Arts.
        Mr. Woodruff is a graduate of Miami University in Oxford,
    OH.
        I want to thank each and every one of you again for taking
    time out of your busy schedules and coming here today. And I
    look forward to hearing every one of your remarks.
        Senator Cassidy, will you please get us started?

                 STATEMENT OF HON. BILL CASSIDY, M.D.,
                     A U.S. SENATOR FROM LOUISIANA

        Senator Cassidy. I cannot tell you how honored I am to
    testify before my colleagues. I respect you so much. You are
    knowledgeable and you are passionate about health care. You are
    knowledgeable and passionate about our country.
        I hope that you accept that I also have studied health care
    and am passionate about it and am passionate about caring for
    the uninsured. My work for 30 years in public hospitals in
    California and in Louisiana was spent caring for those who have
    less.
        Let me say first, Senator Wyden, I am so sorry about this
    process. I would have preferred hearings, a markup, a
    Democratic cosponsor. For 3 years, I have gone around to
    Democratic colleagues, several in this room, have met with you
    and asked, ``Could we please work together?''
        Susan Collins and I came up with legislation which was so
    bipartisan, in which a State like Oregon could keep Obamacare
    if they wanted. If it is working for you, that is fine. But in
    my State, the individual market is collapsing. In Tennessee, it
    is collapsing. I could go down the list. Allow us to do
    something different.
        It was praised by both the left and the right that this was
    a bipartisan attempt, sincere. All 10 said they could not help.
        Now, after the health-care vote failed in August, I was
    assured that now bipartisan cooperation would begin. That has
    not happened. In the meantime, the individual market in my
    State is collapsing. If you are not getting a subsidy, you
    cannot afford your coverage.
        There was a friend--I put it on my Facebook page; no one
    believes me--and he is paying $39,000 a year for his premium.
    People ask us, wait a second, how do you ensure affordability?
    Is $39,000 a year affordable? That is not including his
    deductible.
        So when I asked people, ``Will you help me?'' For 3 years I
    have been doing this, and for 3 years I was basically told,
    ``Nice try.''
        I am then presented a choice. Do I say, people will not
    help me so I quit trying to help those folks who cannot afford
    policies in my State? That is not why I was sent here. I was
    sent here to work for them. And if this is the only means by
    which I can do so, then I shall.
        Now again, before being Senator Cassidy, I was Dr. Cassidy,
    caring for the uninsured and Medicaid patients in Louisiana's
    public hospital system. My patients had terrible diseases,
    multiple chronic conditions, and I did my best to serve my
    fellow Americans. I truly believe that Graham-Cassidy-Heller-
    Johnson serves these fellow Americans by other means.
        The ACA promised affordable health-care coverage, freedom
    to keep your doctor, and to keep health-care costs down. In
    reality, on the exchange, middle-class families have
    skyrocketing premiums, individual mandates that they hate,
    $6,000 deductibles with costs inflating and doubling in too-
    short a time frame.
        Indeed, if there is one thing we can agree on on a
    bipartisan basis, Obamacare is failing. Fifteen Democratic
    Senators recently declared such while endorsing a single-payer
    system. The problems of Obamacare require a path forward.
        On a positive note, I was presiding the other day when
    Senator Wyden was praising the CHIP program. We agree. Graham-
    Cassidy-Heller-Johnson passes a flexible block grant through
    the CHIP program, keeping the protections and the requirements
    of the CHIP program. We combine the Medicaid expansion dollars,
    Obamacare tax credits, the cost-sharing reduction subsidies,
    the basic health plan, and distribute them in this means.
        By the way, it is a mandatory appropriation. And yes, the
    CHIP program requires reauthorization. This will too, but it
    does not mean the money goes away automatically in 10 years as
    some have absurdly stated.
        Let me address the inevitable comment--oh, by the way, we
    do not affect one-sixth of the economy; that is a misstatement.
    We are not touching Medicare, we are not touching employer-
    sponsored insurance, we are not touching Tricare. None of that
    is touched. We are in the individual market. We are in the
    Medicaid expansion and traditional Medicaid. This is not one-
    sixth of the economy.
        There will be the inevitable comment that we are ending
    Medicaid expansion. Actually, a State could take the dollars
    that we are giving and continue the expansion program as they
    have it now. They have the flexibility, I can tell you. Despite
    me pointing this out, it will be said.
        To help States, many of which are not able to meet their
    expansion match in 2020, the Medicaid expansion match is
    waived. The flexible block grant functions like a combined
    1115/1332 waiver.
        We preserve protections like mental health parity,
    guaranteed issue, prohibiting charging women more, no lifetime
    caps.
        States applying for waivers must prove that the Americans
    with preexisting conditions have access to affordable, adequate
    coverage, period, the end. And you define ``affordable'' as
    ``able to afford.'' Contrast that with $39,000-a-year premiums.
        This raises an issue, perhaps to end here. Many on the left
    are threatened that we give States and patients the power that
    Obamacare usurped. Under this narrative, States are inept,
    corrupt Governors scheme to deprive the citizens of their State
    of protections, and patients only get better if told what to
    do. This amendment rejects that narrative.
        And by the way, partisan Virginia gets 4 billion more
    dollars; Florida, 15 billion more dollars; Missouri, 5 billion
    more dollars, increasing access to cancer screening and cancer
    treatment for folks in those States who currently do not have
    it. I wonder if those opposing this amendment care about those
    in that State, because right now, those in Virginia will have
    more for these tests.
        We need to pass Graham-Cassidy-Heller-Johnson, returning
    power to patients and States, while expanding access to
    coverage for millions.
        Thank you.
        The Chairman. Thank you, Senator.
        [The prepared statement of Senator Cassidy appears in the
    appendix.]
        The Chairman. Senator Santorum?

                   STATEMENT OF HON. RICK SANTORUM,
                A FORMER U.S. SENATOR FROM PENNSYLVANIA

        Mr. Santorum. Thank you, Mr. Chairman.
        It is an honor to be here before my former committee. And I
    am here because I am a father, a father of a child who, like
    many outside this room, is in a wheelchair because she cannot
    walk and she cannot talk either. So I am trying to speak for
    her and for others like her.
        I see the hysteria that has been developed around this
    bill, and it is really disturbing to me that what is a clearly
    responsible proposal that, as many on the right have
    criticized, keeps 90 percent of the taxes and 90 percent of the
    spending, is going to cause everybody who was ever covered by
    Obamacare to be without insurance, that just does not make any
    sense. It is irrational. It is not supported by any facts or
    any of the evidence.
        And it just shows the frustration that many Americans have
    outside of Washington in seeing something put together by, let
    us just say, not two of the most conservative members of the
    Republican caucus, Lindsey Graham and Bill Cassidy, who
    sponsored a plan with Susan Collins to try to get bipartisan
    support. These are the sponsors of this legislation, people who
    are not on the far end of the Republican Party, yet it is being
    treated as this draconian slashing.
        This is not the first time that I have had experience with
    this type of reaction to a change in entitlement programs.
    Twenty-one years ago I was in the United States Senate and had
    the privilege of managing the bill on the floor of the Senate
    to reform welfare. The very same organizations and groups that
    are out in the halls and others complaining about this bill
    were saying that people would be sleeping on grates and bread
    lines would be redeveloped and we would be cruelly cutting
    people off all of these services that they so badly needed.
        The reality is that we are doing the same thing in this
    bill as we did in 1996. That is the idea when I talked to
    Lindsey and Bill and others about this idea; it was based on
    the success of the 1996 welfare law, a bill that got bipartisan
    support.
        Even though there was hysteria, there was a recognition
    that this program was not doing as well as it could be and that
    there were innovations at the State level that could be
    replicated and done better, to care for people better, to get
    people off of welfare, that we should not measure the success
    of welfare as to how many people are on it, but how we
    transition them off and get them to work and how we lower
    poverty rates.
        And the same as here. It should not be how many people we
    are getting into a government program, but how much affordable
    insurance we are providing for an entire market, like myself,
    who is on the Obamacare exchanges and pays around $30,000 a
    year for our policy.
        Now, I do not know how families do that. I mean, that, to
    me, the idea that this is affordable, is ridiculous. It is not
    affordable.
        And so I came forward, based upon the information that I
    had and experience I had in working on welfare, and suggested
    that we can do the same.
        And I did, by the way, with welfare, when I was on the
    committee and even before, I had nine people in my office whom
    I hired who were former welfare recipients. I take this
    responsibility of getting engaged and involved in public
    policy, whether in office or out, that the primary purpose here
    is to make sure we have a system that works well for America.
        And the hysteria that is being developed here at a bill
    that, candidly, is modest in its reductions in spending, modest
    in its reductions in taxes, and even modest in the flexibility
    that we give to the States outside of the ACA to be able to
    provide care for those who are in need in our society who fall
    through the cracks----
        This legislation is in two parts: one is a block grant of
    the ACA monies, as Dr. Cassidy described, and the other is the
    Medicaid per-cap cap. As everyone knows, the Medicaid per-cap
    cap was proposed by President Clinton. Now it is seen as this
    draconian measure. The Medicaid per-cap cap ties the per-capita
    rate of growth of Medicaid at around the level of medical
    inflation.
        Now, we have advocates who have gotten up and said we need
    government-run health care for everybody and that is the most
    efficient and effective way. Yet when we put the cap on
    Medicaid at the rate of inflation for health care, we are told
    that this government program will collapse. How can you have it
    both ways, that government health care is the most efficient,
    but if you put it at the rate of medical inflation, which
    includes all these, quote, ``inefficient'' private plans, it is
    going to collapse? You cannot make that argument. You cannot
    say you are the best, but you cannot keep up with inflation.
        On the second, the block grant, it is very simple. We give
    States an enormous amount of money. People say, well, this
    would be going back to the old system. The old system did not
    have $1.2 trillion to be spent by the States to be able to make
    the system work.
        I look forward to the opportunity of getting into the
    details of how we designed this to make sure that States who
    expanded Medicaid are not disadvantaged over the long term,
    that we gradually ramp in the formula, that we do a lot of
    things that Dr. Cassidy and others have worked on to make sure
    that this is a fair system, that all poor people in America and
    those in the individual market get the opportunity to get some
    help from the Federal Government so we can have affordable and
    stable insurance markets.
        Thank you, Mr. Chairman.
        The Chairman. Well, thank you. That was very, very
    interesting, as far as I am concerned.
        [The prepared statement of Mr. Santorum appears in the
    appendix.]
        The Chairman. Let us turn to you, Mr. Smith, and take your
    testimony at this time.

     STATEMENT OF DENNIS G. SMITH, SENIOR ADVISER FOR MEDICAID AND
      HEALTH CARE REFORM, ARKANSAS DEPARTMENT OF HUMAN SERVICES,
                            LITTLE ROCK, AR

        Mr. Smith. Thank you very much, Mr. Chairman.
        It is a privilege to be with all of you today. And I am
    here to discuss the Graham-Cassidy-Heller-Johnson amendment.
    And I am also pleased to convey Governor Hutchinson's support
    for this proposal, as we believe that it makes a great deal of
    sense and will protect the interests of individuals on Medicaid
    as well as those who are subsidized in the private sector as
    well.
        In 2017, CBO estimates that on the Medicaid expansion, the
    premium subsidies, the tax credits, the cost sharing, we will
    spend about $111 billion, the Federal Government. In 2026,
    under the proposal, it will be $190 billion. That is a 70-
    percent increase in the amount of Federal spending available to
    provide coverage.
        In the original estimates, the Congressional Budget Office,
    when it modeled the Affordable Care Act for what the coverage
    would look like in 2017, in this year--so they modeled it 7
    years ago--what they predicted then was very much inaccurate in
    that CBO had in its baseline by 2017 that there would be 35
    million non-
    elderly individuals on the Medicaid program under current-law
    baseline. And under the Affordable Care Act, 15 million would
    be added to that number. And if you will recall, that is when
    Medicaid expansion was mandated under the legislation, which,
    of course, turned out not to be true.
        Today we have 69 million non-elderly individuals on
    Medicaid and CHIP, of which 13 million have been made eligible
    by the ACA. So the individuals that CBO predicted would be
    receiving subsidies over in the marketplace in fact are in
    Medicaid instead.
        This legislation puts those two populations together. So
    again, now we would form a pool of 22 million lives which are
    relatively young and healthy, and that would be the new pool.
        Again, everyone keeps talking about, how do we stabilize
    the premiums for this population? We keep trying to throw more
    money at it. Well, the solution is, put more people into it;
    that is what will truly stabilize the pool.
        Also, I have my remarks on the CHIP program. Again, I was
    privileged to be, 20 years ago, with Chairman Hatch and Senator
    Grassley at the time to help create the CHIP program, so I
    believe it is a great vehicle to use for that purpose, to build
    upon that. And it has the benefits of having a structure
    already in place.
        CHIP is a very popular program. People know what it is. But
    it is also a capped allotment to the States. It is flexibility
    to the States. It is deferring to the States on many of the
    decisions that have been made. And I would suggest CHIP has
    been wildly popular on a bipartisan basis for 20 years.
        The third point I want to talk briefly about is per-capita
    caps in Medicaid. We already have per-capita caps in Medicaid.
    Virtually every State that has an 1115 waiver agrees to a cap
    on the amount the Federal Government will give to that State to
    live under that waiver, including the State of Arkansas. We are
    living under a per-capita cap. If we exceed that cap, then we
    are at risk for every dollar above that cap.
        States will manage the programs to those caps. Those caps,
    by the way--the Office of the Actuary now produces an annual
    report on Medicaid spending. And in 2015, the actuaries made
    their projections out through the year 2024 for what Medicaid
    was going to be spending. Last year, they reduced their
    projected spending for Medicaid by $140 billion. Nobody is
    arguing that there is somehow $140 billion that has been lost.
        You have revised the baseline. The baseline changed. In
    many respects, the baseline is changing. It is lowering,
    because the States do not have their share of the funds to be
    able to continue to accelerate Medicaid spending at the rate it
    is.
        So, the consumer price index of medical inflation plus one
    for the disabled and elderly populations that the proposal
    provides for, when you look at the actuaries' report, that is a
    higher growth rate than what CBO is estimating that its per
    elderly and disabled beneficiary will grow by. So again, the
    reality is, slowing spending on a per-beneficiary basis is
    lower than what the bill is providing for.
        The last point is on work requirements, which are a feature
    of the bill, again, we have passed, with Governor Hutchinson's
    leadership. Work requirements received overwhelming bipartisan
    support in Arkansas. Again, I think that this is a vehicle that
    States will be able to readily adapt to, will be ready to put
    into place, and will continue the tradition of this committee
    in extending coverage to the most vulnerable Americans.
        The Chairman. Well, thank you so much.
        [The prepared statement of Mr. Smith appears in the
    appendix.]
        The Chairman. Ms. Miller, we will call on you now.

      STATEMENT OF TERESA MILLER, ACTING SECRETARY, DEPARTMENT OF
      HUMAN SERVICES, COMMONWEALTH OF PENNSYLVANIA, HARRISBURG, PA

        Ms. Miller. Good afternoon, Chairman Hatch, Ranking Member
    Wyden, and members of the committee.
        I sit here today honored to have this opportunity, but also
    very, very concerned about the potential for this legislation
    to become law and what that will mean for the millions of
    Americans who rely on the Affordable Care Act for quality
    affordable health insurance. Since passage of the ACA,
    Pennsylvania is experiencing an all-time-low uninsured rate. We
    just announced that we have gone from over 10 percent uninsured
    before the ACA to 5.6 percent today.
        As we face an opioid epidemic that is devastating our
    communities, 175,000 people have been able to access substance
    abuse treatment thanks to the ACA and Governor Wolf's Medicaid
    expansion. I could go on and on about all the benefits people
    in Pennsylvania and around the country have realized because of
    the ACA, but it is also important to point out that the ACA is
    not perfect.
        I had the opportunity to testify a few weeks ago before the
    Senate HELP committee about ways that we could work together to
    stabilize individual markets, which is really the limited area
    that needs attention. A group of insurance commissioners from
    red and blue States alike talked about targeted reforms that
    could be put in place to stabilize our markets to ensure the
    ACA works for everyone going forward.
        I was optimistic after that hearing because, for the first
    time in this debate, it appeared that Senators from both sides
    of the aisle were genuinely interested in focusing on the
    problem, the need to stabilize the individual market, and
    finding a solution to that problem, rather than using the
    problems in the individual market as an excuse to repeal the
    ACA entirely and, as the National Association of Medicaid
    Directors put it, ``make it the largest intergovernmental
    transfer of financial responsibility from the Federal
    Government to States in our country's history.''
        And yet now, I find myself here again talking about a
    proposal that would make draconian cuts to Medicaid and force
    Governors across the country to make the most gut-wrenching
    decisions they can possibly face.
        According to an analysis by Avalere Health, Pennsylvania
    would lose $15 billion in Federal funding in the next decade.
    Kaiser Family Foundation put the number at $22.7 billion. Our
    own analysis estimates we would lose $30 billion, assuming
    average cost growth. This forces Governors across the country
    to make impossible decisions. Who should receive health care: a
    child born with a disability, a young adult struggling with an
    opioid addiction, a mom fighting breast cancer, a senior who
    has worked hard all his life and needs access to quality health
    care to age with dignity?
        Having been a State insurance regulator in two different
    States and having spent time as a Federal regulator, I truly
    believe States are in a better position to make decisions
    impacting our residents. We know our markets better, we are
    more nimble and able to respond to issues impacting our
    consumers. So when we hear that you want to give us more
    flexibility, you do pique our interest.
        I gave the Senate HELP committee some ideas for ways the
    Federal Government could streamline the 1332 waiver process and
    make it easier for States to get these waivers. But cutting
    billions of dollars from Medicaid and giving States reduced
    funding in the form of block grants, funding that goes away
    after 7 years, is not the kind of flexibility that we are
    looking for.
        I have been thinking a lot over the past few days about
    what we would do in Pennsylvania if this bill becomes law. And
    honestly, I am really struggling to figure out how we would
    respond. We would have 2 years to completely revamp our health-
    care system, work with stakeholders to figure out what a new
    system could look like, develop whatever infrastructure would
    be needed, make system changes required, pass legislation, get
    any necessary Federal waivers, and a host of other activities.
        All of this would need to happen apparently without Federal
    funding to support these essential planning activities. The ACA
    gave States almost 4 years and a lot of funding to support
    their work. Oh, and after 7 years, the funding disappears and
    the State would be left holding the bag to fund whatever system
    we put in place. That alone makes it highly unlikely we would
    get anything in place in Pennsylvania by 2020.
        In my experience, State legislatures, they do not want to
    put a system in place with Federal dollars if we do not have a
    way to ensure it is sustainable after we lose those Federal
    dollars. But let me be clear. Providing implementation funding
    or extending this funding indefinitely into the future would
    not fix the insurmountable flaw in this bill: the staggering
    cut in Federal funding.
        Pennsylvania is facing a $2-billion structural deficit in
    our budget now. We do not have a balanced budget for this
    current fiscal year 3 months into it, and we certainly do not
    have the ability to cover the loss of anywhere from $15 billion
    to $30 billion in Federal funding over the next decade.
        We have had less than 2 weeks to analyze this bill, a bill
    that would have a devastating effect on the more than 3.2
    million Pennsylvanians with coverage through Medicaid and on
    the Federal exchange. Please do not paper over these draconian
    spending cuts, which will inevitably increase the number of
    uninsured under the guise of State flexibility.
        On behalf of Pennsylvanians, on behalf of children,
    seniors, individuals with disabilities, our most vulnerable
    populations, I implore you to return to the bipartisan process
    that the Senate was engaged in earlier this month and craft a
    compromise bill to stabilize the individual market and improve
    our current system.
        Thank you.
        The Chairman. Thank you.
        [The prepared statement of Ms. Miller appears in the
    appendix.]
        The Chairman. Ms. Mann, we will turn to you now.

       STATEMENT OF CINDY MANN, FORMER DEPUTY ADMINISTRATOR AND
    DIRECTOR OF THE CENTER FOR MEDICAID AND CHIP SERVICES, CENTERS
     FOR MEDICARE AND MEDICAID SERVICES, DEPARTMENT OF HEALTH AND
                     HUMAN SERVICES, WASHINGTON, DC

        Ms. Mann. Thank you. Good afternoon, Chairman Hatch,
    Senator Wyden, and distinguished members of the committee.
        This Nation has made enormous progress, increasing the
    number of people who have health insurance and moving health
    care to a system that provides greater value with lower total
    costs. But we still have a long way to go.
        Virtually every major health-care provider and health plan
    association and consumer group, from the AMA, the American
    Hospital Association and AHIP, to the American Cancer Society
    and the American Academy of Pediatricians--those are just some
    in the ``A'' category--have voiced opposition to the Graham-
    Cassidy proposal. None of these groups, however, would say that
    there is not a need for ongoing reforms and improvements in our
    health-care system.
        Graham-Cassidy, however, would inevitably take us backwards
    and in a reckless and dangerous manner. It would create chaos
    and uncertainty, new levels of marketplace instability, higher
    premiums and out-of-pocket costs for many, and an increased
    instability throughout our system. It would also, and probably
    most significantly, take away the financial resources and the
    certainty about those resources that are critical for States to
    maintain coverage and to continue moving forward.
        As the group of 10 Governors, both Republicans and
    Democrats, wrote earlier this month, Graham-Cassidy is not the
    answer. Instead, we need bipartisan efforts to make health care
    more available and affordable for all people, including
    America's taxpayers.
        My remarks look at the key implications of this proposal on
    Medicaid and the 73 million people covered by that program,
    focusing on three points. First, it is important to keep in
    mind that the
    Graham-Cassidy proposal builds on the Better Care and
    Reconciliation Act, BCRA, the bill that was voted down by the
    Senate in July.
        BCRA imposed deep cuts to the Medicaid program, and so does
    Graham-Cassidy. CBO estimated that BCRA would have cut Medicaid
    by $756 billion over 10 years, and those cuts grow over time
    because the per-capita cap included in both proposals gets
    tighter in the out-years.
        The cuts in BCRA to Medicaid come principally from changes
    to the Medicaid expansion funding and from the caps on the
    Federal funding for the program. Graham-Cassidy maintains and
    deepens the cuts to Medicaid expansion that were in the BCRA
    bill. Not only would States no longer get the enhanced funding
    that is provided under the ACA, but under the Graham-Cassidy
    proposal States would not even get funding at regular match
    rates to be able to cover very low-income adults.
        And Graham-Cassidy, like BCRA, would impose arbitrary caps
    on Federal funding for virtually every population covered under
    traditional Medicaid. That means the Federal Government would
    end its commitment to share the full cost of providing coverage
    for pregnant women, for children--Medicaid covers one out of
    three children in this country--and for people with
    disabilities and for the elderly.
        Six out of 10 dollars spent in the Medicaid program are for
    people over 65 and people with disabilities. If Congress adopts
    the Graham-Cassidy proposal, it is cutting and capping funding
    for the very beneficiaries whom the supporters of this
    legislation point to as those whom Medicaid ought to protect.
        My second focus is on the block grant that Graham-Cassidy
    creates in place of the Medicaid expansion dollars and the tax-
    cut subsidies and cost-sharing reductions.
        Let us start with basics. First, it is a block grant, which
    means the dollars do not grow based on actual cost of care or
    based on enrollment. Overall, at least looking at the version
    of the bill that was released on September 13th, the block
    grant cuts about $82 billion between 2020 and 2026. But if
    health-care costs are higher than projected--the need for
    coverage or subsidies is greater than anticipated--the gap
    between actual need and funding widens.
        The second basic fact is that the funding for this block
    grant, as has been pointed out, is time-limited. But let us go
    beyond the basics. Graham-Cassidy reshuffles the deck,
    allocating dollars not based on historic spending or projected
    need or costs, but to the point where everybody gets, every
    State gets, the same level of funding per poor person. You
    could say it creates a one-size-fits-all funding formula. The
    problem is, one-size-fits-all makes little sense.
        Our analysis in a report attached to my testimony is
    similar, directionally, to other analyses. Twenty-nine States
    would receive less Federal funding than they would under
    current law with an average reduction of 19 percent.
        In 2026, 18 States plus the District of Columbia would lose
    one-quarter or more of their funding, including six States
    represented on this committee: Delaware, Colorado, Michigan,
    New Jersey, Oregon, and Washington. Six States, including
    Alaska and Oregon, would see their funding cut by half or more.
        There would be adjustments, but in some cases, whether
    those adjustments are made and, in all cases, how those
    adjustments would be made would be left to the Secretary's
    discretion. States do not know and will not know what those
    allocations will be, but notably those adjustments have to be
    budget-neutral. Upward adjustment for one State means a
    downward adjustment for another State.
        The block grant does provide States with broad flexibility,
    except, of course, with respect to whether a State can continue
    to rely on Planned Parenthood clinics to provide women health-
    care services.
        But how many of us really believe that a State that loses
    one-fourth to one-half of their funding will be able to replace
    the lost coverage and to improve stability and costs in the
    marketplace? That kind of flexibility only means that States
    will be able to decide which groups of people will not get
    coverage, which services will not be covered, and how many
    people will see their premiums and out-of-pocket costs go up
    rather than down.
        Finally, I just want to touch briefly on the issue of
    implementation. Simply stated, Graham-Cassidy would create
    chaos in our health-care system with frightening implications.
        Twenty-three million people are projected to receive
    coverage through the marketplace and the Medicaid expansion in
    2019. On January 1, 2020, by the terms of this proposal, that
    coverage and those subsidies will end. It is simply impossible
    for States to make their plans and have new programs in place
    by then, even without considering that they will not know how
    much money that they have from year to year or whether they
    will have any money in 2027.
        On this point, let me quote Dr. Atul Gawande, who wrote
    that with respect to implementation, ``It is not just
    impossible; it is delusional.''
        There are no winners in this bill, but there are many who
    will lose, and many others who will be at grave risk. It is
    instructive to consider the array of special fixes in this
    bill. There are many, and they are growing with every version,
    all aimed at softening the blow for one State or another.
        Whatever else you might think about these special deals for
    certain States, they do help us appreciate just how flawed the
    underlying structure of this bill really is.
        Thank you for your time.
        [The prepared statement of Ms. Mann appears in the
    appendix.]
        The Chairman. Mr. Woodruff, we will take your testimony.

     STATEMENT OF DICK WOODRUFF, SENIOR VICE PRESIDENT OF FEDERAL
       ADVOCACY, AMERICAN CANCER SOCIETY CANCER ACTION NETWORK,
                             WASHINGTON, DC

        Mr. Woodruff. Thank you, Chairman Hatch, Senator Wyden, and
    members of the Finance Committee. I appreciate the opportunity
    to speak about the needs of cancer patients today and other
    patients with serious and chronic illness.
        But first, I want to say, as you have said, this committee
    has a long tradition of bipartisan achievement and workman-like
    effort. And passing the CHIP bill many years ago, funding it
    with the tobacco tax--that was a two-fer for cancer.
        And I am honored to be here before you today.
        Let me start with a short personal story. I am sure
    everyone in this room has one, given that one in two men and
    one in three women are diagnosed with cancer in their lifetime.
    My mother was diagnosed at the age of 48 with breast cancer. In
    1963, the standard treatment was a radical mastectomy and
    massive radiation. She survived and lived to be 93, which was a
    wonderful thing, but she was lucky.
        For 45 years thereafter, she lived with a preexisting
    condition. My dad had a good job with insurance that kept her
    covered until she reached Medicare eligibility, so she was
    lucky again.
        My point is, until 2010 cancer patients and survivors had
    to be lucky to get coverage and access to care. Those who had
    to buy in the individual market were mostly priced out of it.
    Others faced annual and lifetime limits on their benefits. And
    as a consequence, many families with cancer faced medical
    bankruptcy.
        That all changed with passage of the Affordable Care Act.
    Patients had certainty and stability. They could buy insurance
    that covered their care no matter their health status. Very
    low-income, working, single men and women for the first time
    had access to coverage through the Medicaid expansion.
        Yes, the current system has flaws. Premiums are far too
    high for some families. And 19 States declined to expand
    Medicaid, which has left over 4 million low-income citizens
    uncovered. That Medicaid patchwork created by the 2012 Supreme
    Court decision is revealing of what could happen if the Graham-
    Cassidy bill is passed, creating a new patchwork of standards
    in 50 States in both Medicaid and the individual market.
        The bill before you would completely restructure the
    individual markets and Medicaid, as others have said around the
    table here. And how that would come out in each State is not
    known.
        What is known is that the proposed cuts to Medicaid
    delivered through the block grants and per-capita caps will end
    Medicaid coverage for millions of working men and women and
    children and disabled citizens.
        The mandatory patient protections in current law that
    explicitly prohibit pricing based on health status, the
    essential health benefits, and the ban on lifetime and annual
    caps that are tied to those benefits, all of those would become
    discretionary depending on what State you live in, and now some
    States could decide not to cover even preventive services, like
    cancer screenings, routine mammography, or colonoscopy.
        Prevention is the key really to treating cancer, and it is
    really a way to have health care much less expensively if we
    encourage prevention.
        A couple of weeks ago I was struck by the common-sense
    statement that was made by former Governor and HHS Secretary
    Mike Leavitt during his testimony before the HELP committee.
    When he was asked about the appropriate balance between Federal
    and State involvement in health care, he said we need to have
    national standards and State solutions, because without a
    national standard that ensures adequate and affordable
    coverage, how do we really make sure that people get the
    treatment they need when they get sick?
        As others have said, the timeline written into Graham-
    Cassidy for each State to restructure Medicaid and redevelop
    their individual markets by 2020 is not realistic and not
    likely feasible. In the words of the State Medicaid directors,
    States will need to develop overall strategies, invest in
    infrastructure and systems changes, negotiate provider and
    managed-care contracting, et cetera, et cetera, et cetera. This
    group, it is said, is not a group with a reputation for
    hyperbole.
        We are worried at the Cancer Society for millions of people
    who may lose their insurance. Hundreds of billions of dollars
    will be taken out of health care if this bill passes.
        If the EHBs go away, so does the protection against annual
    and lifetime caps, because the caps are tied to those benefits.
    Insurers could be allowed to offer plans that do not cover
    treatment for all of the services that cancer patients need. In
    that situation, the plan they need may not even be offered or
    it may be too expensive for them to afford, and then they would
    go without coverage. And this is what happens: their cancers
    are discovered later, they are more expensive to treat, they
    have a lower chance of survival, their medical costs force them
    into debt, they forgo preventive care and cancer screenings,
    and we are right back to where we were 7 years ago.
        With health care, what people want is stability and
    certainty. Our goal is to relieve patients of their fear.
    Cancer is scary enough, but what is really frightening is not
    being able to afford to fight it.
        The American Cancer Society Cancer Action Network and our
    affiliate, the American Cancer Society, are nonpartisan
    organizations, and we believe the only way to resolve this long
    impasse over health care coverage is a bipartisan solution.
        We would like to work with the Finance Committee going
    forward and help you find solutions that improve the current
    health-care law, ones that make premiums affordable for all
    Americans who need health care.
        Thank you again for the opportunity.
        The Chairman. Well, thank you, sir.
        [The prepared statement of Mr. Woodruff appears in the
    appendix.]
        The Chairman. We are grateful for this panel. It has been
    an excellent panel.
        And let me just start the questioning by asking you,
    Senator Cassidy, can you please walk us through the changes
    made to the text that posted on your website this morning so we
    all have a clear understanding of the current language?
        Senator Cassidy. Yes. So what we found as we introduced our
    first bill is that the rate of inflation was far higher for the
    individual market and Medicaid markets than we had anticipated.
    And that rate of inflation did cause a transfer of dollars from
    those States which had expanded to those which had not. We want
    equity so that, no matter where an American lives, she or he
    can get the care they need, but we also did not want to see an
    abrupt change.
        So we did a couple of things to, frankly at the expense of
    the non-expansion States, prolong the glidepath to equity, so
    now equity only occurs out in 10 years, not in 6.
        Secondly, we capped the amount of money a State could see
    as an increase to 25 percent. So Mississippi, for example--that
    ends up going up dramatically because they are so low now--is
    capped at 25 percent per year. They do really well. The folks
    in Mississippi will have far more resources to screen and treat
    for cancer than they do now; but nonetheless, it prevents a
    dramatic shift for other States.
        And so in that way, secondly, we went around and we looked
    at some States--they were just outliers for whatever reason.
    Hawaii and Alaska have Federal poverty levels that are 1\1/2\
    times that of the other 48, but they only get paid by Medicaid
    as if they were the same as the other 48. So we actually, for
    those two States, we corrected the amount they get from
    Medicaid so that Hawaiians and Alaskans will have a more
    appropriate reimbursement for the costs in their State.
        We did other things like that, trying to minimize, whether
    it was a blue State or a red State, a problem they may have
    with this new formula.
        The Chairman. Let me ask you this, Mr. Smith. How can the
    Federal Government work with States to promote private-market
    coverage for low-income individuals while preserving Medicaid
    for the most vulnerable?
        Mr. Smith. I think, Mr. Chairman, States are already
    experimenting with those strategies now, including Arkansas, in
    which Arkansas elected to have the Medicaid expansion under the
    previous administration. We have continued to refine that and
    develop it. But the reality is, the public/private partnerships
    that we have been finding in Medicaid for the last 20 years,
    private-sector managed care companies, are now delivering a
    great deal of the services to the Medicaid population.
        In Arkansas, for the private, qualified health plans
    marketed on the exchange, 80 percent of the amount of subsidies
    is for a
    Medicaid-eligible population.
        So again, I think that where we are in these private/public
    partnerships--they have been underway for 20 years--there is a
    platform to build upon.
        The Chairman. Thank you.
        Senator Wyden?
        Senator Wyden. Thank you very much, Mr. Chairman.
        Mr. Chairman, first of all, when this hearing was
    announced, we set up on our side a website so we could hear
    from the American people. Almost 27,000 citizens commented.
        I would ask, per our agreement, unanimous consent that all
    emails sent to our site by the start of this hearing be entered
    into the record.
        The Chairman. Without objection.
        [The email responses can be viewed on the committee's
    website.]
        Senator Wyden. Thank you, Mr. Chairman.
        First of all, before I get into my questions, I want to
    make two points that I think my colleagues are going to echo.
    First of all, we feel very strongly on our side we ought to be
    working on a bipartisan basis today.
        The Chairman. I agree.
        Senator Wyden. There are two clear opportunities for the
    Senate to do that. The first is our bipartisan CHIP bill, where
    funding is going to run out at the end of the week. And the
    second is working to stabilize the private insurance markets.
    That is what we are for on this side of the aisle.
        And finally, we think this process has just been an
    abomination. We are talking about something that is going to
    affect millions of Americans. We do not have any objective
    information about what it is going to mean to people's
    premiums. We do not know what it is going to mean with respect
    to coverage. We do not know whether the health markets are
    going to survive in the next year. We ought to have that
    information. That is what you get if you take the time in the
    regular order.
        Now, Senator Cassidy, let me start with you. You managed to
    bring together people and organizations in the health-care
    field who rarely agree. I guess congratulations are in order,
    because they all think what you are talking about is a
    disaster. And they particularly agree that America's health-
    care system is going back into the business of charging folks
    with preexisting conditions more for health insurance.
        Now, I would like a ``yes'' or ``no'' answer to this
    question. The question is, do you continue to believe that the
    thousands of doctors and hospitals and patients' groups who are
    writing us saying that you are wrong on preexisting conditions,
    do you continue to believe as of today they are wrong? And that
    is a ``yes'' or ``no'' answer.
        Senator Cassidy. That is begging the answer. I think if you
    are in an orange State in which you did not expand Medicaid,
    so, therefore, the patients and hospitals in your State do not
    get benefits, if you are in Maine or Missouri or Florida or
    Virginia, you are pleased about this bill.
        Senator Wyden. Colleague, I asked you for a ``yes'' or
    ``no'' answer.
        Senator Cassidy. And so the simple answer--but you are
    begging the answer, and I think it is more important to have
    the right answer than the one that is begged. And I do not mean
    to be disrespectful.
        The Chairman. Yes, he should----
        Senator Cassidy. But the Tennessee Governor said this is a
    gold mine or a Godsend or something like that for Tennessee. If
    you are a doctor or hospital in Tennessee or Missouri or Maine,
    you are so pleased about it.
        Now, if it is a national association----
        Senator Wyden. Mr. Chairman, let the record show that our
    colleague does not want to answer the question. And it appears
    to me that the revised bill, the one we got this morning,
    indicates that a State could allow insurers to set higher
    premiums based on a person's health status.
        Senator Cassidy. That is not true, by the way.
        Senator Wyden. Now, what I would like to do----
        The Chairman. Well, let me----
        Senator Wyden. You are entitled to your opinion, you are
    not entitled----
        The Chairman. Senator, let me just interrupt for a minute,
    and I will give you the extra time.
        Look, I want our colleagues treated with great respect. It
    is not easy for him to testify on this, although it is because
    he is a doctor and he understands this probably better than
    anybody in this room, or at least any of us, although I was a
    medical liability defense lawyer, so I am not some neophyte
    here. And I have probably passed more health-care bills than
    anybody, certainly in the Senate.
        So let us show some respect for Senator Cassidy. This is
    not easy for him. The fact that you disagree with him, that is
    fine. But he ought to be able to disagree with you also. But go
    ahead, we will give you back your time.
        Senator Wyden. Mr. Chairman, one of our past great
    chairmen, Pat Moynihan, said everybody is entitled to his own
    opinion, but not his own facts. So let us hear from the
    American Cancer Society with respect to the real facts. They
    have a lot of members who understand the hurt that comes from
    being discriminated against for having a preexisting condition.
        Mr. Woodruff, what do you think with respect to this bill
    and what it is going to do to people with a cancer fight on
    their hands?
        Mr. Woodruff. Well, it does not protect them, Senator. It
    basically makes the patient protections that were enacted into
    law in the Affordable Care Act discretionary on the part of
    each State. And each State can decide to keep those patient
    protections or not.
        But what is important about what the act achieved is, it
    created a definition, a national standard for what is adequate
    insurance and what is affordable.
        And so with the essential health benefits, we actually have
    an assurance that when you buy insurance, it is going to cover
    the services that you need when you are sick, whether you have
    cancer or any other disease. The essential health benefits are
    there to protect you.
        Senator Wyden. Thank you.
        Mr. Woodruff. Sure.
        Senator Wyden. And I want the American people to understand
    the consequence of that statement. The Cancer Society knows
    something about what it means for patients to get clobbered by
    an extraordinary illness, and what they have said is, this
    opens up the door to charging those people more.
        Now, let me ask one other question if I might, Senator
    Cassidy. We are trying to make sense out of all the bills that
    have been released. So here is the first bill. This was posted
    on your website on September 13th. This is the second bill that
    was on Senator Graham's website. That was on September 13th. We
    got a third version last night at 7:30, and we got a fourth
    version last night at 7:50, and then we got a fifth version at
    9:23 in the morning.
        Now, is this bill the one that the United States Senate is
    going to actually be voting on? Because I think the American
    people would like to know. We are on the cusp, we are on the
    eve of voting on this extraordinary piece of legislation. We
    are trying to sort out what it is people are even going to vote
    on, let alone the fact we do not know what is going to happen
    to their premiums, we do not know what is going to happen to
    their coverage, we do not know what is going to happen to the
    individual markets. Is this what we will actually be voting on?
        Senator Cassidy. A couple of things, Senator Wyden, I----
        Senator Wyden. That is a ``yes'' or ``no'' answer,
    colleague.
        Senator Cassidy. Can I say something, please?
        Senator Wyden. Of course.
        Senator Cassidy. I apologize earlier if I was rude to you.
    And I am sorry; I did not intend to be. The last version was
    correcting drafting errors; 99.9 percent the same, it just
    corrected drafting errors.
        And lastly, I will say it is 148 pages, not 990 pages as
    was the Affordable Care Act. So the American people should be
    able to read this and comprehend it.
        Senator Wyden. So is this the last version?
        Senator Cassidy. Yes, I believe so. I mean, there might be
    a drafting error. I hope correction of a drafting error does
    not constitute a whole other version; it is just, like, a
    drafting error.
        Senator Wyden. All right. Again, I want to highlight,
    colleagues, we have one of our colleagues--and I want to treat
    every member of the Senate with the opportunity to be heard,
    but we got this at 9:20. I just do not think when you are
    talking about a bill of this magnitude and our colleague saying
    he believes that this is the final version, that that is good
    enough when we are talking about putting at risk millions of
    Americans.
        Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator.
        Senator Grassley?
        Senator Grassley. First of all, for the people who
    introduced this bill, I want to thank you for your leadership,
    truly improving the American health-care system.
        The point has been made--I think Senator Wyden made a point
    about all the stakeholders who are involved in this bill and
    against it. They have concerns about it. I think that those of
    us in Washington know that when all those strong forces speak
    up, it is to protect the status quo or protect their interests;
    it really is not about providing adequate health care for
    Americans.
        What I care about is what happens to Iowans. Obamacare has
    failed in Iowa. There is only one company planning to offer
    insurance in 2018 in Iowa. That company's premiums are well
    over a 50-percent increase. People in Iowa tell me their copays
    and deductibles on Obamacare make it too expensive to use.
    These are issues that must be addressed.
        Today, despite our ideological differences, we are able to
    have a discussion about a path forward.
        Dr. Cassidy, if I could have your attention, does this bill
    provide more dollars in 2026 in Iowa than it receives today in
    Medicaid subsidies and reinsurance?
        Senator Cassidy. It does.
        Senator Grassley. Well, obviously, it is not a cut then. Is
    this not slowing the rate of growth?
        Senator Cassidy. It does slow the rate of growth across the
    country. It does.
        Senator Grassley. Doesn't everyone agree we need to slow
    the rate of growth in health-care spending?
        Senator Cassidy. Apparently not everyone, but I would.
        Senator Grassley. Okay.
        Senator Cassidy. And by the way, I also say that I have
    words from Senator Wyden, when he previously introduced a
    Medicare bill, in which he said a cap on growth serves as a
    backstop, and the best way to hold down health-care costs is to
    give Americans the ability to hire and fire their insurance
    company.
        So I think that these caps on growth have been something in
    the past which have had bipartisan support.
        Senator Grassley. To you also, do States have the right
    incentives under the current Medicaid program matching-funds
    system to control costs by coordinating care and fighting
    fraud?
        Senator Cassidy. You can empirically say they do not, that
    it is a cost-plus program: the more the State spends, the more
    they get. The only limit is on the ability of the State fisc to
    support their end of the match.
        Senator Grassley. Lobbyists for the American Hospital
    Association, the American Medical Association, the AARP, and
    the insurance companies all endorsed Obamacare. Could you say
    that these folks have a financial interest that does not take
    into account individuals in Iowa?
        Senator Cassidy. If you look at the stock prices of
    insurance companies, pharmaceutical companies, and for-profit
    hospitals since Obamacare passed, they have done extremely
    well. In parallel, premiums have risen for those who do not get
    subsidies, and tax outlays have risen for the American citizen.
    There is a direct relationship between the two. They have done
    extremely well under the Affordable Care Act.
        Senator Grassley. Okay. I have time left for three
    questions, so I hope I can have short answers.
        I want to ask, Mr. Smith, is Medicaid sustainable at its
    current inflation rate?
        Mr. Smith. Whether you look at the Government
    Accountability Office or the National Association of State
    Budget Officers, the answer would be ``no.''
        Senator Grassley. Ms. Mann, is Medicaid sustainable at its
    current inflation rates?
        Ms. Mann. States are working very hard right now and have
    been to be able to improve their programs through better
    delivery of care and different payment mechanisms that reward
    value rather than volume. Taking away the foundation of
    coverage will only make costs grow because people only come in
    when care is needed and more expensive.
        So we need to control the rate of growth, Senator, but we
    need to do that in a way that improves care rather than takes
    care away.
        Senator Grassley. The same question to you, Ms. Miller. Is
    Medicaid sustainable at its current inflation rates?
        Ms. Miller. Thank you, Senator. I would echo Ms. Mann's
    comments and also say I think this whole debate for the last
    several years has been about coverage, and we have not been
    talking about the cost of health care. At the end of the day,
    insurance is a reflection of the cost of health care. So if we
    do not have a debate in this country and a discussion about how
    we get at the underlying costs of care, we have a major
    problem. That is really the debate we should be having and the
    discussion we should be having.
        Senator Grassley. Okay.
        The Chairman. Senator Stabenow?
        Senator Stabenow. Well, thank you very much, Mr. Chairman.
        I have so much to talk about, I am not sure where to begin.
    And I did want to talk about specific provisions.
        And thank all of you for being here.
        But I do feel like I need to talk numbers, even though this
    has got to be about people, not numbers. Let me just say, the
    truth of the matter is, when we cut down the number of people
    walking into emergency rooms who do not have insurance, which
    is what has happened in Michigan, 50 percent fewer people
    walking into the emergency room who cannot pay, the State of
    Michigan is saving money.
        Our Republican Governor working with Democrats and
    Republicans in the legislature did the right thing, made sure
    that people who are minimum-wage workers could receive health
    care and take their children to the doctor. And what has
    happened? We have saved $435 million in taxpayer money because
    people can go to the doctor instead of using the most expensive
    way to get health care, which is the emergency room.
        Let me also just say that it just came across the news that
    Standard and Poor's has now said that this bill would cost
    580,000 jobs in 2027--580,000 jobs--so that is something we
    certainly want to look into.
        I think I want to take just a moment to go to this whole
    question of whether or not this, as Senator Santorum said, is a
    modest change--and welcome back to the committee--a modest
    change or, as Ms. Miller said, a staggering cut, because that
    is a pretty big difference.
        And Senator Cassidy has indicated that, well, it is a block
    grant, Graham-Cassidy is a block grant, and after 10 years we
    can just continue it like we do other block grants.
        Well, here is the reality. In 10 years, to continue that
    block grant would cost $190 billion for that next year at level
    funding. The entire Health and Human Services budget for our
    country is $164 billion. So if we stopped doing everything else
    in education and health and human services, you could not pay
    for extending that block grant. It is not believable. It is
    just not credible.
        And I want to show one other thing. These are the
    staggering numbers for me in Michigan, because the cuts to
    Michigan when this is fully implemented, according to Avalere,
    are $140 billion--$140 billion. Our Governor just signed next
    year's budget, $56 billion. There is no way--there is no way--
    that we will not see people's health care, nursing home care,
    children's health care, cut as a result of this bill.
        Let me get into specifics. And let me talk about something
    near and dear to my heart, and that is, under essential
    benefits we have said that maternity care would be covered. And
    as a result of that--and I do have to say that maternity care
    was a major debate in this committee as one of the 10 essential
    health benefits, trying to make sure that just being a woman
    would not be viewed as a preexisting condition or somehow women
    have to pay more for a rider if a young family wants to have a
    child.
        Interestingly, my staff tells me it was 8 years ago today
    in this committee when a former colleague from Arizona and I
    had a debate back and forth about whether or not we should
    cover maternity care. He said he did not need it, and it should
    not be covered. I reminded him that his mom probably did. And
    so we ended up putting it in.
        And so now here we are. We have a situation where we could
    very easily be going back to pre-health-reform days when in
    Michigan only 4 percent of the plans that a young couple could
    get on the individual market would cover maternity care.
        And we know from studies that young couples get married and
    may not be planning on having a child for a long time and then,
    oops, more than half the time there is an unplanned pregnancy.
    And so then she has a preexisting condition, and prior to the
    Affordable Care Act could not find any care.
        We also know that to get an average coverage rider at that
    time was over $17,000. If you could not find coverage, you
    would be paying from $30,000 up to $50,000 out of pocket.
        And so, Ms. Miller, I wonder if you might respond to the
    issue of maternity care and your experience as an insurance
    commissioner. Can you talk about what the individual market
    looked like for women a few years ago before maternity coverage
    was a basic benefit?
        Ms. Miller. Thank you, Senator. And I think my experience
    is similar to what you just indicated. I think women before the
    ACA, if they had coverage in the individual market, often did
    not have an option to purchase coverage that included maternity
    as a benefit.
        We have a lot of discussions about what should be in the
    essential health benefits package, and this bill obviously
    gives States a lot of latitude to waive those essential health
    benefits. But where I struggle is, when you start looking at
    those essential health benefits, I do not know which one is not
    truly essential. And maternity coverage is certainly one of
    those benefits that, in my mind, is absolutely essential.
        And I worry that if we go back to the world that we had
    before the ACA, where women in the individual market could not
    get coverage to cover maternity care, then they are left paying
    out-of-
    pocket tens of thousands of dollars if they have a baby. And I
    think then we return to a world where we see people going
    bankrupt because they simply cannot pay for the medical bills
    that they have.
        Senator Stabenow. Thank you very much.
        Thank you, Mr. Chairman.
        Senator Roberts [presiding]. The acting presiding chairman
    recognizes Senator Roberts.
        Thank you, Mr. Chairman. [Laughter.]
        Fact: The Affordable Care Act----
        Senator Bennet. I object. Just kidding. That was a joke.
    [Laughter.]
        Thank you, Mr. Chairman.
        Senator Roberts. Would the timer please not count the
    gentleman from Colorado's untimely insertion of his remarks?
        This is about much more than trying to fulfill campaign
    promises, I think. Simply put, the Affordable Care Act is not
    affordable. It is failing the people, the very people it
    promised to help. Insurers continue to pull out of markets,
    then for their coverage in States, they are requesting dramatic
    premium increases again for next year.
        In Kansas, premiums have doubled since the law has been in
    effect. Next year, if we assume all the plans have filed rates
    and the States sign the final contract in the next few days,
    all Kansans will have just two options of insurance carriers on
    the exchange, and one is on a teeter-totter. They may also face
    premium increases of up to 29 percent.
        When I was back home at the State fair in Hutchinson, KS
    just a couple of weeks ago, there was nothing but concern and
    frustration and, yes, anger from my constituents over the law's
    failures and questions, if not demands, as to why we here in
    the Senate have not successfully passed reform.
        Now, I do believe, as has been pointed out, that we reached
    bipartisan agreement that the law is not working. Over in the
    HELP Committee, as has been pointed out, we have held numerous
    hearings over the past several weeks to review proposals to
    address premiums and stability in the individual market next
    year. Unfortunately, many of our colleagues simply wanted more
    money to patch this problem, not proposals to address many of
    the law's fatal flaws.
        There is another alternative out there. A longtime champion
    of single-payer, Senator Bernie Sanders, has recommended
    Medicare for all, government-run health care and has
    reintroduced his proposal with 16 Senators of my friends across
    the aisle endorsing that idea.
        I am continuing to review the proposal before us from
    Senators Graham and Cassidy and others, getting feedback from
    actuaries at the Congressional Budget Office and, most
    importantly, Kansans. What I am positive of is that this
    proposal that we have before us certainly is better than
    socialized medicine.
        Senator Cassidy, one provision that is included in your
    proposal, and many of the other proposals Congress has
    considered over the last year to address the increasing growth
    in the Medicaid program--I am being repetitive, but I think it
    needs to be repeated--is switching from an open-ended
    entitlement to what is known as per-capita caps.
        Would you characterize such a reform proposal where
    spending continues to increase every year, every year, as
    slashing the program?
        Senator Cassidy. No.
        Senator Roberts. While its inclusion in the debate
    surrounding the Affordable Care Act has led many to believe
    this is a Republican-only idea, it is not. It was actually
    something proposed by former President Clinton, embraced by
    former Chairman Baucus of this committee, then-Senator Biden
    and Senator Patty Murray.
        Our Kansas Medicaid folks tell me they estimate Medicaid
    spending in our State will increase 3 percent a year over the
    next few years.
        Senator Cassidy, what is the growth rate in your proposal
    for my State?
        Senator Cassidy. There are two aspects to your State. In
    the traditional block grant, if you will, Kansans will have
    lots of money for cancer screening, et cetera. In Kansas under
    our proposal you will go from receiving $2.9 billion from 2020
    to 2026 under current law to $4.7 billion from 2020 to 2026 to
    provide cancer screening and cancer treatment for lower-income
    Kansans.
        Senator Roberts. Is it fair to say the Kansas cap is in
    fact higher than what they currently spend?
        Senator Cassidy. Yes. You can also supplement, if you will,
    the traditional Medicaid budget with the extra dollars that
    Kansas is receiving. And you have the flexibility to do that as
    well.
        Senator Roberts. Let us go to the ``yes'' or ``no''
    questions, but you can cheat on that a little bit. Are
    dependents up to 26 still allowed to remain on their parent's
    plans?
        Senator Cassidy. Yes.
        Senator Roberts. Will mental health parity requirements
    still be in place?
        Senator Cassidy. Correct.
        Senator Roberts. Let us say a State does submit a waiver to
    redefine the essential health benefits. That has been a
    concern.
        To Ms. Miller and to Ms. Mann, would prior State-mandated
    benefits still be in effect, or are we looking at a Wild West
    like some are claiming?
        Senator Cassidy. No--one, there is the supposition that
    Governors are not going to take care of the people in their
    State, which kind of underlies all these questions by some who
    have opposed the bill. I disagree; I think Governors want to
    take care of the folks in their State.
        But if they apply for a waiver, the statute specifically
    says that the Governor must establish that those with
    preexisting conditions have access to, quote, ``adequate and
    affordable coverage.'' If they fail that, there is a provision
    in which the Secretary of HHS can pull dollars back, both deny
    and pull dollars back, if they misuse the funds by not
    providing access to adequate and affordable coverage.
        Senator Roberts. Senator Carper?
        Senator Carper. Thanks very much.
        Welcome to all of our witnesses. Thank you so much for your
    great testimony, your presence today.
        I have a friend. You ask him how he is doing, he likes to
    say, compared to what? And I would like for us to go back
    about, oh, gosh, 8 years or so ago, to the time we spent in
    this room debating the Affordable Care Act. We did not have 1
    day of hearings. We had, as I recall, 97 hearings, roundtables,
    and walk-throughs on health care reform--97.
        The Senate Finance Committee itself did 8 days of markup on
    the legislation. I think 130 amendments were considered. We
    actually had the folks who run CBO here at this table to tell
    us what the effect would be on our budget if the Affordable
    Care Act were adopted. And we were told that under their score,
    which they actually had time to produce, the budget deficit
    would be reduced in the first 10 years by $130 billion and the
    second 10 years by $1 trillion.
        During the course of the debate here in this committee and
    the Health, Education, Labor, and Pensions Committee, some 300
    amendments were offered, 160 Republican amendments adopted.
        The Senate then spent 25 consecutive days in session on
    health-care reform, the second-longest in the history of our
    country.
        We are here for 1 day of a hearing--1 day.
        You ask my friend how he is doing, he says, compared to
    what? Well, how about compared to what you participated in, Ms.
    Miller, in the last several weeks before the Health, Education,
    Labor, and Pensions Committee? They did not just have one
    hearing. Senator Alexander and Senator Murray had 4 days of
    hearings. Governors, insurance commissioners, providers, health
    insurance companies, health economists from all over the
    country--4 days. And those were preceded each day by
    roundtables, bipartisan roundtables where people like us who do
    not serve on the HELP Committee could actually meet with and
    question the witnesses, including you. That is what we did.
        This is an unprecedented effort. One of the things that I
    take my hat off to--and I think our two Republican colleagues,
    one currently here and one who used to be here, with whom I
    worked on welfare reform, a bipartisan effort, look for a panel
    of witnesses to be able to unite us. And I would say this
    proposal from my friends has united some 400 organizations,
    health-care organizations and groups--I have never seen a
    coalition like this in my life.
        Maybe they are all wrong. Maybe they are all wrong. They
    stretch from coast to coast, every nook and cranny. But they
    say, please do not do this, slow down, hit the pause button,
    and do what Ms. Miller has suggested over and over again and
    which our colleague John McCain suggested again as recently as
    last week.
        One of the things that is missing here is--Obamacare, where
    did it come from? It came really, initially, from the Heritage
    Foundation. They were asked to develop a market-based
    alternative to Hillarycare, and they did. It was introduced in
    the United States Senate as legislation by John Chafee,
    Republican from Rhode Island, cosponsored by two of our
    colleagues here. The senior two Republicans on this committee,
    Orrin Hatch, Chuck Grassley, cosponsored that legislation.
        It is called Obamacare. Barack Obama had nothing to do with
    its creation. This is a Republican invention. And frankly, as
    one Democrat, I thought it was a pretty good invention. It is
    kind of like Dr. Frankenstein operating on his patient and
    trying to kill it. Well, why do we not fix it?
        And let me say, Ms. Miller, during the debate and the
    hearings that you have participated in, what were some of the
    good ideas to fix that which the Republicans initially created
    and now call Obamacare? What are some of the cures?
        Ms. Miller. Thank you, Senator. I think what we heard from
    Commissioners from red States and blue States is, you know, the
    problems with Obamacare are really just in the individual
    market. And most of the people in that market have access to
    financial assistance, so the law is actually working well for
    them. It is really for the people who are not getting financial
    assistance that it is not working well.
        But I think what you heard from all of us, whether we are
    from a red or blue State, is that continuing to pay cost-
    sharing reductions, CSRs, implementing a reinsurance program,
    ensuring that we have an effective mandate in place, making
    sure we get more young, healthy people into the pool, and then,
    importantly for our whole system, trying to figure out how we
    can get at the underlying costs of care and try to reduce
    those, those are things I think we could all get behind.
        And there is a path to a bipartisan solution here to fix
    the individual market, which is really where the problems are.
    If we all came together, I know we could get there. And I think
    we outlined that in the HELP Committee.
        Senator Carper. Yes. Colleagues, I was in Boston. I was in
    Boston last Friday, and I talked to a number of people there
    about Romneycare, which is really based on the Heritage ideas.
    And I said, how are you guys doing with the Romneycare up here?
    They said, 98 percent of our people are covered. The increase
    in our premiums for the last year was 4 percent. And one of the
    reasons why is because they have a healthy mix of people to be
    insured and they have a lot of competition within the
    exchanges.
        That is what we need to do, and we have to fix this. The
    idea of simply doing this, the legislation that is before us
    today, and not stabilizing the exchanges, which are eminently
    stabilizable, eminently so, is a big mistake.
        Thank you.
        Senator Roberts. Thank you.
        The distinguished Senator from Ohio, Senator Portman.
        Senator Portman. Thank you, Mr. Chairman.
        And to my colleague, Mr. Carper, nobody is more focused on
    a bipartisan solution than you. I get that.
        I will say that the experiment in Massachusetts was what
    they wanted to do. And with a lot of flexibility they were able
    to put together a plan that works for them. Their costs are
    also very, very high, their health-care costs are probably some
    of the highest in the country. But that is how they chose to do
    it.
        And I think what has been missing a little bit in this
    debate is, you know, what this is all about. And it is a very
    different proposal than the proposals that we have been looking
    at previously.
        This is one reason that Senator Graham and Senator Cassidy
    have received some heat from conservatives, because it takes
    the funding in the Affordable Care Act and it sends it back to
    the States and gives the States the flexibility to be able to
    do what they think is right for their citizens and to be able
    to more effectively cover low-income citizens in those States.
        I totally agree with what Ms. Miller and Ms. Mann,
    Democratic witnesses, this morning have said in terms of
    getting at the underlying costs of health care. I would just
    suggest that one way you are going to get at the underlying
    costs of health care is to give the States that flexibility to
    be able to get at it. And we seem to be sort of talking past
    each other a little bit, but that is fundamentally what this is
    about.
        Yes, there is a change in traditional Medicaid as well. And
    we can argue about that. I mean, as Senator Graham said
    earlier, if you do not do something on Medicare and Medicaid,
    it takes up the entire budget within 30 years. I mean,
    everybody, I think, acknowledges we have to do something on
    entitlements, I hope. If not, we have to figure out an entirely
    different way to get revenue in this country.
        But even there, again, there has been some criticism from
    the right saying, you know, this is essentially taking the
    existing costs and continuing them. I mean, if you look at the
    per-capita cap, that means that it increases by population, so
    the traditional Medicaid does change, but it goes up by
    population. But second, there is an annual adjustment by
    inflation, and it is medical inflation and medical inflation
    plus one.
        What CBO projects for the rate of growth with regard to,
    for instance, the blind and disabled category under Medicaid is
    actually slightly less than what these guys are proposing for
    their per-
    capita program and the annual increase in Medicaid in that
    category, because it is M and M plus one--3.7 percent.
        So it is actually a proposal that has been a little bit
    mischaracterized. But let me just talk about why we are here
    then. I mean, what is the problem?
        And you all hear it, because you all have individuals in
    your States who depend on the individual market--small
    businesses, families. I got an email from a guy named Dean. He
    is a guy who lost his job back in 2009, he finally found a plan
    that worked for him, then the Affordable Care Act comes in, and
    he loses his plan. He is now paying, according to Dean, twice
    as much for a plan that has less benefits for him and higher
    deductibles.
        Mike from Westlake told me recently, his health-care
    insurance rate for single employees under 30 went from 198
    bucks a month to 560 bucks per month. We just had a small-
    business roundtable on Friday in Ohio. Health-care costs were
    obviously a huge topic for them, and no wonder.
        Joanne from Dublin sends an email saying she feels as if
    she does not have health care at all because, under the
    Affordable Care Act, her deductible has gone up to $11,000 for
    a family. ``We will never reach that deductible,'' she says.
    ``I do not have health care.''
        So here are the numbers from Ohio. And I do not know what
    your States are like, but we just a couple of weeks ago
    published the numbers for 2018: 34-percent increase. Who can
    afford that? To these small businesses, what is our answer? And
    so the status quo is not working.
        And by the way, I agree with what Senator Carper said about
    the CSRs, these cost-sharing reductions to be put in place to
    help with stabilization. If we do that in Ohio, the insurance
    companies say it will be a 23-percent increase. So it helps,
    but it is still totally unacceptable.
        So I guess to you, Mr. Smith, because you are one of these
    experts who is dealing with this every day: can you explain how
    this block grant model would help someone I have talked about
    like Mike or Joanne or other folks in Ohio who are seeing their
    costs just skyrocket under the Affordable Care Act?
        Mr. Smith. Yes. Thank you, Senator. Again, I think that, in
    giving the flexibility back to the States, I think we ought to
    judge what States will do on what they have actually done. And
    again, I would point out CHIP as being a very good expression
    of that, where they had tremendous flexibility in defining what
    the benefit package was, defining cost-sharing, et cetera, and
    States put their efforts into competition, into good,
    comprehensive health care, and also into trying to be as
    efficient as possible with those.
        Again, I think that, as I pointed out, the CBO got the
    insurance pool so vastly wrong, because the subsidized pool
    turned out to be much smaller and the Medicaid pool turned out
    to be much larger. This proposal puts those pools together, and
    bringing those healthy lives into a larger pool is what is
    going to help stabilize premiums.
        Senator Portman. Mr. Chairman, my time is expired. I look
    forward to a second round of questions. I am going to talk more
    about the formula. So we talked about the theory of getting
    back--I do continue to have concerns, as you know, Dr. Cassidy,
    on the formula, and I want to talk to you more about that and
    how it affects the various States.
        Thank you, Mr. Chairman.
        Senator Roberts. Thank you, Senator.
        Senator Cardin?
        Senator Cardin. Thank you, Mr. Chairman.
        I want to thank all of our witnesses for being here today.
        I ask consent to put into the record, Mr. Chairman, letters
    that I have received from people and groups in Maryland in
    opposition to this bill.
        Senator Roberts. Without objection, so ordered.
        [The letters can be viewed on the committee's website.]
        Senator Cardin. I want to point out that the process being
    used here today--I want to just make it clear. We are 8 months
    past the time Congress, the Senate, passed the budget that we
    are now reconciling to with this amendment. We have finished
    the debate time on the floor of the United States Senate. We
    have had no committee markups, no chance for amendments. We do
    not have a CBO score on Senator Cassidy's proposal.
        We do know, though, that tens of millions of people will
    lose their coverage, premiums will go up, and the quality of
    coverage will go down. We do know that.
        So, Ms. Miller, I want to concentrate on comments that have
    been made here. Senator Cassidy, I think, correctly identified
    the problem. We have a problem in the individual marketplace
    with individuals who are not receiving subsidies. And all the
    examples that Senator Portman just gave fall into that
    category.
        Now, in my State, I believe that is about 1 percent of the
    population. Now, that is a significant number. I am not trying
    to underestimate the problem. But could you just confirm
    whether the numbers I am talking about are correct?
        Ms. Miller. Yes, Senator. In Pennsylvania, we estimate that
    that population is between 1 to 2 percent of the population. So
    as you said, very small, but very important, because they are
    buying coverage on their own, but very small.
        Senator Cardin. So the proposal that is being brought
    forward, though, will affect tens of millions of people,
    because tens of millions of people are going to lose their
    coverage, many others are going to lose the quality of their
    coverage, and we are going to see significant cost shifting for
    those who do not have health coverage.
        Mr. Smith, I think, correctly analyzed what the States are
    going to have to do. And I am going to use his language. He
    says they will manage to the cap, and I think that is accurate.
    States have budgets; they have to comply with their budgets.
        States have already shown great initiative in delivery
    system models to try to bring down costs and make the system as
    cost-
    effective as possible. So what is left to manage to the cap
    seems to me to be two major factors: reducing eligibility,
    cutting people off the Medicaid rolls, and then, since they no
    longer have the mandate on essential health benefits,
    eliminating certain benefits that are currently covered.
        Are there other options available that I do not see?
        Ms. Miller. When you are trying to cut the dollars out of a
    program like we would be doing, you really only have three
    levers. You can reduce the number of people receiving services,
    you can reduce the services that you are providing, or you can
    reduce payments to providers. And those are really your
    options.
        Senator Cardin. So that is how you manage to the cap. So I
    am just going to--one of the individuals in Maryland whom I was
    with today, Peggy Roche, was talking about her daughter who has
    absence epilepsy. And she is very concerned. You gave some
    genetic examples of families that have children that are born
    with disabilities and how they are going to be at risk because
    the State in managing to the cap may have to limit the amount
    of services they provide to these high-cost individuals.
        So we had today a New Jerseyan, Alison Chandra, who
    identifies philosophically with pro-life, whose child was born
    with a rare birth defect heterotaxy. There was not a dry eye in
    the room as she explained what she is going through.
        But she said she knew at least this Nation would take care
    of her child so she would not have to go into bankruptcy, that
    she had a protection that was out there. Are we not in danger
    of losing that protection that is out there where we say every
    child, every person is entitled to make sure that there are
    benefits available? Is that not lost under this proposal?
        Ms. Miller. I believe it is.
        Senator Cardin. And I could go through those who are
    suffering from the opioid drug addictions. We know before the
    Affordable Care Act that the programs did not cover those
    services. That is certainly at risk as the State manages to the
    cap. Would you agree with that?
        Ms. Miller. That is true. And I think it was brought up
    that mental health parity stays in place, but mental health
    parity does not guarantee access to coverage. It requires
    parity if you have the coverage to begin with, but that would
    not be guaranteed going forward.
        Senator Cardin. As Senator Carper pointed out, this
    proposal does not even deal with that 1 percent problem,
    because there is nothing in this bill that shores up the
    individual marketplace to deal with the specific problems that
    those who are trying to repeal the Affordable Care Act continue
    to monitor. These are real issues that we have to deal with.
        And yes, dealing with the cost sharing, dealing with
    reinsurance, dealing with the mandates, that will actually deal
    with the problem, not this bill.
        And what we put at risk--we all talk about our compassion
    for those who suffer from cancer. But we know that some of the
    treatments are pretty expensive. Managing to the cap is going
    to limit the opportunities of those for young women who have
    breast cancer, the type of treatments that will be available to
    them.
        I think that is what, Mr. Woodruff, you are saying is at
    risk.
        Mr. Woodruff. Absolutely.
        Senator Cardin. Thank you, Mr. Chairman.
        Senator Roberts. Senator Scott?
        Senator Scott. Thank you, Mr. Chairman.
        Thank you to the witnesses for being here today to discuss
    this very important issue.
        I have heard a lot today about stability and certainty in
    the marketplace. And in South Carolina, that is a very
    important issue. In 2014, we had nine insurers in the
    individual market. And as we look at 2018, we will only have
    two left in the market and only one in the exchange.
        On top of the lack of choice in the marketplace, the South
    Carolina individual market is seeing a 27-percent rate increase
    in 2017. That does not sound affordable to me--a 27-percent
    rate increase in 2017.
        On top of that, we are looking at a 31-percent rate
    increase in 2018. These rate increases are coming right out of
    the paychecks of the average person in South Carolina.
        Furthermore, the instability in the marketplace is so
    severe that those who signed up in 2017, out of a hundred folks
    who signed up in 2017, only 69 are still insured. In other
    words, the stability and the certainty that we hoped for in the
    ACA is missing. It is not missing in the future, it is missing
    right now. Thirty-one percent of South Carolinians who signed
    up at the beginning of the year simply cannot afford to
    continue their coverage.
        That is just the exchange population. But beyond the
    exchange population, families--I spoke with one in Summerville,
    SC, Brent, whose family pays $31,000 for their insurance. And
    the ``A'' in the ACA stands for ``affordable.'' That is not
    affordable at all.
        And on top of that, we still have 136,000 South Carolinians
    trapped in the coverage gap who are ineligible for any
    insurance.
        So when my friends on the other side demonize any effort to
    take a look at anything other than the ACA--well, let us fix
    it--they miss the obvious point that, for so many people today,
    the ACA is not an option.
        And yet my friends celebrate Romneycare. We are saying, why
    not pass those decisions to every State to make decisions? And
    if you look at all the polling information, one thing is clear:
    residents and citizens throughout the entire country say that
    their local and State politicians have their confidence more
    than their Federal politicians.
        This seems like a no-brainer to give the money to the
    States to provide the very important opportunity to carve out
    strong, reliable, affordable health-care options for their
    citizens whom they see at the Piggly Wiggly, at the Walmart, at
    the grocery stores every single night.
        Mr. Smith, based on your experience and your expertise,
    please delve into the issue of State flexibility and how this
    could create lower premiums and allow more South Carolinians to
    stay on their plan.
        Mr. Smith. Thank you very much, Senator. And again, I think
    that in many respects the States are the ones who understand
    their own markets. There is no such thing as a national health
    insurance market. Health insurance markets are statewide, and
    even below that, they are local.
        The idea that CMS--and again, they are my former colleagues
    and I have the greatest respect for them, but to say that they
    can manage every single market across the United States, again,
    the examples that you have made show that that is not very well
    done.
        Senator Scott. We call that hogwash in South Carolina.
        Mr. Smith. So to give back to the States the flexibility to
    be able to make decisions, to adopt new tools that are on the
    surface and--in some States that are trying to lead the way, of
    helping, again, to manage to the cap, we now have managed long-
    term services and supports models that we did not have
    previously. We are now partnering with the private sector to be
    able to manage the
    highest-cost individuals who are out there in the fee-for-
    service world, or what we used to call fend-for-self, the
    highest-cost people having no one to coordinate their care,
    having no one to help them.
        Senator Scott. Thank you. I know that I am almost out of
    time here. I figured Senator Cardin went over by about 63
    seconds, I would just do the same. Thank you.
        One last question for my colleague.
        Senator Roberts. Okay, 23 seconds.
        Senator Scott. Thank you so much, sir.
        Senator Cassidy, to Senator Cardin's point which has to do
    with opioids, can you share with us, amplify a little bit, how
    the
    Graham-Cassidy proposal would help those folks who are today
    suffering under the weight of opioids?
        Senator Cassidy. Mental health parity protections are
    maintained per the current law. That is number one.
        Number two, States have the ability to take this money and
    to craft something which is particular for the opioid epidemic.
    It does not have to fit into somebody in Washington, DC's
    concept of what it should look like; it can fit into what that
    State knows works and the locality in which it is needed.
        Senator Scott. Thank you.
        Senator Cassidy. Let the State have the ability----
        Senator Scott. Thank you, sir. I wanted to answer that
    question for Senator Cardin.
        Senator Roberts. Senator Bennet?
        Senator Bennet. Thank you, Mr. Chairman.
        I am not sure quite where to start.
        I can tell you this, to my Republican colleagues, and I
    know they will disagree with this, Edmund Burke is spinning in
    his grave at legislation like this. The kind of dislocation
    this is going to create merely to keep a campaign promise to
    repeal Obamacare is a disgrace.
        The Senator was quite incorrect earlier when he said that
    we did not have a bipartisan process in place. Ms. Miller has
    testified to that. At the HELP Committee, we had a number of
    hearings, both in the committee room and outside.
        And I think, Ms. Miller, you said that there was actually a
    consensus between Republicans and Democrats. Is not that
    correct?
        Ms. Miller. That is correct.
        Senator Bennet. And what we were trying to deal with in a
    conservative manner was to deal with the individual market,
    which these folks are talking about having to be stabilized,
    that is to say they have said it is destabilized--it is in many
    cases destabilized--and that is what we are trying to address.
    Is not that correct?
        Ms. Miller. That is right.
        Senator Bennet. And that is 7 percent of the people who
    have insurance in this country.
        Ms. Miller. Or less.
        Senator Bennet. Or less. And of those, the ones who have
    need of subsidies are even far less. Is not that correct?
        Ms. Miller. That is right.
        Senator Bennet. And I would say that all of our politics
    for the last 9 or 10 years, almost, about health care has been
    distorted as a result of trying to figure out what the right
    answer for that 7 percent is. Would you agree with that?
        Ms. Miller. Absolutely.
        Senator Bennet. And now we are right at the moment where we
    have bipartisan consensus on how to deal with that 7 percent,
    and it is snatched away in favor of this partisan effort. Is
    not that right?
        Ms. Miller. That is right.
        Senator Bennet. Or I will say that, you do not need to
    agree with that. It is true. And sitting here listening to the
    comments, the only thing I can come to is a conclusion that
    says this is to keep a campaign promise to repeal Obamacare,
    because in the bill we talked about in the HELP Committee,
    Obamacare would not be repealed. Is not that right?
        Ms. Miller. That is right.
        Senator Bennet. And we might have to admit that it was not
    actually a complete Bolshevik takeover of the United States
    economy. You do not have to answer that.
        And instead, well, let me ask you this, Ms. Miller. Is
    there anything in this bill that is responsive to the
    bipartisan testimony we heard in the HELP Committee?
        Ms. Miller. Well, there is a 2-year reinsurance program. I
    will tell you, that is not going to be enough to stabilize the
    market.
        Senator Bennet. Is there anything in your mind as an
    expert, somebody who is an insurance commissioner, is there any
    doubt in your mind that this bill will create massive
    instability in the private insurance market for the 7 percent
    of the people who are in that individual market?
        Ms. Miller. There is no doubt in my mind that this will
    create chaos.
        Senator Bennet. And you will own that chaos, because if you
    do not do what the consensus was with the CSR and with creating
    some flexibility and having the mandate or some other idea to
    have the mandate, you will get instability like you have not
    seen before. Right?
        Ms. Miller. That is right.
        Senator Bennet. And so, why are we here, colleagues, making
    matters worse? It is disgraceful. As all of you have said and I
    will agree, there are things in the Affordable Care Act that
    need to be fixed.
        You know--and my view is this on that subject. Whether you
    are for the Affordable Care Act or you are not has a lot to do
    with whether you supported President Obama or not, not exactly
    because there are people who had preexisting conditions before
    who are now covered, but it tends to be that way.
        But what I discovered in my State is, whether people
    support the Affordable Care Act or whether they do not, they
    are deeply dissatisfied with the way their family intersects
    with the health-care system in America, with the way their
    small businesses intersect with the health-care system in
    America, because they know they are having to make choices that
    nobody else in the industrialized world has to make because
    this Congress cannot get its act together.
        And right now when we have this issue staring right at us
    in the individual market, we choose not to take any of the
    recommendations that have been made in a bipartisan way in
    hearings in the HELP Committee. And on top of that, we look for
    an excuse to cut poor people off of Medicaid.
        Do you think that about sums it up, Mr. Woodruff?
        Mr. Woodruff. I think that sums it up very well.
        Senator Bennet. Could I ask you, do you work for an
    insurance company?
        Mr. Woodruff. No.
        Senator Bennet. Is the American Cancer Society an insurance
    company?
        Mr. Woodruff. No.
        Senator Bennet. So let me just close by saying I cannot
    believe the hypocrisy of people supporting this bill and saying
    that they are fighting against insurance companies when what
    they are doing is stripping hard-earned consumer protections
    from the American people. It is a disgrace.
        And what we should be doing is going upstairs to the HELP
    Committee, continuing the bipartisan work that Ms. Miller
    described, and addressing what is a serious problem in South
    Carolina, in Ohio, and in Colorado.
        As somebody who voted for the Affordable Care Act--and I
    still have taken less time than Mr. Scott or Senator Cardin. As
    somebody who voted for the Affordable Care Act, let me say for
    the record, when somebody comes up and they say to me, Michael,
    because of the bill you voted for, I have to buy insurance that
    is too expensive for my family because I live in a place where
    there is not enough competition and the price is high, the
    deductible is too high, and when I call and I want my
    insurance, for some reason it is never there because they can
    have people stay on the phone longer than I can stay on the
    phone; you caused that problem, fix it, I say to them, you know
    what, your criticism is exactly right. We should fix it. Now is
    our opportunity to fix it instead of playing politics with the
    American people's health-care system.
        Thank you, Mr. Chairman.
        Senator Enzi [presiding]. Thank you.
        And since Senator Cassidy is on the panel, our tradition is
    that a panelist cannot question the other panelists in the
    middle of a hearing.
        So the next person would be Senator Casey.
        Senator Casey. Mr. Chairman, thank you very much.
        One of the more compelling pieces of evidence or testimony
    in this whole debate has been what we have heard from folks
    around the country, what we have heard from our individual
    States.
        We just had a--I do not know if Sara has that pile of
    letters--but we had a series of letters delivered from the Arc
    of Pennsylvania, just over the last couple of days, a pretty
    hefty sum there, and then other letters that went to the
    Finance Committee from Pennsylvanians and folks in other
    States. So we are grateful for that.
        I think the process here--I think even folks who are
    supportive of this Republican bill would say that the process
    is not in any way commensurate with the gravity of the
    challenge and the scope of this legislation.
        I would incorporate by reference what Senator Bennet said
    about what has been happening in the HELP Committee, some of
    the best bipartisan work on health care maybe in a decade,
    moving towards a consensus and having four hearings just on
    those very limited number of topics, nowhere near the scope of
    this bill. And yet we had 2 weeks of hearings, great bipartisan
    work.
        We should return to that, get that bill done and then
    maybe, I hope, move on to other issues.
        I do not think there is any question--when you compare the
    hearing time, either in the Finance Committee or the HELP
    Committee, on the Affordable Care Act, there is obviously no
    comparison. Once you get above one, of course, one hearing, you
    are above where we will be tomorrow in this committee.
        Eleven days of hearings in the Finance Committee over the
    course of the consideration of the Affordable Care Act, 26
    hearings in the HELP Committee. The final bill incorporated 147
    Republican amendments--so, a stark contrast.
        And then finally I would say that, in terms of process, we
    could move in that direction and have a series of hearings on
    this legislation or any other, but I know that there is a
    deadline that some want to meet, which I think is not the
    measure that the bill should be guided by, that September 30th
    deadline, instead of working over months on a series of
    hearings.
        I have a couple of questions that I just have been
    wondering about. And I will just throw them out--I guess more
    statements than questions.
        What I cannot understand is the obsession that Republicans
    have on this committee, and it seems across the Congress,
    against Medicaid or the hostility they have to Medicaid. I do
    not understand it. It has gotten me very angry the last couple
    of weeks and months because I care deeply about that program. I
    want to protect it, to strengthen it, to preserve it. It covers
    more than 70 million Americans, kids and people with
    disabilities, seniors getting into nursing homes. I do not
    understand that.
        And I also do not understand, what is the big problem with
    11 million people getting health care in this case through
    Medicaid expansion, the balance getting health care through the
    exchanges? Why is that a problem? Why is that wrong?
        We all benefit when people gain health-care coverage. And I
    think we are all diminished and in fact potentially injured
    when they do not. Do we want 11 million people to not have
    health care? Should that not be considered a measure of
    progress?
        Senator Toomey and Senator Santorum are here with us today,
    and I welcome Senator Santorum back to the committee. They know
    that in our State we have a huge rural population. We have 48
    rural counties out of 67.
        I spent a lot of time in the month of August going across
    the State. And a lot of those trips were in those rural
    counties. And talking to folks there just about the opioid
    crisis, as Commissioner Miller, Secretary Miller, and others
    have said, just that alone is a huge challenge in rural areas.
    And in several counties, they said, thank God we have Medicaid
    expansion. It is having the biggest impact on that problem, not
    a magic wand, not solving the problem totally, but people in
    Pennsylvania are getting treatment and services for an opioid
    addiction problem solely because of Medicaid expansion. So I do
    not understand the obsession with winding down and ultimately
    getting rid of Medicaid expansion.
        So let me get to some questions, because I know we are
    limited in time; we will get another round, but I want to start
    with Secretary Miller.
        As Senator Bennet mentioned, you testified before the HELP
    Committee. And when you reviewed the work that we were doing
    there that you participated in, along with Governors and
    others, and then when you reviewed this legislation, did you
    find any evidence of the stability proposals that we were
    working on in the HELP Committee? Did you find any of those in
    this bill, the Republican bill that we are discussing today?
        Ms. Miller. Senator, the only provision that we discussed
    that I saw in this proposal is a reinsurance program that lasts
    for 2 years. But it is not going to be enough to stabilize the
    market without CSR funding, without the mandate, with the
    repeal of the mandate. Those things are going to seriously
    destabilize the market in 2018.
        Senator Casey. And just very quickly--I want to be
    observant of time, and I am over.
        But, Secretary Miller, Pennsylvania expanded Medicaid. You
    understand that better than most. This plan would block-grant
    the Medicaid expansion funding in 2019 and eliminate the
    funding entirely in 2027. Could you explain the impact this
    would have on Pennsylvania?
        And maybe on my second round I will ask, Ms. Mann, if you
    could do that from a national perspective.
        Could she answer that question?
        Senator Enzi. Well, you are already a minute and a half
    over. And we have a whole lot of people waiting.
        Senator Casey. How about a short answer, can we do that?
    Can I ask for a very short answer?
        Senator Enzi. Yes, a short answer.
        Ms. Miller. I think the impact of these cuts will be
    devastating to Pennsylvanians. The Governor has done
    everything, and all of us in his administration have worked
    very hard to make sure we expand access to affordable coverage
    for as many people as we can. And even if you look at the
    conservative estimates, whether we are talking about $15
    billion or $30 billion, which is our estimate, any of that
    range is going to--those cuts are going to have a real impact
    on people who rely on Medicaid for their health care.
        Senator Casey. Thank you.
        Thank you for indulging me, Mr. Chairman.
        Senator Enzi. In the short time that I have been here, we
    have had rapid escalation of the amount of time that Senators
    are taking. I hope that some of the other people on both sides
    will reduce their amount to make up for the extra time that
    others have taken.
        Senator Warner?
        Senator Warner. Probably not. [Laughter.]
        Thank you, Mr. Chairman.
        Let me just make a couple of comments and try to get a
    couple of questions in.
        One, I have to give the sponsors of this legislation credit
    for one thing. This is the most radical, the most audacious
    change in our health-care system I think we have ever
    addressed. What started as an effort to do away with
    Obamacare--and let me add to the voices at least on this side
    of the aisle that will acknowledge there are a lot of things in
    Obamacare that need to be fixed and dealt with--has morphed
    into a dramatic deconstruction of a program, of Medicaid, that
    has existed for more than 60 years.
        And I am not asking you to take the word of some wild-eyed,
    Democratic, left-leaning liberal group. Let me just cite the
    American Enterprise Institute, a well-respected, center-right
    think tank. Their quotation as they go through the analysis,
    talking to the sponsors and supporters of this legislation is,
    quote, ``They should be mindful of the public perception that
    the most important piece of domestic legislation in many years
    is being pushed through Congress before there is time to fully
    understand it or raise legitimate questions about it.''
        Senator McCaskill is going to be up in a moment, and I do
    not want to steal her thunder, but Standard and Poor's, not,
    again, some wild-eyed, left-leaning group, has come out with an
    analysis at 3:00 today that their first look or analysis of the
    Graham-
    Cassidy proposal indicates that over the next ensuing period it
    would cost our country 580,000 jobs, $240 billion of lost
    economic activity. Not some wild-eyed group, S&P.
        I would say to my colleagues, good and radical ideas ought
    to be debated. But if this is a good idea, it would be a good
    idea 3 weeks from now after we had appropriate review. It would
    be a good idea 3 months from now after we actually got to
    hear--echoing what Senator Bennet said--from the hosts, not of
    insurance companies, but of doctors, hospitals, State
    advocates, the literally hundreds of people who are sitting
    outside this hearing room, wanting to have their voices heard.
        If this is such a great idea, let us take the time to
    analyze it, review it, and put it through all the same hoops
    that Obamacare went through. Chances are there might be
    Democratic amendments that would actually be accepted. But no,
    we are going through this trumped-up process to try to get a
    political scalp before September 30th.
        I also would say, clearly, some of the sponsors--and I have
    great respect for all of them--but none of them has ever been a
    Governor. Now, Senator Carper and I have been Governors. We
    have had the responsibility at the State level to try to
    implement massive programs and changes.
        Our legislature meets in a short session. We get a new
    Governor coming up, we only have a 4-year term in Virginia,
    unfortunately, but we had a new Governor come January. The
    notion that a new Governor with a fresh legislature could
    redesign a whole health-care delivery model, submit it by March
    of 2019, and that this administration could somehow provide a
    host of waivers between then and 2020 is obviously put together
    by somebody who has never run a program or surely never run a
    State.
        And again, do not take my word for it. The National
    Association of Medicaid Directors said, again, quote, ``Taken
    together, the per-capita caps and the envisioned block grant
    would constitute the largest intergovernmental transfer of
    financial risk from the Federal Government to the States in our
    country's history.''
        And quite honestly, to those of you who are sponsors of the
    legislation, I think most State legislators and most Governors
    ought to weigh in. And why, if we want to do this kind of
    process, why would we not invite Governors? Let us invite
    Republican Governors here to weigh in on this legislation
    rather than trying to jam it in before some arbitrary deadline.
        And, Mr. Chairman--I will not get to my question because I
    will try to honor my 5-minute time--I have to join my
    colleagues. I believe strongly in a bipartisan process. I think
    I have the scars to prove it from previous actions where I was
    willing to take on entitlement reform. But this current process
    is a travesty.
        Senator Enzi. Next is Senator Cantwell, followed by Senator
    Brown, and then Senator Isakson.
        Senator Cantwell. Thank you, Mr. Chairman. I was hoping
    that Senator Hatch would be here. And I just wanted to take 30
    seconds to say, as critical as this situation is, and I view it
    as very critical, I also view the situation in Puerto Rico as
    very critical.
        I would hope that our colleagues would work hard to make
    sure that there is a Federal FEMA declaration for all of Puerto
    Rico, every county. And I would hope that our colleagues would
    work very diligently to encourage the White House to appoint a
    lead at the White House, perhaps a czar, to work with all
    Federal agencies in coordination.
        I know Senator Hatch cares a lot about the health-care
    issue, but these are issues that are going to take a long time
    for us to recover from, and I hope our colleagues will work to
    encourage such coordination at the White House level. Thank
    you.
        On this subject, I am having a tough time understanding the
    overall philosophy of this legislation. I can say that I
    definitely had town meetings and was encouraged by the fact
    that Senator Cassidy wanted flexibilities for States. I was
    encouraged. I think I even mentioned it that he wanted
    flexibility.
        But the reason why we are not working together now on this
    legislation is because it is taking the premise of flexibility
    and turning it on its head as it relates to a program that has
    been a 52-year relationship between the States and Federal
    Government. It is taking a 70 million population and basically
    saying, I am going to change the way health care is delivered
    to you under the ruse that you are trying to address the
    individual market, which is 18 million. So you are trying to
    say to people, I am fixing that in the individual market, when
    you are not. States that expanded Medicaid have 7-percent lower
    premiums in the individual market.
        And the notion that we should do this because of TANF, that
    TANF was some sort of lifeline, the TANF experiment--and I
    should bring up, your State is the lowest in the Nation in per-
    capita TANF benefits in the sense of, for every hundred people,
    you serve the least TANF benefits. What has driven people out
    of poverty in America is not the way we structured TANF, it is
    the EITC, it is the SNAP program. That is what has helped.
        And so now you take this block grant experiment and say
    that you are going to somehow magically drive down costs in
    health care when in reality you are just kicking millions of
    Americans off with the ruse of putting them into a capitated
    program and then cutting their benefits.
        So to me, it is not a panacea for the future. I would love
    to see--oh, by the way, you take the one creative, flexible
    idea that States have, section 1331, that has allowed 650,000
    people in the State of New York to get cheap, affordable health
    care at $500 a premium, and X that out. So you took one of the
    most creative ideas that will cost New York billions, probably
    $3 billion to $4 billion, because you have X'd it out.
        So my point is this, to Ms. Miller. I am pretty sure there
    are innovative ways in the Affordable Care Act to drive down
    costs. I am pretty sure your State, Pennsylvania, took
    advantage of them. I think you helped expand a program to get
    people off of nursing home care and to community-based care. In
    our State, that saved billions. I am pretty sure that probably
    will save a lot of money in Pennsylvania.
        What about those ideas for driving down the cost of
    Medicaid? Because my colleagues on the other side, I think,
    seem to think the only way that you can drive down the cost of
    Medicaid is cutting people off. And I totally disagree.
        In fact, I think this chart raises the question on health
    care in rural America. The non-expanded States have seen the
    most closures of rural hospitals in America. Why is that? Why
    is that?
        So the notion that somehow we have, in the corner of
    Graham-Cassidy, figured this out, I just do not believe it.
        So do we have innovation in the Affordable Care Act that is
    driving down costs in the Medicaid market in a very significant
    way, and can we push it faster?
        Ms. Miller. Thank you, Senator. I think you are alluding to
    our Community Health Choices program that we are rolling out. I
    think we all know that seniors want to be served in their
    communities. And I think our Governor has made a real push to
    get people out of nursing homes and let them age in their
    communities.
        And we also know that, in terms of the costs to Medicaid,
    it is mandatory in terms of paying for nursing home services,
    but
    community-based services are not mandatory. And yet, moving
    people out of institutions and into the community is how we are
    going to save money for both the States and Federal Government.
        Senator Cantwell. Thank you.
        Thank you, Mr. Chairman. Thank you.
        Senator Enzi. Thank you.
        Senator Brown, then Senator Isakson, and then Senator
    McCaskill.
        Senator Brown. Thank you, Mr. Chairman.
        These are 200 of the literally thousands of letters and
    emails that my office has gotten recently in opposition to this
    plan. I would like unanimous consent, Mr. Chairman, to enter
    these in the record.
        Senator Enzi. Without objection.
        [The letters can be viewed on the committee's website.]
        Senator Brown. Mr. Chairman, thank you.
        I appreciate what Senator Bennet said a moment ago about
    the discussion from the other side on, their words, the failure
    of Obamacare. It has been centered on 7 percent of the market,
    and not even on 7 percent, more like 1 percent who are not
    getting subsidies. So the importance of--I think it really did
    answer the dishonest kind of opposition to the Affordable Care
    Act in what has been happening.
        But something else was said a moment ago. One of my
    colleagues said there is a coverage gap of 30,000 people in his
    State who simply are not getting insurance, that the Affordable
    Care Act has not taken care of. Well, the fact is in his State,
    his Governor did not expand Medicaid. That is the reason he has
    the coverage gap, the coverage trap, whatever term he tends to
    use.
        And I am proud that in my State, a Republican Governor,
    John Kasich, did in fact expand Medicaid; 700,000 people--
    700,000 people--in my State have health insurance because the
    Governor did that. Two hundred thousand people right now in
    Ohio are getting opioid treatment because of Medicaid, because
    of the expansion of the Affordable Care Act, something that
    none of us on this committee should forget.
        Now, Mr. Cassidy, you sort of answered this question about
    opioid treatment. And I want a more direct answer. Included in
    the BCRA was $45 billion specially requested from some of us on
    this committee for opioid addiction treatment. Is there a
    provision--I need a ``yes'' or ``no'' answer--is there a
    provision in your bill, a similar provision with dollars
    specifically targeted for opioid treatment?
        Senator Cassidy. It is in the flexible block grant. States
    can choose to spend that as they wish. And I presume in your
    State they would.
        Senator Brown. Okay. I guess I would take that as a ``no,''
    because I quote The Columbus Dispatch, a generally very
    conservative Republican paper, the State's second largest,
    which says, ``This bill does not specifically include money to
    treat the epidemic of opioid addiction.'' It goes on to say,
    ``This study suggests lawmakers in Columbus would have to find
    billions of new State tax dollars to maintain current levels of
    health care for people receiving Medicaid.''
        And I also listened to what Governor Kasich said, who is
    the Republican Governor of my home State, as I said: ``First,
    more than eight people in Ohio likely will die today, if this
    is a typical day, due to an opioid overdose. We tragically lead
    the Nation in the number of people who died in the course of
    the last couple of years from opioid overdose.''
        Governor Kasich's press secretary said, ``Make no mistake,
    losing billions of dollars would be devastating to Ohio as we
    work to provide care to our State's most vulnerable and drug-
    addicted. The only ones who can support this legislation are
    those who have not had time to properly assess the damage it
    would do.''
        And as my colleagues have pointed out, you certainly, Mr.
    Chairman and Senator Hatch and Republican leadership, have not
    given us the time.
        As Senator Casey said, he and I sat on the HELP Committee;
    150 Republican amendments were accepted. The hearings went on
    for weeks and weeks and weeks in that committee and this
    committee. Nobody is going to have time. You can say the bill
    is shorter than the Affordable Care Act, okay, big deal, but it
    has not been analyzed--we know that.
        But do not take my word for it. I was at the Talbert House
    in Cincinnati meeting with a group of people about opioid
    treatment. A father sat there with his 31-year-old daughter. He
    turned to me and touched her on the shoulder and said she would
    not be alive now if it were not for Medicaid. Or the sheriffs--
    I met with a group of sheriffs in Columbus at a training center
    this week. Those sheriffs talked about the importance of opioid
    treatment and other things that they need to do. Or a woman in
    Youngstown who said her son is getting treatment today because
    of Medicaid.
        We know the importance of that. We know this Graham-Cassidy
    bill does not at all address the issue of opioid treatment, of
    treatment paid for by Medicaid.
        So my question is, Ms. Mann and Ms. Miller, will States
    have the tools, in your mind, to fight the opioid epidemic if
    we adopt this bill?
        I will start with you, Ms. Mann.
        Ms. Mann. They will be losing the Medicaid expansion
    dollars. They will be losing even the ability to cover those
    individuals with regular Medicaid matching dollars. So that
    source of incredible, important funding for services will dry
    up. And it is easy--and that is the danger of a block grant--to
    say, well, not a problem because, in fact, you can take some
    money out of the block grant to address the opioid crisis. You
    can take money out of the block grant and you can provide
    coverage to everyone and you can solve all the problems in the
    marketplace.
        The fact is, the money is not there to be able to do all of
    those important goals.
        Senator Brown. Ms. Miller, if Graham-Cassidy is passed,
    will more people die of opioid addiction or something else?
        Ms. Miller. I am concerned they will, because I do not
    think we will have--with the reduced funding, Governors are
    going to have to make very difficult decisions, and some of
    those decisions may be eliminating essential health benefits
    like substance abuse treatment.
        And before the ACA, I think it is worth noting, oftentimes
    people could not access substance abuse treatment because it
    was often a benefit, particularly in the individual market,
    that was not covered.
        Senator Brown. So you see in Columbus and in Harrisburg and
    in Lansing--just to comment really quickly, Mr. Chairman, you
    took 20 seconds of my time at the beginning when I asked for
    unanimous consent on this, I am just taking it back if you do
    not mind----
        Senator Enzi. It was not 20 seconds.
        Senator Brown. You can see in Columbus and Harrisburg and
    Denver and Jeff City, you can see lobbyists for nursing homes
    fighting with advocates for children's hospitals, fighting with
    opioid addiction counselors for those declining dollars, those
    scarce dollars that now are generally available, but will not
    be in those days.
        Ms. Miller. That is exactly the problem.
        Senator Enzi. Senator Isakson, followed by Senator
    McCaskill, followed by Senator Toomey.
        Senator Isakson. Thank you, Mr. Chairman.
        Just to make a point, Senator Casey, I want a ``yes'' or
    ``no'' answer. Is it not true that you recently cosponsored a
    bill with a Republican legislator to create priority review
    vouchers for rare childhood diseases, and 2 weeks ago the first
    drug under that program was approved that now cures a certain
    type of cancer for youth? Is it not true you did that on a
    bipartisan basis?
        Senator Casey. I did, and that Senator is a good man.
        Senator Isakson. The reason I mention it is, I have been
    here the whole time, I have listened to accusations about all
    this, give me ``yes'' or ``no,'' you always know it is a loaded
    question. But ``yes'' or ``no,'' we do a lot of things together
    as Republicans and Democrats that we do not tell the public
    about. So I thought I would leave the hearing with one piece of
    good news after having the hearing today. Thank you very much.
        Ms. Miller, Mr. Smith, my State has 159 counties. Next year
    we will only have one carrier in 96 of those 159 counties. Do
    you have this similar type of decline of available carriers for
    your citizens under the Affordable Care Act?
        Ms. Miller. Senator, for Pennsylvania, actually, we did
    lose a few carriers, but we still have five insurance companies
    in our market. And this year, at the beginning of the year, we
    heard from all of those carriers that our individual market was
    stabilizing. And when we received the rate filings, those rate
    filings averaged 8.8 percent. They will not be that in a week
    or so when we end up approving rates because of all the
    instability coming from DC, but if the world stayed the way it
    is today for next year and all of these discussions went away,
    in Pennsylvania our market is stabilizing and we would see 8.8-
    percent increases.
        Senator Isakson. To what do you attribute the fact that you
    are not losing and in fact are seeing stabilization, pending
    what we may do up here? To what do you attribute that?
        Ms. Miller. The market is stabilizing. The ACA included 3-
    year programs. Two of the premium-stabilization programs were
    3-year programs. I think those who developed the ACA recognized
    that when you change the world, like you do, you change all the
    rules, you get a new population covered, it is going to take a
    few years to stabilize.
        And I think what we saw is exactly what those drafters of
    the ACA thought. After 3 years, in 2017, our market is
    stabilizing.
        Senator Isakson. Mr. Smith, what is Arkansas State going to
    be?
        Mr. Smith. Arkansas has three carriers Statewide. We hope
    to attract more. We hope to do that by building on competition
    and inducing new ways of a service delivery system. We are
    developing an entirely new service delivery system on the
    Medicaid side of things.
        And again, part of my concern is, we have gotten bogged
    down into false choices about, you have to cut this or you have
    to cut that or you have to cut that. If we started doing things
    smarter, if we started doing things that inject competition--we
    are developing an entirely new form of organized care, an
    organized care model in which providers are accepting risk.
    These are the things that invite us to be able to make Medicaid
    sustainable for the long run for both the States and the
    Federal Government.
        We have to do things differently in Medicaid. And it is a
    false choice to simply say, well, all you have to do is cut
    benefits, all you have to do is cut eligibility. I believe we
    are demonstrating more ways to do things better that are better
    for the individual, the people whom we have been talking about,
    the people with developmental disabilities, people with mental
    illness, who are the least capable of being able to maneuver
    through a fee-for-service system. We are organizing care around
    them that will keep them out of the hospitals, people in our
    nursing home populations.
        We put together in 2005--the Deficit Reduction Act of 2005
    included a provision called Money Follows the Person. That was
    a Republican idea to help get people out of institutions and
    back into the communities.
        So there are a lot of ideas. Unfortunately, I do not think
    we have really talked about any of the ideas that we can do to
    make the program sustainable, to continue to serve people, and
    in the manner they choose to be served.
        Senator Isakson. Thank you very much.
        Senator Cassidy, do you remember the date that you
    introduced Cassidy-Collins?
        Senator Cassidy. I do.
        Senator Isakson. What was that date?
        Senator Cassidy. Well, I cannot remember the exact day, but
    I remember the kind of----
        Senator Isakson. Approximately, what day was that?
        Senator Cassidy. Oh, probably now, man, 10 months ago or 8
    months ago? I am sorry, I do not remember the exact date.
        Senator Isakson. For the record, I wanted to ask that
    question because if you had listened to a lot of the questions,
    you would have thought it was introduced last week and tonight
    is the only time we are going to talk about it. But in fact,
    your original concept, which was Cassidy-Collins, was
    introduced almost a year ago, and it has been worked on during
    that period of time by you. And I was a cosponsor of that
    legislation about 6 months into that period of time. Is that
    not correct?
        Senator Cassidy. Yes, sir.
        Senator Isakson. Well, I thank you for your leadership.
        Thank you very much for the opportunity to ask questions,
    Mr. Chairman. I yield back.
        Senator Enzi. Thank you.
        Senator McCaskill, followed by Senator Toomey.
        Senator McCaskill. Thank you, Mr. Chairman.
        Let me briefly go through what the S&P said this afternoon
    at 3:00 on insured levels, lower levels of insured. On the
    macroeconomy, as has already been mentioned, 580,000 lost jobs,
    $240 billion in lost economic activity, ensuring that GDP
    growth remains stuck in low gear of around 2 percent, at best,
    in the next decade--2 percent GDP, at best, in the next decade.
        U.S. States' increased flexibility comes with fewer Federal
    dollars--this is the S&P that has done this analysis--creating
    increased fiscal and operational burdens on the States.
        Insurance industry: increased uncertainty in the short term
    with repeal of the mandate and lack of clarity around cost-
    sharing reductions.
        AEI--I do not typically read a lot of AEI, but I read this
    article because I thought it was really interesting. I am just
    going to read two short portions from the American Enterprise
    Institute which typically would not be read from this side of
    the room, typically. ``Although an important policy goal for
    Republicans is to lower premiums in the individual market,
    Graham-Cassidy, like the BCRA, is likely to have the opposite
    effect. Because Graham-Cassidy is so complex and far-reaching,
    we believe more time is needed to understand and debate its
    merits. And the legislation would benefit from a traditional
    markup in committee where serious amendments could be
    considered. Moving too fast risks significant unintended
    consequences and public resentment.''
        Now, moving too fast means that, when I got on the plane
    this morning, I thought I knew what the bill said. When I got
    off the plane, it did not say that anymore.
        And an important change--I have not had a chance to read it
    all; my staff tells me this is one of the changes that was
    made. I have not had a chance to digest all of them, but one of
    them is we have now moved, in terms of legislative history and
    the litigation that will occur around this legislation--I can
    assure you there will be plenty of it--they will look at
    legislative history. In the legislative history, in every
    version of the bill until now, the States applied for a waiver.
        No more waiver now. Now the States just have to give a
    description of how the State shall maintain access to adequate
    and affordable health insurance coverage.
        And I cannot find, Senator Cassidy, where ``adequate and
    affordable'' is defined anywhere. Is there a legal definition
    of ``adequate and affordable'' in this bill?
        Senator Cassidy. There is a Merriam-Webster definition of
    affordable; it means you can afford, as opposed to the $39,000
    premiums in the ACA for those in the individual market.
        Senator McCaskill. That is not my question. Is there a
    definition of either----
        Senator Cassidy. But it is the answer.
        Senator McCaskill [continuing]. ``Adequate'' or
    ``affordable'' in the bill?
        Senator Cassidy. Nor is there a definition for the word
    ``and''--a-n-d.
        Senator McCaskill. Okay.
        Senator Cassidy. It is an accepted definition, a-n-d.
        Senator McCaskill. Well, we did a lot of things around
    health care where we tried to set some limits as to out-of-
    pocket and all of those things. None of that is in the bill.
        Also, there is now no waiver for the essential health
    benefits. You can just waive them. I mean, you do not have to
    ask for permission anymore. The essential health benefits are
    now gone, there is no waiver necessary. So the essential health
    benefits, like maternity care, like prescription drug coverage,
    like addiction coverage, I understand you can say, well, the
    States can use the money we are giving them to do that, but we
    are asking them to do more with less.
        And so the question I have for you is, when the State calls
    and says, this is what we are going to be able to do, and I
    guess CMS says, well, that is not good enough, and the State
    says, well, we have to have more money to do what we need to
    do, that is it, right? I mean, there is no more money, right?
    It is capped.
        Senator Cassidy. First, Missouri has lots more money,
    because you are a non-expansion State and you would be treated
    as if you were an expansion State. So in your State, there
    would be lots more money.
        Senator McCaskill. Let me talk about expansion States.
        Senator Cassidy. Sure.
        Senator McCaskill. You said earlier in the hearing, well,
    we just assume Governors will want to take care of the people
    in their State.
        Senator Cassidy. Yes.
        Senator McCaskill. Well, I have been painfully watching in
    my State when the people in charge in Jefferson City, who would
    be in charge of this program, made a decision to turn away
    billions and billions of dollars that the citizens of Missouri
    were entitled to for health care, acting against their own
    self-interest because of politics.
        Senator Cassidy. This bill gives it to them.
        Senator McCaskill. I understand it, but you act as if they
    are always going to do the right thing for their people. A lot
    of these States said, no, we do not even want the Federal money
    to help more people with health care, we are going to turn away
    the Federal money to help more people with health care. Now you
    believe that all of a sudden there is going to be a change of
    heart and they are going to be stretching every dollar? And why
    can't we do waivers now?
        Senator Cassidy. The problem was that States were not sure
    that they could afford the match. Ms. Miller has said that
    there is going to be a problem in Pennsylvania with their State
    budget, and that, in part, is driven by the 10-percent match
    required by the Medicaid expansion.
        We waive that so States who feared they could not cover the
    match now get the dollars without the match; they get the best
    of both worlds.
        Senator McCaskill. They are cutting Medicaid providers in
    my State right now without--without--expanding Medicaid. They
    are cutting providers right now. And I understand the State is
    in a tough position, because they have a balanced budget
    amendment where they have so many dollars and they only do so
    much.
        So I guess this is my final question. There is a 27-year-
    old man--the mandate is gone. I have been lectured about
    personal responsibility by some of my friends across the aisle
    during my career. A 27-year-old man, he can either afford a
    health insurance premium or a Harley. He buys the Harley, there
    is no more mandate. He puts it on the pavement, he is life-
    flighted to a hospital in Kansas City or St. Louis, he is given
    millions of dollars of health care, because we do not stop them
    at the emergency room door and say, sorry, you did not buy
    health insurance. He is bankrupt in 10 minutes. Under your
    bill, who pays that bill?
        Senator Cassidy. Under our bill, he could be automatically
    enrolled so that he would automatically be insured. By the way,
    Missouri would get $4 billion more from 2020 to 2026 to do that
    sort of thing.
        Senator McCaskill. Wait a minute. So everybody is going to
    get insurance if they do not buy insurance?
        Senator Cassidy. You could automatically enroll them if you
    wished; you have that flexibility.
        Senator McCaskill. So under your bill, nobody has to buy
    insurance until they show up at the hospital?
        Senator Cassidy. No, no. The State could--just like on
    Medicare when you turn 65 you are automatically enrolled in
    Medicare--the State could decide that folks who are eligible
    are automatically enrolled. They may give them a policy with a
    high deductible and a catastrophic----
        Senator McCaskill. He is 27 years old.
        Senator Cassidy. Yes. And so the State might say, you are
    in the pool. If you do not want to be, give us a call, you do
    not have to be. But if you do not call us, we are going to
    assume----
        Senator McCaskill. On the second round, I want to see how
    this works that somebody can get insurance when they show up--
    --
        Senator Cassidy. Wonderful. Thank you.
        Senator Enzi. Senator Toomey, followed by Senator Heller.
        Senator Toomey. Thank you, Mr. Chairman.
        I recall that none of the panelists suggested to Senator
    Grassley that Medicaid's growth rate is not on a sustainable
    path. Of course, that has been the case for a very long time.
    And it was observed previously this afternoon that the Graham-
    Cassidy-Heller-Johnson bill and previous Republican bills are
    not the first attempt to restructure Medicaid in a way that
    would put it on a sustainable path.
        In fact, in 1996 the Clinton administration proposed an
    aggregate cap on all Medicaid beneficiary categories and
    proposed further that those caps would grow at a rate of per-
    capita GDP, but not at the rate of medical inflation.
        They also proposed that it would go into effect 6 months
    from the date at which it was first proposed. It was supported
    by the American Academy of Pediatrics; the chairman of the
    National Governors Association, Howard Dean, who praised the
    idea of these caps; the National Association of Public
    Hospitals, now known as America's Essential Hospitals; and
    Secretary of Health and Human Services Donna Shalala.
        And interestingly, in December of that year, every single
    Democratic member of the Senate sent a letter to President
    Clinton saying, and I quote, ``We express strong support for a
    per-capita cap structure.'' That would include Senator Murray,
    Senator Leahy, Senator Feinstein, as well as every other
    Democratic Senator at the time.
        It is worth noting that, unlike the Graham-Cassidy
    proposal, the Clinton proposal did not phase in over 8 years,
    it phased in in 6 months. The Clinton proposal did not include
    bonus payments for high-quality delivery of care, it did not
    exclude the medically complex children, all features in the
    Graham-Cassidy bill.
        Now, some things have changed since the 1990s. What has
    happened with Medicaid? Well, it has grown enormously. Medicaid
    was then less than 6 percent of the Federal budget; now it is
    10 percent. Medicaid now is the single-largest net Federal
    expenditure from general revenues. Other large programs have
    dedicated revenue streams; Medicaid has none. And CBO continues
    to project that it will far exceed the growth of the economy.
        Despite the fact then that Republicans have adopted a
    Democratic idea and proposed a Democratic idea, we have
    colleagues who are suggesting that these ideas are cruel,
    obscene cuts, that it constitutes a war on Medicaid, that it is
    an attempt to decimate the program.
        Colleagues, I understand changing your mind. I understand
    abandoning the reform that your party once unanimously
    embraced, at least at the level of the United States Senate. I
    understand deciding that you are not interested in entitlement
    reform anymore.
        But when you attack the character and the motives of
    Republicans who have proposed your proposal, actually a gentler
    and more generous version of the proposal that once had
    unanimous Democratic Senate support, when you malign the
    character of us for doing that, it diminishes the credibility
    of this message that you so much want to work together on a
    bipartisan basis to get this stuff done.
        Senator Cassidy, let me ask you a couple of questions, if I
    could. We have heard a lot about the devastating spending cuts
    to Medicaid. In what year does Medicaid spending begin to get
    cut?
        Senator Cassidy. For almost every State, 2027, not because
    the block grant is not reauthorized, CHIP is always
    reauthorized. And some of these studies claiming 32 million
    insured assume that all the money goes away in 2027. No,
    because that is the time in which States' costs actually
    inflate to the caps.
        So they will have 10 years to adjust their health-care
    delivery systems so as to respond to the caps.
        Senator Toomey. Mr. Smith, if I understood you correctly,
    the elderly category of Medicaid recipients, that category,
    that per-
    beneficiary cap under this legislation grows at the rate of
    medical CPI plus one for a number of years and then at some
    point the growth rate switches to medical CPI.
        Did I understand you to say that CBO is projecting that the
    actual cost increases are projected to be less than the growth
    in the caps under the Graham-Cassidy bill?
        Mr. Smith. That is correct, under their most recent
    baseline, yes, sir.
        Senator Toomey. So the Graham-Cassidy bill establishes a
    cap, allows it to grow at a rate that CBO does not think we are
    even going to reach.
        Mr. Smith. That is correct.
        Senator Toomey. That is correct. But yet, that is a cut.
    Okay.
        I see I have--do I have time for one more question?
        I will save it for the next round. Thank you, Mr. Chairman.
        Senator Enzi. Thank you.
        Senator Brown. Mr. Chairman, I just want to interject that,
    comments notwithstanding from the panel, CHIP expires this
    Saturday. So let us not pat ourselves on the back until we
    actually do that if we are going to brag about CHIP.
        Thank you, Mr. Chairman.
        Senator Enzi. Senator Heller, followed by me.
        Senator Heller. Mr. Chairman, I want to thank you and the
    ranking member for holding this hearing today on Graham-
    Cassidy-Heller-Johnson. And I want to thank my colleagues,
    Senators Cassidy and Graham, former colleague Senator Santorum,
    and Senator Johnson, for their leadership on this particular
    proposal.
        And when these Senators came to me with an idea that would
    fundamentally change the way our health-care system works, when
    they told me that this plan offered Nevada more flexibility and
    more funding to meet the needs of our patients, I said ``Sign
    me up.''
        Our proposal represents what I set out to do from the very
    beginning of this summer's health-care debate, and that is to
    do what is best for the State of Nevada, the citizens in our
    State and across this country. And we all know that Nevadans
    and Americans across this country are facing higher costs and
    fewer choices under Obamacare.
        As a small-government conservative, I believe any solution
    to our broken health-care system needs to be rooted in
    increased flexibility with a goal of enhancing affordability
    and access to coverage. A one-size-fits-all approach is not the
    answer. So what is the alternative? That alternative is to
    remove Washington from the
    decision-making process, allow a 50-State solution where each
    State is empowered to do what they think is best on behalf of
    their patients.
        In fact, 2 weeks ago I held a telephone town hall meeting
    where I heard from a nurse in Las Vegas who is also a patient
    advocate. She brought up the Graham-Cassidy-Heller-Johnson plan
    and said she is glad people in Washington, DC finally get it.
    She agreed that it is essential to bring health-care decisions
    down to the State and local levels to improve the quality of
    care in this country.
        Our proposal takes Obamacare funding and replaces it with a
    block grant given annually to States to help individuals pay
    for their health care. This plan gives States the flexibility
    to innovate and create health-care systems that will lower
    premiums, expand coverage, and allow States to serve their
    Medicaid population as they see fit.
        This proposal presents States with many options for coming
    up with a tailored approach most appropriate for their
    citizens. For example, States like Nevada that have expanded
    Medicaid can continue serving this population with their block
    grant dollars. And because Nevada will not be on the hook for
    the 10-percent match required under Obamacare in 2020, the
    State will save $1.16 billion.
        As someone who recognizes the increased needs within our
    State as a result of the State's decision to expand Medicaid,
    these provisions are critical.
        Our proposal also allows States to use up to 20 percent of
    their block grant dollars on traditional Medicaid, providing
    States with additional flexibility to serve individuals who
    rely on this program.
        Understanding that Nevada is committed to providing
    affordable, quality care to our patients, including the most
    vulnerable, our proposal allows them to advance these efforts.
    For example, Nevada can enter into arrangements with insurers,
    including managed-care providers, to continue its commitment to
    vulnerable patients as well as ensure that Nevadans who rely on
    Medicaid have access to the services that they need.
        Under this proposal, States can also access additional
    funds that will allow them to address urgent health-care needs
    at home. These are just a handful of examples of how States can
    benefit from this proposal through increased flexibility.
        Senators Cassidy, Graham, Johnson, and I believe that our
    plan is the best path forward to address our Nation's health-
    care challenges. So I am grateful to the chairman for allowing
    us this opportunity.
        A quick question to you, Mr. Cassidy. Could an expanded
    State like Nevada use the money to replicate their current
    Medicaid expansion system?
        Senator Cassidy. Absolutely. Senator Heller, folks say you
    are losing the Medicaid expansion dollars. No, you still get
    them; you just get them in a flexible block grant. And if you
    wish to fund opioid services, you can fund opioid services. If
    you wish to do something good to decrease to transmission of
    HIV, you can do that as well.
        So absolutely, you pegged it: you can keep the money, you
    can keep on doing what you have been doing, if you wish.
        Senator Heller. It was mentioned earlier that 40 percent of
    Obamacare dollars are spent on four States: California,
    Maryland, Massachusetts, and New York, and they only represent
    22 percent of the population. Do you think this speaks to an
    equity issue inherent in the current system?
        Senator Cassidy. It does. And as a doctor who worked in the
    public hospitals of Louisiana for so long trying to bring
    services to those who do not have insurance, the idea that you
    could somehow give these folks in an orange State equity, no
    matter where you live, you can still have access to the same
    level of support from the Federal Government and your State
    does not go bankrupt because it has to come up with a match--
    which Ms. Miller tells us that Pennsylvania is going to have a
    hard time doing--because we waive the match, we think we get to
    where we need to be.
        Senator Heller. Does this legislation give Nevada more
    dollars with more flexibility?
        Senator Cassidy. Correct.
        Senator Heller. Thank you.
        Mr. Chairman, thank you.
        Senator Enzi. Thank you.
        And I am going to switch places with Senator Thune who has
    another engagement.
        Senator Thune. Thank you, Mr. Chairman.
        And I think we have heard discussions today about how this
    is going to create chaos. And I think it kind of depends on
    what your definition of chaos is.
        In my State of South Dakota, we have seen premiums increase
    by 124 percent since 2013 in the individual marketplace. We
    once had 17 carriers in that marketplace; we now have two. And
    almost half the counties in America this next year are going to
    have one--one--option when it comes to buying in the exchanges,
    in the individual marketplace. That, to me, seems like the very
    definition of chaos.
        And I think what the gentleman from Louisiana and his
    colleagues are trying to do is to try to bring some order to
    that chaos. And I thought that the Senator from Pennsylvania
    covered very well the history of per-capita caps.
        I have also heard some of my colleagues from the other side
    talk about how radical these ideas are, so radical that
    President Bill Clinton and congressional Democrats proposed
    this back in 1996--per-capita caps.
        Block grants to States--it is something that has been
    talked about around here for a long time. And it has worked; it
    has been successful on some level. And you know, in terms of
    the complication of this bill, this bill, in its current form,
    is 146 pages long--146 pages. Obamacare was 2,700 pages.
        I think this is a very good-faith effort to try to solve a
    problem we all know has to be solved, and that is that we have
    an individual market that is in freefall. And so I give great
    credit to the sponsors of this bill for trying to fix this
    problem and trying to eliminate some of the chaos that exists
    in the individual marketplace today and trying to reform a
    program that we all know is unsustainable.
        So, Dr. Cassidy, your proposal has been developed based on
    feedback from Governors, correct?
        Senator Cassidy. Correct. Fifteen Governors have signed a
    letter in support thereof--18, I am sorry.
        Senator Thune. And it would be my belief--and I cannot
    imagine it would not be shared by most of the people here on
    this panel--that there are going to be some unique needs in
    individual States. Everybody has different populations. And we
    have always, you know--the assumption of Obamacare is that the
    one-size-fits-all approach from Washington, DC is best. And we
    now know that does not work. Higher costs, higher taxes, fewer
    options--that is the legacy of what we have.
        So why not try something different and something that we
    think has a record of success? It has been implemented in the
    past with welfare reform.
        And so I guess my question is, based on the conversations
    you have had with some of these Governors, how do you expect
    States to use their block grant dollars and their ability to
    waive certain regulations, based on the feedback that you are
    getting from Governors?
        Senator Cassidy. Well, the Governors are excited about it.
    They see this as the ability to implement change that is
    tailored for their State as opposed to, again, the kind of one-
    size-fits-all.
        Mr. Smith spoke about a couple of things. And Arkansas has
    been very innovative. But if you have an unstable individual
    market because there are too few people in the individual
    market for actuarial stability, you can combine that with your
    Medicaid expansion population, the bigger pool providing
    stability for the older and sicker, and premiums could go down
    by as much as 20 percent.
        You could also do what Maine did, which the Affordable Care
    Act told them to shut down, the so-called invisible high-risk
    pool, where there is reinsurance the patient does not even know
    exists. They still have the care management from the insurance
    company, but just that itself, according to Susan Collins, who
    knows insurance so well, lowered premiums by 20 percent.
        Ms. Miller kept speaking as if there are only three ways to
    lower costs. She is absolutely wrong. You could actually put in
    policies. In Maryland, there is such market concentration of
    hospitals, there is no competition, and so hospitals charge
    very high rates. If you started to go after market
    concentration, you could lower the health-care costs, because
    market concentration leads to higher costs.
        I could go on, but the Governors who are creative can think
    of all sorts of things.
        Senator Thune. And very quickly, Mr. Smith, you have
    written past papers about the need for maintaining State
    flexibility in health care. How do you think the proposal under
    consideration will accomplish that goal in the individual
    marketplace and in Medicaid?
        Mr. Smith. I think this proposal gives the greatest
    flexibility of all to answer so many different questions.
    Again, Senator McCaskill brought up an individual who had
    traumatic injury. In a low-disproportionate-share hospital
    State, the State may not have any way to pay for that
    uncompensated care to those hospitals, so those hospitals are
    eating the cost.
        Under this proposal, a State could use those funds to say,
    I am going to pay directly for the cost of that care for
    someone who did not get insured. So the flexibility within this
    block grant is really what Governors have been looking for for
    a very long period of time.
        The other thing to remember about the Medicaid expansion
    and why some States did not take it was because they were
    required to go all the way to 138 percent of poverty instead of
    a State saying, we will expand Medicaid to 100 percent of
    poverty because that is the poverty level, and Medicaid is for
    people in poverty.
        Some States, if they would have to go all the way to 138
    would have taken people who were in the private sector paying
    for insurance on their own, taking them out of coverage and
    putting them into Medicaid.
        So the Medicaid expansion issue in question is far more
    complicated than, we just did not want to expand or not.
        In fact, more States, if they would have had that ability,
    I think would have expanded to 100 percent.
        Senator Thune. Thank you, Mr. Chairman.
        Senator Enzi. Thank you.
        Next is Senator Enzi.
        Thank you, Mr. Chairman. [Laughter.]
        Senator Santorum, this has to seem like deja vu to you. You
    were here when we did the Welfare Reform Act. And I am pretty
    sure that the comments that you are hearing here, as I
    remember, are the same kind of comments we heard about doing
    that reform: that there was an assault on the poor that would
    lead to rampant poverty and that there would be deaths of
    thousands, if not millions over time. And how did that work
    out?
        Mr. Santorum. Welfare rolls, once the block grant was
    deployed, welfare rolls dropped 50 percent.
        I remind everybody that we gave TANF a block grant just
    like we are doing here. TANF replaced a broad-based Federal
    entitlement called Aid to Families with Dependent Children. It
    had broad support, but was not effectively helping people
    transition off welfare. And we went to a different system which
    was supported by the ranking member who voted for welfare
    reform, one of the 23 Democrats who voted for this bill. The
    only Republican that voted against it said it did not cut
    enough taxes, it did not cut enough spending. And we have,
    obviously, similar complaints on this bill.
        What happened was, not only did rolls go down 50 percent--I
    say this all the time--but had that been the result and that
    was it, then it would have been a failure. But employment among
    that very group went up and went up dramatically. Poverty rates
    went down and down dramatically.
        And some States really took advantage of this. And you will
    see this here. If this bill is successful, some States will do
    a terrific job in developing really innovative solutions to
    provide great quality care. Wisconsin dropped their rolls by 93
    percent. And it still is an incredible program of transitioning
    people from poverty and welfare to work.
        But the innovation has been copied, even just in Maine
    recently. Governor LePage finally reformed welfare in that
    State. It took them 20 years to do it, but, again, very strong
    results. So there may be a lag effect in some States, there may
    be some inequity, but it creates competition, and it creates
    the opportunity for States to learn from the innovation of
    other States.
        Senator Enzi. Thank you. I will have some written questions
    for you too, because you have a wealth of knowledge on this and
    have actually spent more time on this bill than a lot of other
    people, not including, of course, Senator Cassidy or Senator
    Graham and others. But you have given some history to back it
    up.
        So, Mr. Smith, what kind of delivery system reforms could a
    State engage in with this block grant approach? What would they
    be able to do to impact the costs that drive up premiums?
        In Wyoming, by the way, we are looking at a 48-percent
    increase there. We are not an expansion State. And the reason
    we are not is the State did not trust the Federal Government to
    come through with their promises, and so they have stayed
    conservative in all of these things and in serving people.
        But what could be done?
        Mr. Smith. Thank you, Senator. And again, when we do talk
    about insurance, at the heart of it, you are talking about
    risk. And whom do you spread the risk across?
        And I do want to say, I mean, we have talked about the per-
    capita caps as being risks, the States being willing to accept
    that risk. They are willing to accept it when they are able to
    innovate and have greater ways of serving people differently
    than the way they are doing it today.
        But there is also a risk to the States of a strategy where
    the Federal dollars will always get bigger and bigger and there
    is no end to the Federal Government's contribution. That is a
    risk too. And a lot of States said, we are not willing to take
    that risk, because it is unsustainable for the Federal
    Government as well as the States.
        But the innovation that can be done, again--I mentioned we
    are introducing a new type of organized care for people with
    the highest costs that we can target to the individuals with
    severe mental illness, to put coordinated care around them, to
    take them, to some extent, off the books of the insurance
    coverage, so the State manages their care directly.
        There have been different concepts about sharing the risk
    of reinsurance or the old high-risk pools. They were always
    putting more money to the health-care plan itself to absorb
    that risk. There are different ways to share that risk. And
    those things can help bring down the premiums as well.
        Senator Enzi. Thank you. Just a final comment, and that is
    that this would not be the last bill that would be done on
    health care. It might be one of the first for encouraging
    changes. But I have been at those hearings that I think are
    progressing in a bipartisan way, and I hope they will continue.
        Senator Wyden?
        Senator Wyden. I think Senator Nelson is next up, Mr.
    Chairman.
        Senator Enzi. Oh yes. Senator Nelson?
        Senator Bennet. Mr. Chairman, I am sorry to interrupt, but
    I wonder--the vote has started, and I just wondered, for
    purposes of Senators, whether you could tell us what the
    speaking order is for the next round.
        Senator Wyden. Do you want me to do that?
        Senator Enzi. Yes.
        Senator Wyden. If I could, and I thank the indulgence of
    acting Chairman Enzi.
        So, after Senator Nelson, it would be Chairman Hatch, who
    is not here, myself, Senator Grassley, Senator Stabenow,
    Senator Roberts, Senator Carper, Senators Portman, Scott,
    Bennet, Casey, Warner, McCaskill, of the Senators here. Okay?
        And, colleagues, we do have an agreement with Chairman
    Hatch that Senators get to ask all of their questions. So he is
    going to vote and come back, and I will go and vote after that,
    and we are just going to keep this going.
        Senator Enzi. Actually, I think we will take a 15-minute
    recess so everybody can vote. Well, as soon as Senator Nelson
    finishes.
        Senator Wyden. That is fine on our side.
        Senator Enzi. Okay.
        Senator Nelson. All right, and I will be quick.
        Most of you know that I have been dealing with the
    aftermath of a hurricane, and not only are we facing that, but
    down in Puerto Rico and the Virgin Islands they are in very
    tough shape. And the Medicaid program is one that is
    particularly important to hurricane recovery efforts.
        As it is currently structured, Medicaid can respond to
    public health emergencies and natural disasters. And as the
    needs go up, whether it is because people become eligible or
    because they have lost their jobs or homes or that other
    health-care needs grow, Federal funding goes up automatically
    in response.
        And so the bill in front of us is of great concern. It is
    problematic that it does not provide States with sufficient
    funding to respond to natural disasters like hurricanes. The
    block grant provides a fixed amount of funding, and the
    Medicaid per-capita cap provides a fixed amount per
    beneficiary. So you can see what would happen when people need
    health-care coverage and the costs are rising on a per-
    beneficiary basis.
        And then, what about, in the bill, the public health
    expenditure exclusion from the cap? Well, of course, we have
    had three hurricanes right in a matter of a few weeks, not to
    mention the ongoing opioid epidemic and the presence of zika.
    The bill guts the Medicaid program and, therefore, cuts
    hundreds of billions of dollars of support to pregnant women,
    low-income adults, and children over time.
        Relaxing the per-capita cap by $5 billion in total for 50
    States over a 5-year period just simply is not adequate,
    especially when the decision whether to grant the exemption is
    left up entirely to the Secretary.
        Public health emergencies are going to continue. And that
    exemption does not do anything for the greater Medicaid needs
    after a natural disaster like these hurricanes.
        The bill assumes that States even have enough resources on
    their own to draw down on the Federal funding and that they are
    not using that money to plug other holes in the disaster. And I
    am telling you right now, my State is trying to get every
    dollar that it can in help from the Federal Government.
        Look at Hurricane Katrina back in 2005. States had to
    access $2 billion, so $5 billion for 50 States over 5 years is
    simply not enough.
        I am really worried, and just not about my home. As I
    mentioned, Puerto Rico and the Virgin Islands as well are
    struggling. Their Medicaid programs are already subject to a
    block grant. And it will not adjust. It would not adjust if
    there were not a natural disaster. And now their needs are
    huge.
        But I am afraid that is what the bill in front of us wants
    to accomplish, subjecting the rest of the country's Medicaid
    programs to the same rigid, inflexible, flawed financing
    structure.
        Mr. Chairman, I know we have to go vote, so I will stop
    right there.
        Senator Cassidy. Can I address some of those issues,
    though, Mr. Chairman?
        Senator Nelson. After he gets through with the recess,
    sure. Let us go vote.
        Senator Enzi. Yes. We will recess for 15 minutes.
        [Whereupon, the committee was recessed at 5:38 p.m.,
    reconvening at 5:55 p.m.]
        The Chairman. I'm glad to call the committee to order.
        Now, I expect this to go two rounds, but no more. I mean,
    let us face it, we are not getting anywhere, as far as I am
    concerned, other than we are getting some interesting
    testimony. But it is not going to solve the problems that we
    have here in the Senate, and we will just have to see what
    happens.
        Senator Wyden has a few more questions to ask, but we will
    go through one more round, and then that is going to be it.
        Senator Wyden. Mr. Chairman, I am going next to Ms. Mann.
    And again, these are the kind of substantive questions that you
    and I agreed could be asked at this hearing.
        The Chairman. Sure.
        Senator Wyden. Now, let us talk, Ms. Mann, because you are
    an expert about Medicaid, about flexibility. And put it in the
    context of the Nation's senior citizens. That is my background.
    I was director of the Oregon Gray Panthers for about 7 years. I
    watched all these older people. They fought our wars, they
    built our communities, they raised the families, they scrimped
    and saved, but growing old in America costs a lot of money.
        So today, senior citizens have a guarantee that Medicaid is
    going to cover the cost of nursing home care. And this is
    hugely important, because Medicaid picks up the bill for two
    out of three senior citizens in nursing homes in America. That
    is a guarantee for literally millions of older people.
        This proposal, the Graham-Cassidy proposal, I call it
    Trumpcare, the next version of Trumpcare, ends that guarantee
    and effectively turns it into a guarantee in name only.
        So we are not talking here about some abstraction and
    bending the curve and all this hocus-pocus about State
    flexibility. We are talking about the types of choices a State
    is going to have to make to their Medicaid program and what it
    is going to do to impact those senior citizens on an economic
    tightrope, every month balancing their food against their fuel
    and their fuel against their rent.
        Tell us what this proposal means for the Nation's senior
    citizens.
        Ms. Mann. Thank you for the question, Senator Wyden. Very
    few people, I think, truly understand what you just discussed,
    which is the importance of the Medicaid program to our elders
    in this country. There is no public support for long-term care
    except in the Medicaid program. Medicare only does it in very
    narrow ways. And about 21 percent of our spending in the
    Medicaid program is for people 65 and older. So it is a very
    important part of where the dollars in the Medicaid program go.
        And as a result, when there is a cap, if there would be an
    arbitrary cap on the amount of dollars that a State can spend
    in its program, where a State will go, not necessarily because
    it is its first choice, but because of the math, is where the
    expensive services and the expensive individuals are.
        And they will look to people with disabilities, and they
    will look to the elderly. So they may still have the
    requirement to do nursing home care, but States have expanded
    some eligibility for nursing home care to make sure more people
    have that option who have worked hard all their lives. And so
    those optional nursing home-eligible individuals might lose
    their coverage.
        The other thing that States have been doing under the
    flexibility in the Medicaid program is expanding to home and
    community-based services and really making those more
    available. But that is wholly an option in the Medicaid
    program, and those are outlier costs. And when you are under a
    cap, you are going to manage to the cap, as we talked about,
    and cut the high-cost cases.
        Senator Wyden. I appreciate your saying that, because I
    want people to walk out of here and understand that the
    Nation's senior citizens who have counted on a guarantee, under
    this program they effectively are seeing that guarantee
    hollowed out. And I very much appreciate your testimony.
        I have one other question, again on the State flexibility
    issue. And I think you know, I feel strongly about State
    flexibility. It is the flexibility to do better, not to do
    worse.
        And what I would like to have is your opinion about
    whether, as a result of this particular piece of legislation,
    any State is going to actually do better overall. And I want to
    underline ``better overall,'' because it seems to me that what
    this bill does is, it gets people coming and going. It
    basically is about, nationwide, repealing the Affordable Care
    Act, but it is also about, State by State, repealing the
    Affordable Care Act.
        So if you would, tell me whether, in your opinion, as a
    result of this legislation, any State is actually going to do
    better overall or if one State will or two States. I would like
    to hear your thoughts on it.
        Ms. Mann. I think overall, the answer is absolutely not,
    they will not do better.
        Senator Wyden. Not a single State overall will do better?
        Ms. Mann. Well, do better is--I am not sure of the
    question. I think overall, when you have a cap and you are
    going to manage to a cap as opposed to thinking about how to do
    the kinds of things that Mr. Smith talked about that States can
    do now under flexibility--have a better delivery system,
    integrate behavioral health, physical health, do accountable
    care organizations--those are flexible things that States can
    do to improve care and to lower costs. And States can do that
    now.
        But what will happen under a cap is that you have to manage
    so that you never go a dollar over that cap, or if you do, you
    will owe the Federal Government more dollars. And so you have
    to focus on quick, immediate steps to bring down your costs so
    that you are never at risk or you are trying to at least not be
    liable for that extra payment back to the Federal Government.
        Senator Wyden. I will hold the record open for your views
    on that because that, to me, seems like a threshold question.
    You know, we have been hearing all afternoon about State
    flexibility that is some magical elixir that, you know, if we
    have it in the
    Graham-Cassidy version, then everything is going to be hunky-
    dory. You have pointed out that that is not the case because of
    the way the cap option----
        Ms. Mann. And it is the Medicaid directors themselves
    around the country, not in the red States, not in the blue
    States, but around the country who have said that when you have
    flexibility without funding, that is not flexibility at all, it
    is only flexibility to cut.
        Senator Wyden. I am going to quit while I am ahead. Thanks.
        Thank you, Mr. Chairman.
        The Chairman. Well, thank you.
        Let me just say this.
        Mr. Santorum and Mr. Smith, can you respond to Senator
    Wyden's question?
        Mr. Santorum. Let me just say about funding, the idea that
    some States are not going to do better under the Graham-Cassidy
    bill is just fallacious. Clearly, the non-expansion States get
    an enormous amount of money coming into their coffers to use
    for, quote, the ``Medicaid expansion'' or basically the
    individual market.
        In addition, they can use up to 20 percent of that money to
    support the per-capita-granted Medicaid program. So they have
    increased flexibility in addition to more money coming in for
    this population that right now they are not drawing down any
    kind of Medicaid expansion dollars for, so they can draw down
    these block-granted dollars.
        Again, in this second block grant, this replacement of the
    Affordable Care Act that is in Graham-Cassidy, only 13 States
    under this formula get less money than they are projected to
    get under current law. So the idea that all of these States are
    being slashed or there is this great redistribution of wealth
    between States that are, quote, ``blue States and red States''
    is simply just not the case.
        The phase-in of this program is deliberate. It is slow. It
    takes 10 years. There is a lot of flexibility that comes with
    this extra money.
        I mean, yes, you have flexibility in, well, as I said, all
    but 13 States, so that would be--well, that includes the
    District of Columbia, so in 38 States you are talking about
    more money and more flexibility to be able to deal with this
    population that was the target of the ACA.
        So I do not know if Dennis wants to add the part about how
    this interacts with Medicaid, but I think that interaction is
    actually positive too.
        Mr. Smith. Thank you, Mr. Chairman.
        The Chairman. Sure. Give us your view on that, and then we
    are going to turn to Ms. Mann. We will have Ms. Mann sum it up.
        Or if you would like to, let us go first to you, Ms. Mann,
    and you can make any comments you want. And then we will come
    back to you, Mr. Smith.
        Ms. Mann. So I am not sure what numbers Senator Santorum is
    referring to. I think it is numbers that actually add in State
    dollars and States' own dollars to what they would get under
    the block grant. You cannot have everybody getting more money
    under a block grant that at the end of the day redistributes
    the dollars very radically from high-cost and high-coverage
    States to those that are not doing it.
        There are no winners under this bill. You have every State
    putting the bulk of their Medicaid program, the vast majority
    of their Medicaid program--the elderly, the disabled, the
    children, the pregnant women--under a cap, so that when cancer
    treatments come out, if they are more expensive, the State will
    not be able to afford those costs or at least not without
    cutting something else. If there is the next hurricane, they
    cannot afford to address that emergency unless they cut
    something else. That is not how the financing in the Medicaid
    program works now.
        And it is so important to understand the basic structural
    change to financing for the vast majority of Medicaid
    beneficiaries.
        The Chairman. Okay.
        Mr. Smith?
        Mr. Smith. Thank you, Mr. Chairman.
        Again, obviously, we believe that Arkansas will be better
    off, or I would not be here today. And a number of other
    Governors feel the same way. So we believe that there is great
    value in this, in terms of a level of funding that is
    sustainable for both the States and the Federal Government.
    These dollars continue to grow over time.
        As I mentioned previously, medical CPI plus one is higher
    on a per-capita basis for elderly and disabled enrollees; it is
    higher than what CBO has in their baseline. So we believe that
    this is sustainable.
        We also believe that, while we have had progress--and both
    Ms. Mann and I have been part of that at CMS as we held the
    same job of, again, encouraging States to adopt greater and
    greater services in the home rather than in an institutional
    place of care.
        But I will also say, States have a long, long ways to go
    with what they can do. I think we just recently hit the 50-
    percent mark for long-term services and supports, with barely
    over 50 percent of the Medicaid dollars for LTSS going to home
    and community-based service settings rather than to an
    institutional case setting.
        So that tells me we still have a long ways to go to be able
    to serve people in their own homes, in their own settings,
    where they want to be. And that will, again, help to lower the
    cost curve, as we know that those are more cost-effective over
    time.
        The Chairman. Senator Carper, have you had your time?
        Senator Carper. Senator Casey has asked me to yield to him.
    He has another engagement.
        So I am happy to yield to him and maybe slip in later.
        The Chairman. That will be fine.
        Senator Casey. I want to thank Senator Carper for that
    courtesy.
        Just for the record, there was a reference earlier, or
    several references, to the Governors. That letter that they
    wrote, those 10 Governors, bipartisan, in the first paragraph
    they suggested not considering the bill--that is significant--
    but then they ended with what I think is a pretty good
    summation of what we should all be doing. And I think we
    started this in the HELP Committee. Here is the Governors'
    second-to-last paragraph, quote: ``We ask you to support
    bipartisan efforts to bring stability and affordability to our
    insurance markets. Legislation should receive consideration
    under regular order, including hearings in the health
    committees and input from appropriate health-related parties.
    Improvements to our health insurance markets should control
    costs, stabilize the market, and positively impact the coverage
    and care of millions of Americans, including many who are
    dealing with mental illness, chronic health problems, and drug
    addiction.''
        I think that is a pretty good summary of what we should all
    be doing. And I hope we can get back to that. But part of the
    predicate for that is, this bill does not pass, so we have some
    work to do this week.
        Ms. Mann, I promised that I would come back to you with a
    question that I posed to Secretary Miller with regard to what
    happens to Medicaid expansion. I asked her about the impact on
    Pennsylvania. In your judgment, based upon your experience--and
    I want to refer again to your time as both Deputy Administrator
    and Director of the Center for Medicaid and CHIP Services for
    CMS--what is your sense of what that means for the country,
    just the winding down of Medicaid expansion?
        Ms. Mann. Thank you, Senator. Well, first of all, it is not
    even winding down. January 1, 2020 it simply goes away.
        Senator Casey. Right.
        Ms. Mann. And some 11 million people who are covered under
    the Medicaid expansion, they simply will not have--the States
    will not have the legal authority or any ability to get Federal
    matching dollars in order to continue to cover them.
        The expansion has been enormously valuable in those States
    that have done it. Those are the States that have lowered their
    uninsured rates to record lows. And while the Nation as a whole
    has lowered its uninsurance rates, particularly it has happened
    in expansion States.
        But more than that, people have been getting care. Governor
    Snyder keeps a great dashboard in Michigan of how many people
    got mammograms and how many people got colonoscopies and how
    many people got preventive care.
        The Louisiana dashboard for their expansion, they got
    433,000 people covered under their Medicaid expansion, and they
    can tell you how many people got preventive testing and then
    were found to have illnesses and then got the treatment for
    those illnesses. It is real people, real services.
        But in addition, it has lowered uncompensated care costs.
    It has really helped hospitals stabilize their funding. You saw
    the map before about rural hospitals being most affected in
    non-expansion States.
        And it has also helped State budgets, as expenditures that
    a State might otherwise be needing to make now can be covered
    through the Medicaid expansion.
        All of that goes away if the expansion goes away.
        Senator Casey. And one of the points that you make, which I
    think is of paramount concern to me, is just the guarantee of
    Medicaid. In other words, you could have a family that has--and
    we saw this in some of the reaction of folks around the country
    the last couple of months--families with high incomes, good
    health care, but who still need Medicaid because their son or
    daughter has a profound disability of one kind or another. So
    not only--I mean, we have all kinds of families benefitting
    from that guarantee.
        The last thing I will say is, on page 3 of your testimony
    you mention the taking away of that guarantee. And then you go
    on to talk about the other side of Medicaid, meaning the
    original Medicaid program itself.
        You say the consequences of this major change in financing
    falls solely on those enrolled in the traditional Medicaid
    program, newborns and other children, very low-income parents,
    pregnant women, low-income seniors, and people with
    disabilities.
        And, if you want to add anything to that in 15 seconds----
        Ms. Mann. Well, and that is the irony of this, because a
    lot of the criticism about the expansion, even though there are
    people at 10 percent of poverty, 15 percent of poverty, 60
    percent of poverty, is that, oh, the resources should go to the
    traditional Medicaid program. And yet, this bill would cut
    those resources and impose an arbitrary cap. So those pregnant
    women and those children and those elderly and disabled
    individuals will not have that guarantee for funding, and the
    States will not be guaranteed that they will be able to afford
    the kind of treatment that those individuals need.
        Senator Casey. Thank you.
        Thank you, Mr. Chairman.
        The Chairman. Senator Stabenow?
        Senator Stabenow. Thank you, Mr. Chairman.
        First, I would like to submit for the record some of the
    emails that I have gotten just in the last several days from
    folks who are opposing this bill.
        The Chairman. Without objection. Without objection, they
    will be included in the record.
        Senator Stabenow. So I will leave this with you. Thank you
    very much.
        [The emails can be viewed on the committee's website.]
        Senator Stabenow. Mr. Chairman, I also want to emphasize
    again that I wish we were having a markup on the Children's
    Health Insurance Program, which you and our ranking member and
    myself and others have introduced, a bipartisan bill that is
    very important, 9 million children, and we will see CHIP ending
    at the end of this week----
        The Chairman. That is right.
        Senator Stabenow [continuing]. Along with community health
    center funding. Senator Blunt and I have 70 members of the
    Senate on a letter indicating we want to make sure that
    community health center funding is done by the end of this week
    as well.
        And we have a very important effort that is going on right
    now in the HELP Committee, a bipartisan effort with Senator
    Lamar Alexander, Senator Patty Murray. I want to thank you, Ms.
    Miller, for being a part of those discussions.
        And that is what we should be doing: a bill that rolls all
    that in together. And frankly, what we are hearing about today
    and over and over again in terms of the Affordable Care Act is
    really the part of the Affordable Care Act that is the
    individual marketplace, where less than 10 percent of the
    people are--in fact it is 6 percent in Michigan--who have
    gotten increased coverage through the individual markets.
        And in fact, we have situations where copays and premiums
    are too high. No question about that.
        But it is being used as a smokescreen, in my opinion, to
    hide what is really going on here behind the curtain, which is
    a gutting of Medicaid. Seniors in nursing homes--three out of
    five seniors in Michigan are in nursing homes--and Alzheimer's
    patients get their nursing home care through Medicaid, and
    children, and families.
        And now we have a CBO score that literally just came out
    that tells us the facts. And they are, in addition to seeing
    Medicaid coverage going down and coverage in the insurance
    system and so on going down, that just in Medicaid in the 10
    years, 2017 to 2026, there would be a cut of $1 trillion.
        Now, I have been using numbers that were not $1 trillion,
    but now it is $1 trillion in coverage cuts to seniors in
    nursing homes and children and families. And that is really
    what the goal is, I believe, with all due respect. I mean, that
    is what folks are going for, because we can fix the individual
    market without gutting Medicaid and taking away individual
    coverage for people.
        I want to talk about one of the areas of individual
    coverage, and that is mental health, something I care deeply
    about.
        I know, Senator Cassidy, you and I have talked about our
    interests in community-based services for mental illness and
    opioid addiction. And in the first bill you introduced, I know,
    the Patient Freedom Act, you actually included protections for
    mental health and substance abuse, even though you were
    creating the possibility of eliminating the essential health
    benefits.
        But in this new bill, that is not the case. There is no
    protection under essential benefits for mental health.
        Senator Cassidy. Can I respond to that, please?
        Senator Stabenow. Yes, you may.
        Senator Cassidy. First, let me say one thing about the $1
    trillion cut to Medicaid. It is repurposed into the flexible
    block grant. The money is still there, it is just not called
    Medicaid.
        As regards mental health parity, yes, mental health parity
    is still there under this law. And I do not have it in front of
    me----
        Senator Stabenow. I am going to stop you only because I
    agree, mental health parity is. In fact, I was proud to author
    that provision in the bill in this committee.
        Senator Cassidy. No, no, I am talking about my bill.
        Senator Stabenow. No, I know. I understand it is still
    there. That is not what I am talking about. So what you are
    saying--what we said with mental health parity is, that if you
    offer insurance, you have to offer this same kind of insurance
    for mental health. But because it is not included as an
    essential benefit, you no longer have to offer it.
        Senator Cassidy. That is not true. What it says is, any law
    before 2009 still applies.
        Senator Stabenow. Okay.
        Senator Cassidy. So if they offer insurance for physical
    health, they have to offer matching care for mental health.
        Senator Stabenow. Okay, well, let me turn now to get----
        Senator Cassidy. That is in the bill.
        Senator Stabenow. Essential benefits, offering that, what
    is in a package is different than mental health parity. I would
    agree with you that mental health provisions are in there.
        But, Ms. Miller, under this bill, insurers can end coverage
    of mental health and substance abuse services just like any
    other essential health benefit. Is that correct?
        Ms. Miller. That is correct.
        Senator Stabenow. Okay. And so it is not the same thing as
    parity, because you do not have to offer it in insurance plans.
        Also, Ms. Mann and Ms. Miller, what is a person in a
    situation supposed to do who can no longer get the treatment
    that they need for substance abuse, opioid addiction, or mental
    health services? And what would it cost for someone who is in
    that situation?
        The Chairman. Senator, your time is up.
        Senator Stabenow. I would like them to answer, please.
        The Chairman. Well, let us live within the 5-minute rule.
        Senator Stabenow. If they could just answer the question,
    Mr. Chairman.
        The Chairman. We are all getting tired of this.
        Senator Stabenow. Okay. Mr. Chairman, if they could just
    have a chance to answer the question of what is a person in
    that situation who no longer has mental health coverage
    supposed to do.
        The Chairman. Let her answer the question.
        Ms. Miller. I think that is a really good question. I think
    one of the things I worry about is, under Medicaid expansion in
    Pennsylvania and our individual market, the impacted markets
    here with this proposal, we have had 175,000 people in
    Pennsylvania who have accessed substance abuse treatment. And
    moving to this block grant and this reduced funding, I worry
    about whether or not those individuals who are getting that
    treatment will in the future be able to continue that
    treatment.
        Senator Stabenow. Thank you.
        The Chairman. Yes. The one thing that bothers me is, nobody
    asks, especially on the Democrat side, where is the money
    coming from? How do we pay for this? Who is going to get socked
    for all this, regardless?
        Now, we all want to help in every way we possibly can, but
    there is a limit to everything.
        Senator Portman?
        Senator Portman. Thank you, Mr. Chairman.
        I am glad to be back. I was here for a few hours earlier.
    And I support hearings, and I think we should have had more
    hearings with regard to this particular bill and, for that
    matter, health care in general. And so I would agree with what
    was said earlier about the need for more regular order, because
    we are actually beginning to get some of the facts out.
        And one of the facts, as I understand it, is that--as an
    example with regard to expanded Medicaid, which we did in Ohio,
    which has been very important on substance abuse treatment--
    that money continues to flow.
        And so the notion that you are worried about what is going
    to happen in Pennsylvania, Ms. Miller, I would hope that you
    and your Governor and others would continue to provide that
    funding for mental health and for substance abuse treatment,
    because it is going to be needed.
        And you know, the one thing that also has not gotten talked
    about here today--and look, I am still undecided on this bill
    because of the numbers. I am looking at the numbers, and they
    have changed, let us face it, even over the weekend, where Dr.
    Cassidy was helpful to us in Ohio and I think you in
    Pennsylvania and other States in allowing us to make some
    adjustments on the formula.
        But certainly in my State, and I assume in all of the
    States, this 10-percent match is really onerous. I mean, it is
    really onerous to the point that in Ohio, you know, our
    legislature is not interested in providing the 10-percent
    match. Moving just from 5 to 10, I am talking about. And in
    this legislation, you do not have to put up the match in order
    to get the money.
        So I mean, I am looking at the HHS numbers here, and, Dr.
    Cassidy, maybe I have this wrong, but current law would be, in
    year 2026, about $49 billion. Under this, it is about 9 percent
    more--these are HHS and OMB numbers--up to $53.7 billion if you
    include the State match not having to be paid to get that
    money. In other words, you would be able to get it without
    putting up a match, so that is about a 9-percent increase.
        Other numbers I have seen show that it would be about a 3-
    percent reduction over that 10-year period or, I guess, 10
    years from now, a 6-year period during the bill.
        If I were a Governor and you told me, you get flexibility
    to be able to cover these low-income folks in the way you want
    to, the most effective way--and by the way, 40 percent of our
    providers in Ohio are not accepting Medicaid. I do not know if
    that is true in your States. But Medicaid is incredibly
    important. It is absolutely essential to have it.
        But let's face it, it needs reform for a lot of reasons.
    One is, the reimbursement is such that many providers do not
    want to take it, and they are not required to. And so Medicaid
    recipients do not have the choices that many of us around this
    dais have.
        But that flexibility, I think, is what I hope--regardless
    of what happens with regard to this hearing and this week and
    any vote we have, we ought to have an honest conversation about
    that. And I think Democrats and Republicans alike believe there
    ought to be more flexibility, I hope. Because some of the
    examples that were used earlier of some States that have been
    innovative and some States that want to be a lot more
    innovative to get people into private plans who are in Medicaid
    right now and to cover them with better health care where they
    have more options, they can go to more specialists and more
    doctors, is that not a good thing?
        So I guess I would ask someone, Dr. Cassidy, I guess you
    are the best, am I right about the numbers, that actually Ohio
    under this provision would get more funding based on the HHS
    and OMB analysis? And why is that different than where the CMS
    actuaries were?
        Senator Cassidy. Yes. So the CMS actuaries had the first
    bill, and that is when we learned over the weekend that the
    inflation rates are just incredible that are projected for the
    individual market.
        So we reworked the bill. We do not get to equity as soon as
    we would like. On the other hand, we keep there from being a
    big drain from States which have already expanded.
        And you are right. Ms. Miller, in all due respect, seems
    not to think that Governors will have any imagination on how
    they will use these dollars.
        But obviously, Mr. Smith comes up with all these
    imaginative ways. And your Governor has been imaginative. And
    Maine has been imaginative.
        By waiving the match--in your State it is $49 billion under
    current law, it is $47.54 billion under our proposal, and then
    you can waive the match to the tune of $6.2 billion.
        Senator Portman. And that is how you get to 53.7.
        Senator Cassidy. Fifty-three-point-seven.
        Senator Portman. Yes.
        Mr. Santorum. If I could add to that.
        Senator Portman. But why is that different? The CMS
    actuaries were lower, and why was that?
        Senator Cassidy. Well, they had done the previous bill.
        Mr. Santorum. Right. The change we made in adapting this
    bill was, number one, going from a phase-in of the formula over
    a 6-year period of time to a 10-year period. So the States that
    are expansion States keep their levels higher longer, and that
    is one reason. And the second is, we put a cap on the growth of
    the non-
    expansion States.
        Senator Portman. Okay. Let me ask another question about
    the formula. I was pleased to see over the weekend, and we
    talked a lot about this--I was concerned about Ohio. We removed
    the CHIP AV formula that I think would have hurt Ohio by
    resulting in less funding. That is out of there now?
        Senator Cassidy. Yes.
        Senator Portman. That is one reason I think Ohio and other
    expansion States do better now.
        Another one that concerns me still is not to include those
    between zero and 50 percent of the Federal poverty line. Why do
    we only include 50 percent in your bill up to 138 percent? Why
    not include those between zero and 50 percent in the formula?
        Senator Cassidy. That is just the means to distribute the
    dollars, the denominator, if you will.
        On the other hand, the money can be spent as long as the
    focus is on the lower income and the working income, and that
    is per CHIP regulations. Again, this goes through CHIP with
    those guardrails.
        But on the other hand, that is just the means to
    distribute. We had to pick a number, and that is kind of the
    CHIP focus.
        Senator Portman. Well, it is a means to distribute, but in
    Ohio we cover those people, so----
        Senator Cassidy. And you still can. You would just use the
    dollars. Again, it does not prejudice how you spend the money.
        Senator Portman. I understand.
        The Chairman. Senator, your time is up.
        Senator Portman. It helps us to have his formula.
        Thank you, Mr. Chairman.
        The Chairman. Senator Bennet?
        Senator Bennet. Thank you, Mr. Chairman.
        And I think we have heard a lot today about how you can cut
    all this money and continue to insure people. We now know from
    the CBO with their truncated score, a score that they should be
    able to do over the next weeks and months, that millions of
    people will lose their insurance if we pass this bill.
        Now, I understand that somebody could have a principled
    position. Senator Santorum may have had this position in the
    past, I do not know, a principled position to say the Federal
    Government should not be in the business of health care. I have
    heard people say that for 8 years. And I have heard others, my
    friend--and he is my friend--from Ohio say that Medicaid needs
    reform.
        The problem that we are facing as a country, not just in
    these States, and I will--Mr. Chairman, may I insert for the
    record all the money Colorado is losing as a result of this
    legislation?
        The Chairman. Without objection, we will put that in the
    record.
        [The information appears in the appendix on p. 91.]
        Senator Bennet. Thank you. And I would say it has been
    amazing to watch supporters of this bill waving a flag around
    or a map around of who the winners and the losers are.
        Senator Paul said it very well, that this is a transfer
    from Democratic States to Republican States. It is obvious what
    is going on here. And in a world where the cornhusker kickback,
    so called, set off so many people, they should be appalled by
    that kind of discussion here.
        But in any case, the problem that we face as a country is
    that I have a bunch of people in Colorado who make too much
    money to be on Medicaid, but who cannot afford private
    insurance. That is a huge problem in America.
        And it is a huge problem that there are a bunch of people
    on Medicaid who, if they lose their Medicaid, will have an even
    harder time buying insurance than middle-class people who
    cannot afford it because we have not created the kind of
    transparency around health care that other countries have, and
    we have not created the kind of incentive structure that would
    drive down costs, which is really what we need to do if we are
    concerned about preserving the entitlement and doing something
    useful for our budget.
        This throws a bunch of people off Medicaid with absolutely
    no suggestion about how they will be covered, which means that
    we will once again have uninsured people showing up in
    emergency rooms all over the country.
        In Colorado, Mr. Chairman, a lot of rural hospitals had 14
    percent bad debt--they called it uncompensated care--before the
    Affordable Care Act was passed. That number has dropped to 2
    percent. That represents a huge savings that, if those folks
    are no longer on Medicaid, will be wiped out, and we will be
    once again chasing our tail around this place.
        I appreciate my colleagues' commitment to federalism, but I
    suspect that part of the reason why this has become an
    attractive vehicle is not just that it is the last one
    standing, but that it appeases my colleagues on the other side,
    who have voted 60 times in the House to repeal Obamacare, but
    in 7 years were unable to forge a consensus among themselves
    about what a theory on improving American health care should
    be.
        And so what they have done is left it to the States. An
    admirable thing to do from a federalism perspective; I am just
    suggesting that there might have been other reasons.
        But in doing it the way they have done it, Mr. Chairman--
    and, Ms. Miller, I am coming to you. We talked, you and I
    talked about the instability in the individual market as a
    result of this legislation. Now let us talk about the
    instability over the next 2 years as every State in America is
    going to be forced at exactly the same moment to try to create
    an entirely new health-care system in a 24-month period without
    knowing what the funding levels are going to be for months and
    months and months, with part-time legislators, full-time
    legislators. What does that all look like in America?
        And who are we, by the way, to set that agenda for our 50
    States? It certainly will be a great boon to health-care
    consultants in America, but I am not sure it is going to be
    great for the American people.
        Ms. Miller? Thank you.
        Ms. Miller. Well, I think one of the problems is, I do not
    know that it will be a big boon to the health-care consultants,
    because States do not have any funding like we did when the ACA
    passed to hire consultants to help us figure out how to do
    this.
        Senator Bennet. So is there no money? There is no money in
    this program to set up the program?
        Ms. Miller. To help us figure out what to do, no. And I
    think that is one of the fundamental issues.
        But I think it is also that, in a 2-year period, I have no
    idea how we would figure out what this new system is going to
    look like. Getting legislation passed in Pennsylvania is not an
    easy thing to do.
        Senator Bennet. Really? It is so easy here, I do not know
    why it would be hard there. [Laughter.]
        Ms. Miller. And we do have a full-time legislature, but we
    would have to bring all of our stakeholders together, figure
    out what this new system could look like, and put all the
    pieces in place to make it happen.
        With the ACA, States had 4 years and they knew what they
    were aiming for. They knew that if they wanted to create a
    State-based exchange, that is what the new system would look
    like.
        Here, we do not know what this new system would look like.
    And 2 years--I am not sure if we could do it in 5, but in 2
    years I do not know how we would possibly do that. And I think
    in the meantime we have individual markets that are going to be
    significantly destabilized because this bill will throw the
    individual market into chaos.
        Senator Bennet. Thank you, Mr. Chairman.
        The Chairman. Thank you.
        Senator Cassidy. Mr. Chairman, could I correct a question
    of fact?
        The Chairman. Sure.
        Senator Cassidy. There is a $2-billion implementation fund
    included in the bill, number one. Number two, the CBO score,
    JCT score which you quote, does say that States could elect to
    continue their current Medicaid programs. So I just wanted to
    correct that.
        The Chairman. I have to give you credit. You have been very
    effective here in front of this committee, and you are a
    doctor.
        Senator Bennet. Well, Mr. Chairman, I appreciate the fact
    that we are now relying on a CBO score which should have come
    months ago or weeks ago.
        The Chairman. Well, I agree with you.
        Senator Bennet. And I know you would. But it says that
    millions of people will lose their health insurance as a result
    of this terrible piece of legislation.
        The Chairman. Senator Carper?
        Senator Carper. Mr. Chairman, I ask unanimous consent that
    these messages from citizens of Delaware be admitted for the
    record, please.
        The Chairman. Without objection, they will be admitted.
        [The messages can be viewed on the committee's website.]
        Senator Carper. Mark Twain once said, ``It ain't so much
    what people do not know that bothers me, it's what they know
    for sure that just ain't so.''
        I am going to ask, starting with Ms. Miller, Ms. Mann, and
    Mr. Woodruff, just to think back on some things you heard from
    us, from this panel, it could have been the other witnesses,
    but some things you heard that just ain't so.
        Do you want to lead it off, Ms. Miller? Be brief. This is
    not to impugn anybody's integrity or honesty, but what have you
    heard that just ain't so?
        Ms. Miller. I think the difficulty I have with a lot of the
    discussion is that we are talking about, in this proposal,
    making drastic cuts in Medicaid. I mean, that is what we are
    talking about, but we are doing it under the guise of
    Obamacare's failing.
        And again, when we talk about Obamacare failing, what we
    are talking about is the problems with stabilizing the
    individual market. And we have all agreed there are problems
    with the individual market, and we need to stabilize that
    market.
        Senator Carper. And a lot of them are self-inflicted
    wounds, if you do not mind my saying so. Yes, there are things
    that we could do. Go ahead, go ahead.
        Ms. Miller. There absolutely are. I think the very people
    who want to get rid of Obamacare were the very people who have
    helped it struggle in some cases. And I think that
    fundamentally there is nothing in this bill that will stabilize
    the individual market. It will do just the opposite.
        Senator Carper. Good point.
        Ms. Miller. But we also just need to be clear about what we
    are doing. We are making major, major reductions in the
    Medicaid program.
        Senator Carper. Thanks.
        Ms. Mann, what have you heard that just ain't so?
        Ms. Mann. I have a long list, but in the interest of time,
    let me hit on three points.
        Senator Carper. Really quickly.
        Ms. Mann. One is, there has been a lot of discussion about
    the 10-percent match. Of course, it was not fully a 10-percent
    match for a while, but it was a 10-percent match that has kept
    some States from expanding Medicaid.
        For the most part, it was, besides the politics, the
    uncertainty about whether the 90 percent would still be there
    that kept a lot of States from jumping into expansion. And look
    at the uncertainties of the funding in this new bill. You have
    zero funding in 2027. You have to imagine something will come
    about at that point. That uncertainty makes the uncertainty
    about Medicaid expansion funding pale in comparison.
        Second, again, concern about States meeting their State
    match. On the traditional Medicaid side--the much bigger
    expenditure for States rather than the expansion--this bill
    would reduce States' flexibility to rely on provider taxes, a
    very prominent way that States have used to be able to finance
    their Medicaid programs. It would reduce their reliance on that
    considerably.
        And then finally, it is this myth that we can have a capped
    amount of money and, if you are concerned about this problem,
    we can fix it; if you are concerned about that problem, we can
    fix it.
        As I understand from CBO, their analysis says, sure, every
    State could replace their Medicaid expansion with these block
    grant dollars and there would be not a penny left then to do
    the insurance reforms and the stabilization that we also think
    are incredibly important.
        Senator Carper. Thank you.
        Mr. Woodruff, what have you heard that is just not so?
        Mr. Woodruff. Just really quickly, the absurdity of the
    allegation that you can take hundreds of billions of dollars
    out of Medicaid and continue to insure the same number of
    people who are being insured now.
        And secondly, that we can expect the States to create out
    of whole cloth a new insurance system in 2 years when they had
    such a difficult time doing a much easier system in 4 years
    under the Affordable Care Act.
        Senator Carper. All right. Let me just note for the record,
    I have never been a doctor. I have been a Naval flight officer,
    studied some economics, got an M.B.A., State Treasurer,
    Governor, chairman of the National Governors Association, lead
    Governor on welfare reform. And I have thought a lot about
    these issues.
        One of the reasons why welfare reform worked is because we
    launched right in the middle of one of the greatest economic
    expansions in the history of our country. Unemployment went
    down; revenues went up. We were able to make sure that people
    were better off getting off of welfare and going to work.
        What we have coming at us right now is a tsunami. It
    includes a combination of things: a baby boomer generation, a
    tidal wave that just keeps on coming.
        It used to be when I was State Treasurer, most of the money
    we spent on Medicaid was for moms with children in poverty.
    Today, it ain't so. It is, like, two-thirds of the money we
    spend on Medicaid is for people--our parents, our grandparents,
    our aunts, and our uncles--a lot of whom have dementia and are
    in poverty.
        Two million of the folks who use Medicaid are veterans. I
    am a veteran. Two million are veterans, and we have this tidal
    wave of drug abuse that is sweeping across our country.
        And before we go ahead and pull the rug out from the
    States--before we go ahead and pull the rug out from the
    States--we need to hit the pause button, and why do we not just
    set it aside and say, let us maybe stop working just as
    Democrats or just as Republicans; maybe we should try this
    together.
        An old African proverb--I will close with this, Mr.
    Chairman--an old African proverb goes something like this. If
    you want to travel fast, go alone. If you want to travel far,
    go together. This is an issue that begs for us to travel
    together on.
        Thank you.
        The Chairman. Senator Cantwell?
        Senator Cantwell. Thank you, Mr. Chairman.
        I want to go back to my first round, because now that we
    have the CBO score, which is pretty illuminating--well, I would
    say it is pretty detailed in the bill's effect on Medicaid. On
    page 7, I note it says, quote, ``In general, States would not
    have substantially additional flexibility under the per-capita
    cap.'' So a few States would probably obtain additional
    flexibility.
        And then it goes on to say, quote, ``However, because
    funding under the program would grow over time at the rate of
    CPIU, CBO anticipates that it would be attractive mainly to the
    few States that expect to decline in population and would have
    little effect on enrollment in Medicaid.'' That is who would be
    attracted to it.
        It would not be attractive to States that are experiencing
    population growth, as they would not be adjusted for that
    growth.
        So, okay, I do not know if this is the people designing
    this who did not want to expand, who did not think that it is
    increasing affordability, because it is, that it is increasing
    access to care, that it is bringing people up, and now they are
    proposing something that is really about just being attractive
    if you really just think you are going to have lower
    populations and not cover people.
        I am interested, though, because there is a commonality,
    Mr. Smith, between you and Ms. Miller, in that you both support
    Community First Choice programs in the context of delivering
    access to care through more affordable rates. And the 85
    percent of home and community-based care versus 15 percent
    nursing home care, that is what we have been able to achieve in
    our State.
        The Graham-Cassidy bill further cuts that incentive there
    to get States to do that. Wouldn't that be a huge cost saver? I
    am talking in the tens of billions, if not even in the hundreds
    of billions of dollars, if we could get States to achieve a
    better balance on
    community-based care versus nursing home care. Isn't that real
    money?
        Ms. Miller. I think it would be, and that is one of the
    innovations that States can do today under existing waivers.
        Senator Cantwell. Well, Graham-Cassidy actually rolls that
    back. So it disincents it. I think we should put pedal to the
    metal and incent it even more because, frankly, about 10 or 15
    States have taken us up on it. And I think that this is real
    savings. Plus, who doesn't want to get community health at
    home?
        Ms. Mann, I see you nodding your head.
        This is the right strategy. So our colleagues who say that
    there is no savings in changes that we can make in Medicaid,
    here is a win-win-win. People would love to stay at home and
    age, would love to have care delivered there instead, and,
    guess what, it is way cheaper than nursing home care.
        And if you are going to accept a population of people who
    are reaching retirement and demanding more of those services,
    then you want to implement something like this and continue to
    incent it. So definitely you do not want to--yes, Mr. Smith?
        Mr. Smith. Senator, if I may clarify, because I think we
    were talking about two different programs: the Money Follows
    the Person, which we created in 2005, and then the Community
    First Choice provision, which offered an enhanced match.
        But with that enhanced match, States were required to be
    Statewide. So you could not have any waiting list whatsoever.
        In Medicaid waivers--and we have had 30 years of experience
    now in home and community-based waivers--States were allowed to
    have a waiting list. Not under the Community First Choice,
    however.
        So there are a number of States, including Arkansas, that
    could not afford to go Statewide, even with that 6 percentage
    point enhanced match rate.
        So again, part of this is, there are both incentives and
    barriers to be able to do some of the things that were
    available then.
        Senator Cantwell. Yes, I appreciate that.
        Senator Cassidy. And if I may say, on page 100, we ensure
    access to home and community-based services. That is page 100.
        Senator Cantwell. You know, I think the issue for us in the
    Pacific Northwest is, we are just a little tired of the tail
    wagging the dog when it comes to these issues. We deliver
    better care at lower costs. Okay? We deliver less expensive
    care, probably $2,000 to $3,000 less per Medicare beneficiary,
    than Louisiana, and we deliver better care. Okay?
        So we know what innovation is, and we want to run towards
    it. Some people want to walk, and we get that; we want to run
    towards it. These are the real savings.
        So if you cut the innovation out in Graham-Cassidy that
    already exists for State flexibility, then you are going to put
    us even further behind in achieving some of these savings that
    are really on the delivery system side of the case that we have
    to get to.
        And so that is my point, Mr. Chairman. I see my time is
    expired.
        But I just hope that people will hear what Ms. Miller had
    said in the first round, and that is, these are the big things
    that are going to help save us and drive down cost.
        The Chairman. Thank you, Senator.
        Senator Cantwell. Thank you, Mr. Chairman.
        The Chairman. Thank you.
        Senator Brown?
        Senator Brown. Thank you, Mr. Chairman.
        Let me tell you about the young man in the blue shirt on
    the poster board behind me. This is Dr. Bignall, whom I met at
    Cincinnati Children's Hospital. This is Kaden. Kaden is 3 years
    old. This is Kaden's older brother and Kaden's grandmother.
        He looks like any 3-year-old with that mischievous smile on
    his face. He has already been through more in his 3 years on
    this earth than most of us will go through in our lives. He was
    born with failing kidneys due to a condition called obstructive
    uropathy. But thanks to his Medicaid coverage, his doctors at
    Cincinnati Children's were able to make sure that he was able
    to begin life-
    sustaining dialysis treatment when he was 2 weeks old.
        Two years later, Medicaid covered the kidney transplant to
    save Kaden's life. Now, like hundreds of thousands of other
    children in the State of Ohio, Kaden relies on Medicaid and the
    CHIP program, which we have not reauthorized--we have not; this
    committee frankly has failed to do its job. It expires
    September 30th. Because of CHIP and Medicaid, he is doing okay.
    They have given him the chance to grow and learn and play and
    thrive.
        Now, Senator Cassidy, in light of your response on
    questions, your answer that, because of the flexibility,
    Medicaid can take care of Kaden and children's hospitals, and
    Medicaid, because of the flexibility given to Governors, can
    take care of opioid treatment, and because of its flexibility
    Medicaid can take care of seniors in nursing homes, and because
    of its flexibility Medicaid can do all kinds of things, could
    you assure us today that States will have the capacity to fully
    cover high-cost patients like Kaden? ``Yes'' or ``no''?
        Senator Cassidy. Absolutely.
        Senator Brown. Okay.
        Ms. Miller, Ms. Mann, comment on that.
        Ms. Mann. Every aspect of the financing for coverage that
    we are talking about, whether it is in traditional Medicaid or
    whether it is through the new block grant, will have a capped
    amount of Federal dollars. There will be a finite amount. And
    unless a State is able and willing to put up its additional
    dollars, there is no guarantee that high-cost, high-needs
    individuals will continue to see the care that they need.
        Senator Cassidy. May I correct Ms. Mann for one thing?
    Disabled children are specifically carved out of the cap. They
    can receive as much as they currently do.
        And I can also point out, when Mr. Smith points out there
    are capitation payments to managed-care companies, these people
    you describe are within those capitated amounts.
        Senator Brown. Okay. Ms. Miller, before you respond
    specifically to his comments, which I think have been
    fundamentally in error through much of this hearing, we talked
    earlier about the competition in Lansing and Harrisburg and
    Jeff City and in every other capital, in Indianapolis--how do
    you fund opioid treatment at the same time? The competition in
    State capitals from all those advocates, children's advocates,
    opioid treatment advocates, senior advocates, hospital
    advocates, how does this play out? How in fact is Kaden
    protected?
        Ms. Miller. That is my concern. I am looking at the CBO
    analysis that said in 2020 both expansion and non-expansion
    States would receive about 10 percent less funding under block
    grants than the amount they would receive otherwise through
    Medicaid expansion and individual market subsidies.
        But by 2026--and this impacts Pennsylvania--expansion
    States, like Pennsylvania, would receive about 30 percent less
    funding than we would otherwise receive through Medicaid
    expansion and individual market subsidies. And non-expansion
    States would receive about 30 percent more. So I do think we
    are looking at huge transfers of funding from expansion States
    to non-expansion States. And in Harrisburg, that is going to be
    a big problem.
        Senator Brown. So in Ohio, we had a Republican Governor, as
    you know, who expanded Medicaid. Even in Ohio, only 24 percent
    of children with intellectual or developmental disabilities who
    are on Medicaid rely on SSI. So I am confused about this
    proposal which does not seem to protect the remaining 76
    percent of children on Medicaid.
        But let me ask another question to Ms. Miller and Ms. Mann
    in my last remaining minute.
        Three in five nursing home residents in Ohio rely on
    Medicaid. I met Bob at a nursing home in Toledo and his mother,
    Blanche, who lives in a home in Perrysburg. He said, ``My
    mother and father worked all their lives. My mother is 95. You
    have heard this story over and over and over in every community
    in the country. They receive a pension of $1,500 a month.
    Medicaid keeps her alive so she is able to spend time with her
    kids and her grandkids.''
        So, Ms. Miller, Ms. Mann, will quality nursing homes, like
    the one Blanche relies on, be able to survive if Graham-Cassidy
    passes?
        Ms. Mann, you start.
        Ms. Mann. Well, we talked about what the levers are for
    being able to reduce cost. One is provider payments--reducing
    provider payments. And that is usually the first place a State
    will go, because it does not want to reduce eligibility or
    benefits. And so we really worry about the risks to high-
    quality nursing homes. High-quality providers will be affected
    by the limitation on the dollars that States will have to
    spend.
        And if I could just respond to Senator Cassidy's statement
    about disabled kids being exempted from the cap. They are
    exempted from the calculation of the aggregate cap, and that is
    an important feature of the definition of the cap. But at the
    end of the day, the State has to meet a certain amount of
    savings in order to stay below its aggregate cap.
        And nobody in the Medicaid program, including kids with
    disabilities, is going to be immune from the cuts that a State
    will have to make to keep within its cap limits.
        Senator Brown. Thank you, Ms. Mann.
        I would just implore the chairman. John Kasich, my
    Republican Governor, has run for office, has talked repeatedly
    about repealing and replacing the Affordable Care Act, yet he
    has the intellectual integrity to speak out on this,
    understanding that when he expanded Medicaid, it meant 700,000
    Ohioans got insurance.
        I would love, Mr. Chairman, to have another hearing and
    bring in Governor Kasich, bring in the Nevada Governor, who has
    spoken about this, and bring in the Governor of Arizona, who
    changed his position and said he supports it. Let us hear from
    all of them. You know, let the winds on both sides blow through
    this body so we can hear from them about why State Governors do
    not like this proposal. They think it is a disaster for
    Medicaid and consumer protections in my State.
        The Chairman. Senator McCaskill?
        Senator McCaskill. Thank you, Mr. Chairman.
        While the CBO needs more time to fully evaluate this
    legislation--and they probably do not have the latest version,
    since it just happened today--they have very clearly said that,
    all told, Federal spending on Medicaid would be reduced by a
    trillion dollars over the 2017 to 2026 time period.
        They have also said that many millions and millions of
    people would lose coverage in the Medicaid program--and they go
    through the three reasons that would happen--but also, this is
    important, total enrollment in the non-group market would be
    lower because the current-law subsidies for coverage in that
    market would be eliminated and the individual mandate would be
    repealed.
        So more than half of this bill is about Medicaid. And every
    example I hear about the problems with Obamacare are about the
    individual market for people who do not get subsidies.
        As said over and over again, but it bears repeating, every
    example that the Republican Senators have cited has been about
    people on the individual market without subsidies. And I know
    that has gotten very expensive. That is where I buy my
    insurance. I buy it on the individual market, and I do not take
    any employer contribution. So I have seen my premiums go up,
    and I know we need to do something to stabilize that.
        But the notion that this bill is going to do that--there is
    nothing in this bill that will do that.
        The individual market, it is going to see less stability.
    That is in the CBO report, and that is from everyone who has
    looked at it. It is going to be a chaotic time in terms of the
    timeline in which you are asking these States to come up with
    an entire delivery system. There are going to be fewer people
    in the market, not more. There is not going to be a mandate.
        And not only are you going to ask these States to do more
    with less and call it flexibility, you actually said that when
    somebody shows up at the hospital without insurance, the State
    is going to pay the bill. That is not going to happen. There is
    not going to be money for that. That hospital at the end of the
    year is going to call the insurance companies and say, we have
    too much uninsured care, we are raising all your premiums. So
    not only will premiums continue to go up in the individual
    market, they are going to continue to go up in the employer
    market because uninsured care is going to go up under this
    plan.
        And also, there is a big loophole I wanted to ask you about
    on federalism. You have in your bill at one point that the
    Federal Government is allowed to adjust how much States get
    based on an adjustment factor.
        And it says, on page 29 of the bill, that directs the
    Secretary to consider legitimate factors that impact the
    health-care expenditures in the State. But I could not find a
    definition for ``legitimate factor.'' It gives that Secretary
    an awful lot of power, does it not? Couldn't Secretary Price
    say, ``Harvey is a legitimate factor, and I am taking a big
    chunk of the money from other States to take it to Harvey?''
        Senator Cassidy. No, that is a risk adjustment which is
    commonly used in insurance. It uses age--elderly people are
    obviously more expensive--disease burden, cost of living. So if
    you are in a State like Pennsylvania, which has a higher cost
    of living in Philadelphia, that would come in. It would be a
    risk-adjustment factor which would allow movement of
    something----
        Senator McCaskill. But it is an open-ended----
        Senator Cassidy. No, it is actually a very established
    actuarial process, and it is currently being used in Texas, New
    York, and other States. It can move you up 10 or down 10.
        Senator McCaskill. Well, I am talking about the language of
    the bill, Senator. I am talking about the language of the bill.
    The language of the bill does not limit it. The language of the
    bill leaves it open-ended.
        Senator Cassidy. It is a risk-adjustment factor, and it is
    commonly understood what it means.
        Senator McCaskill. Well, it says ``legitimate factors.'' It
    does not say ``risk.'' It says ``legitimate factors that impact
    the health-care expenditures in a State.''
        Senator Cassidy. And those are the actuarially important
    factors.
        Senator McCaskill. I do not think your bill is specific
    about that. I think it leaves an awful lot of power where you
    all are touting it no longer resides, and that is with the
    Secretary of HHS.
        I know that, Mr. Woodruff, you spoke eloquently about how
    we are going to do more with less, we are going to stabilize an
    individual market, we are going to take care of everyone who
    does not buy insurance, we are going to make sure nobody has to
    buy insurance. And by the way, all these States are going to
    set all this up in less than 2 years.
        Could you briefly talk, any of the witnesses, about the
    feasibility of the timeline that is in this bill in terms of
    States taking over this responsibility and having to file plans
    as quickly as they will have to file plans?
        And is it not possible they are just going to default to
    traditional Medicaid?
        Mr. Smith. I would be happy to address it, Senator. Again,
    the time frame for filing an application is by March 31, 2019,
    I believe, and then it goes into effect in 2020. And comments
    were made earlier that there are a number of States that do not
    meet all year round. But in fact, they have committees that
    meet all year round. You have committees who go out and do
    public hearings amongst the States all year round.
        And I would suggest that all of the----
        Senator McCaskill. They cannot legislatively act, though.
        Mr. Smith. No, ma'am, but you can go out. You can go out
    and develop----
        Senator McCaskill. But having a hearing--I wish we could
    legislatively act rather than just having a hearing. But
    unfortunately, we cannot.
        Mr. Smith. You can go out and build your plan. You can get
    the input from the stakeholder community, from consumers, et
    cetera, and put your options together so you are ready when you
    do come back into legislative session. Many Governors can call
    a legislature back into special session if need be.
        But I think what makes this so very different from the ACA
    and the long ramp-up to that versus where we are today is, the
    ACA completely disrupted the distribution system, right? You
    moved from an individual market that was based on insurance
    agents and brokers marketing insurance plans. That all blew up
    because it all got federalized. You had to build
    HealthCare.gov, you had to do all of these things that
    interrupted the distribution system.
        We now have a distribution system. We have carriers that
    are serving people whom they did not serve previously. They are
    going to want to hold onto those customers. They are going to
    want to continue to make it the easiest distribution system
    possible, because otherwise they lose their customers.
        So in all of the infrastructure, the technology that has
    been developed over these past few years, States are not going
    to throw that out. They are going to keep it. That is why you
    are going to be able to implement this so much more quickly.
        Senator McCaskill. I appreciate you jumping in.
        I appreciate the chairman letting you go over for 2
    minutes. I am not sure that he would have allowed the other
    witnesses to go over for 2 minutes.
        But I would have liked to hear from the witnesses who would
    have talked about what a huge mountain this is to climb. But I
    will have to wait for that.
        The Chairman. Thank you, Senator.
        Senator Cassidy, as a member of the committee, wants to ask
    a question or two. And that will be fine. And then Senator
    Wyden and I are going to wind this up.
        Senator Cassidy. Okay. Senator Carper said, ``What have you
    heard that just ain't so?'' So let me just go through some of
    the notes that I have taken.
        First, it has been a little ironic. On the other side of
    the aisle, there has been a lot of, kind of, oh my gosh, States
    cannot pull this off, but a lot of good comments by Senator
    Carper about Romneycare in Massachusetts, a State initiative
    which radically transformed the health care in Massachusetts,
    was done quite successfully, and was being praised at the same
    time we were told that it could not be done.
        There were questions about stability funds. There are
    stability funds in 2019 and 2020. And as we mentioned, there is
    also a $2-billion implementation fund.
        I will also point out that Senator Nelson talked about the
    need in cases of public health emergency. There is $5 billion
    in this fund for public health emergencies. And if there is
    more needed, then more will be given. But it is specifically
    excluded from that which they may have to do.
        He also mentioned the need, in the State of Florida right
    now, to get every dollar they can. We waive the Medicaid match,
    and Florida ends up with 15 billion extra dollars than it has
    right now.
        Senator Stabenow suggested that we are cutting a trillion
    dollars from Medicaid. No, we just repurpose it into other
    areas. So the money is still there, available for the States.
        Senator Bennet suggested that this is a transfer from
    Democratic States to Republican States. Virginia is represented
    by two Democratic Senators, Missouri by Senator McCaskill. Her
    State ends up with $4 billion more between 2020 and 2026.
        Senator McCaskill. Is that factored----
        Senator Cassidy. By the way, on the issue of flexibility,
    Senator Bennet also raised, oh, my gosh, there are folks in
    your State, which I am totally about, Senator Bennet, totally
    about, who cannot afford their insurance. This gives your State
    the flexibility to do premium support, where if they cannot
    afford the employees' contribution to be on employer-sponsored
    insurance, you could do premium supports so they could get on
    there.
        Indeed, the report that just came out from CBO says that
    they imagine that States would imitate successful programs in
    one State and implement them in another.
        There is also an issue of whether or not a restriction on
    the amount of funding will restrict access. And Senator
    Cantwell, whom I have learned so much from, she talks about how
    her State gets less on a per-beneficiary basis on Medicare, so
    they have had to innovate. And as they innovate, paradoxically,
    they have actually improved outcomes. This is what we are
    saying the potential is. And Senator Cantwell's State is one of
    those States which has absolutely done it.
        Let us see; Senator Brown suggested everything I have said
    is fundamentally in error. That is actually an ad hominem
    attack, which I think is actually beneath the dignity of this
    body. And I am willing to, point by point, address whatever
    Senator Brown thinks is wrong. But an ad hominem attack, I
    think is beneath us.
        Regarding people falling off of enrollment, there are all
    these reports that people will fall off. Well, for Senator
    McCaskill's point of view, for the Standard and Poor's study,
    the Standard and Poor's study which says there is going to be
    all these dire effects, they based that on the Avalere study.
    The Avalere study scored us over 20 years, and this bill is
    only for 10.
        The Avalere study assumes for the next 10 years there is no
    money whatsoever, but that is absurd. We actually renew
    programs around here, as we do the CHIP program. And so the
    Standard and Poor's study based upon the Avalere study is
    frankly just not worthwhile.
        As regards eliminating the individual mandate, aside from
    the fact the American people hate it, one of the reasons they
    voted for Donald Trump is because he promised to repeal it. It
    also does not work. It does not work. And that is per Jonathan
    Gruber. The fellow who was the architect of the Affordable Care
    Act, in The New England Journal of Medicine reported research
    that he did for the National Bureau of Economic Research in
    which he said, and I am going to quote Mr. Gruber's comment,
    ``The individual mandate had no significant effect on coverage
    in 2014.'' Now, he tries to say maybe it did, but he cannot
    prove it.
        Now, I am going to submit this for the record, Mr.
    Chairman, Jonathan Gruber saying the individual mandate had no
    effect. The CBO still credits it, even though it has no effect.
        What does have an effect is a Governor getting engaged. If
    a Governor gets engaged, he can, for example, do things like
    automatic enrollment.
        Senator McCaskill, the AEI also has a paper on how
    automatic enrollment could be instituted so that those who
    perhaps cannot get covered for whatever reason could be covered
    automatically, just as we do on Medicare.
        Let me finish by saying this. There is one thing we have
    bipartisan agreement on. The Affordable Care Act is not
    working. The proposal we have advanced has been called radical
    today. But the alternative on the other side of the aisle is
    single-payer. There are 15 cosponsors for Senator Sanders's
    proposal, because it is a tacit acknowledgment that the
    Affordable Care Act is not working.
        And this I submit for the record, Mr. Chairman. These
    yellow counties are the ones in which there is only one
    insurance company covering. And the red ones, some of which are
    in Missouri, are the ones in which there are no insurance
    companies covering.
        We have a problem. We can either go forward with the
    single-payer option, which the other side of the aisle seems to
    favor, or we can do what we have done with Massachusetts, with
    Arkansas, with other States, giving them the opportunity to
    implement. And perhaps like Washington State, they would
    deliver better care at a lower cost. We actually think that
    will happen.
        Mr. Chairman, thank you for indulging me.
        And by the way, by and large my colleagues have been civil.
    You have been so respectful in a really good debate. I make no
    defense of the process, but I do thank you. I thank you for
    thinking carefully about it. I thank you for your civility. It
    is a privilege to be in this body. I cannot praise you enough.
        Thank you. I yield back.
        The Chairman. Well, thank you, Senator. I think that you
    have more than demonstrated civility yourself. And you did go
    over, but that is okay. You have had all these people attacking
    you all day; you should have a little more time as it is.
        But we are going to now finish with Senator Wyden who
    will--oh, Senator Bennet does have another question.
        Senator Bennet. I am very grateful for your----
        Senator Wyden. Just if my colleague will hold up.
        Mr. Chairman, I did have a 5-minute closer. Senator
    McCaskill apparently has something that is particularly
    important to her, so she can take 5 minutes.
        The Chairman. She will take your 5 minutes?
        Senator Wyden. Yes.
        Senator McCaskill. I will only need a minute.
        Senator Wyden. Then I will immediately take my 4 back.
    [Laughter.]
        The Chairman. Well, I do not know. He gave up his 5
    minutes. [Laughter.]
        Go ahead.
        Senator Bennet. I am going to try to be brief. And I want
    to thank you, Mr. Chairman, for holding this hearing and for
    your courtesy and graciousness throughout it, including
    allowing me to ask a final question.
        First, Mr. Chairman, like my colleagues, I would like to
    submit for the record some letters from Colorado about this
    bill.
        The Chairman. They will be placed in the record.
        Senator Bennet. Thank you.
        [The letters can be viewed on the committee's website.]
        Senator Bennet. I would also like to submit for the record
    a study by the Kaiser Family Foundation about the percentage of
    births that are financed by Medicaid.
        The Chairman. Without objection, that will go in the record
    as well.
        Senator Bennet. Thank you.
        [The study appears in the appendix on p. 91.]
        Senator Bennet. And it is interesting just, Senator, to see
    that Colorado is 43 percent of births financed, Alabama is 58
    percent, Alaska is 53 percent, Arkansas is 67 percent. So I
    think there is a lot we have to learn from each other, because
    somebody is going to have to pay for these births.
        Finally, Mr. Chairman, I would say, for the last 7 years,
    the Republican Party has made repealing the Affordable Care Act
    their defining issue. There were over 60 attempts in the House
    of Representatives to repeal a law that helped over 600,000
    Coloradans obtain access to health insurance.
        But President Trump said he could do better and promised a
    much more generous version--the Senator from Louisiana was
    talking about his promise on the mandate--a much more generous
    version of repeal and replace on the campaign trail. In
    addition to promising repeatedly no cuts to Medicare and
    Medicaid, he said, quote, ``Everyone has got to be covered. I
    am going to take care of everybody. I do not care if it costs
    me votes or not. Everybody is going to be taken care of much
    better than they are taken care of today.''
        When asked specifically about repeal and replace, he said,
    ``We are going to do it simultaneously. It will be just fine.
    We are not going to have, like, a 2-day period and we are not
    going to have a 2-year period when there is nothing. It will be
    repealed and replaced and we will know. And it will be great
    health care for much less money, so it will be better health
    care, much better for less money. Not a bad combination.''
        This is what he ran on; this was the commitment he made to
    the American people. And I think on that basis, this piece of
    legislation does not remotely honor that.
        Mr. Chairman, I want you to know that I stand ready to work
    with you and anybody else to meet the outcomes that the
    President suggested when he was running for office.
        The Chairman. Well, thank you.
        Senator McCaskill, I understand you would like to make a
    statement.
        Senator McCaskill. Yes, I just have one question.
        And I am sure that you may not have the answer. But if
    possible, Senator Cassidy, I would like to know how much
    Missouri will lose in terms of the provider tax. And we are
    very, very reliant on the provider tax in my State. And so I
    did not see any analysis of how you have offset that. If your
    staff could provide what the provider tax would be in the
    negative--I know that the shifting of money helps those States
    that did not expand Medicaid, but I would like to know what
    would be left after the provider tax is gone.
        The Chairman. Would you do that for Senator McCaskill? If
    you will submit that, I would appreciate it.
        Senator McCaskill. Thank you.
        The Chairman. Submit it to the whole committee, though, as
    well, okay? All right.
        Senator Wyden, you can make your closing remarks.
        Senator Wyden. Thank you very much, Mr. Chairman.
        Here is where we are with respect to this bill. Senator
    Collins came out against this bill a little bit ago. So some
    people are reporting this fight is over. My message to the
    American people is that it is going to be critical to keep
    fighting this deeply flawed bill, especially until Saturday,
    which is when the next procedural window closes.
        Two other concerns I have. When I asked Senator Cassidy
    whether specifically this fifth version of the bill was it, it
    seemed to me there was a little bit of fudging. And that is
    another reason to keep fighting.
        And then there has been an important development in the CBO
    report that has not been referenced. I wanted to know
    specifically whether there would be ironclad protections for
    people with respect to those who have a pre-existing condition.
    And Mr. Woodruff from the Cancer Society, who knows a little
    bit about this subject, says no, there would not be ironclad
    protections, because the States could waive them.
        That is confirmed, colleagues, word for word in the CBO
    report tonight.
        Two last points, Mr. Chairman.
        First, I really look forward to killing this flawed bill
    and then going back to kind of positive work that you and I
    want to do, that has really been our tradition, starting with
    the Children's Health Insurance Program, and not have this kind
    of abomination of a process ever again.
        And, Mr. Chairman, I would just close by saying I ask
    unanimous consent that a letter from Democratic members of the
    committee requesting that we reconvene as soon as tomorrow to
    continue this critical discussion could be made a part of the
    record.
        And I look forward to working with you.
        [The letter appears in the appendix on p. 150.]
        The Chairman. I think everybody has had enough time on this
    right now, so we are not going to do that. But I do appreciate
    your comments. And I appreciate working with you. It is a
    pleasure for me, and you are a very, very fine man with a very,
    very balanced approach towards these things.
        Senator Wyden. Thank you. Thank you.
        The Chairman. And while there is enough funding to ensure
    CHIP services will be able to continue past the end of the
    month, we certainly recognize that time is of the essence, and
    we must act quickly to extend the funding for CHIP.
        There has been strong support for this program in the
    Senate Finance Committee, and that is why Ranking Member Wyden
    and I have a bill out there to extend the program's funding for
    5 years. It is not going to end, but we need to be careful
    about re-upping it.
        We are committed to working with our colleagues in both the
    Senate and the House to act in swift order and develop a smart
    and fiscally responsible solution that will ensure no lapse in
    care for our Nation's most vulnerable children.
        As the author of the CHIP bill--and I think everybody knows
    that I was able to talk to my friend Senator Kennedy, and in
    fact he leapt over across the divide to join me on the CHIP
    bill and it was one of his proudest achievements. As the author
    of that bill, I can say that that bill has done an awful lot of
    good, and I want to make sure that nobody fouls it up.
        I would encourage my colleagues to work with the HELP
    committee to extend and pay for community health centers. That
    is where that is, and we need to work hard to do that.
        I want to personally thank this group of witnesses today.
    It has been a really hard thing to sit there all of this time
    and answer the questions that you have. You have all been just
    stellar as far as I am concerned, and I think very highly of
    you.
        Some of you I agree with more than others, of course, but
    that is always the case. And all I can say is that I hope we
    can reach a point someday in our lives around here where the
    answer to everything is not more money that we do not have,
    that the answer to everything is not more Federal Government
    that we do not need.
        And the answer around here is that we can work together to
    try to solve these problems without bankrupting the country. As
    you can see, we are already in real difficulty because of the
    health care situation in this country. And the Affordable Care
    Act is anything but affordable and everybody knows it. Most
    people, at least on one side, do not want to admit it, but it
    is true. And we are going to be in real trouble if we do not
    turn this thing around.
        But I want to especially thank our witnesses for being
    here.
        I want to thank everyone for their attendance and
    participation today.
        Like I say, I would especially like to thank our witnesses
    for providing the testimony and expertise today. You have all
    been just really good as far as I am concerned.
        For any of my colleagues who have written questions for the
    record, I ask that you submit them by close of business
    Wednesday, September 27th.
        And so with that, you will be happy to hear, you folks who
    have sat there all day so patiently, the hearing is adjourned.
        [Whereupon, at 7:10 p.m., the hearing was concluded.]

                                A P P E N D I X

                  Additional Material Submitted for the Record

                                  ----------

       Submitted by Hon. Michael F. Bennet, a U.S. Senator From Colorado

           Changes to Federal Spending for ACA Under Graham-Cassidy
                             ($Millions), 2020-2026

    Colorado

    Current Law Federal Funds for ACA Coverage: $17,706

    Federal Funds Under Block Grant Program: $15,419

    Difference ($): -$2,288

    Difference (%): -13%

    Total Change in Federal Spending Under Graham-Cassidy Due to ACA Block
           Grant and Medicaid Per Capita Cap ($ Millions), 2020-2026

    Colorado

    Change in Federal Funds Due to Block Grant: -$2,288

    Change in Federal Funds Due to Medicaid Per Enrollee Cap: -$573

    Total Change in Federal Funds ($): -$2,860

    Total Change in Federal Spending Under Graham-Cassidy Due to ACA Block
              Grant and Medicaid Per Capita Cap ($ Millions), 2027

    Colorado

    Loss of Federal Funds for ACA Coverage if Congress Does Not Extend
    Block Grant:
        -$3,172
    Loss of Federal Funds Due to Medicaid Per Enrollee Cap: -$164

    Total Loss of Federal Funds: -$3,335

    Source: The Henry J. Kaiser Family Foundation, ``State-by-State
    Estimates of Changes in Federal Spending on Health Care Under the
    Graham-Cassidy Bill,'' September 2017, http://files.kff.org/attachment/
    Issue-Brief-State-by-State-Estimates-of-Changes-in-Federal-Spending-on-
    Health-Care-Under-the-Graham-Cassidy-Bill.

                                     ______

                     The Henry J. Kaiser Family Foundation

                          Births Financed by Medicaid

                          Time frame: Varies by State

    _______________________________________________________________________
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    ------------------------------------------------------------------------
                             Percent of                           Percent of
                               Births                               Births
           Location         Financed by         Location         Financed by
                              Medicaid                             Medicaid
    ------------------------------------------------------------------------
    Alabama                         58%  Alaska                          53%
    ------------------------------------------------------------------------
    Arizona                         54%  Arkansas                        67%
    ------------------------------------------------------------------------
    California                      50%  Colorado                        43%
    ------------------------------------------------------------------------
    Connecticut                     47%  Delaware                        48%
    ------------------------------------------------------------------------
    District of Columbia            46%  Florida                         50%
    ------------------------------------------------------------------------
    Georgia                         54%  Hawaii                          N/A
    ------------------------------------------------------------------------
    Idaho                           45%  Illinois                        50%
    ------------------------------------------------------------------------
    Indiana                         50%  Iowa                            37%
    ------------------------------------------------------------------------
    Kansas                          34%  Kentucky                        46%
    ------------------------------------------------------------------------
    Louisiana                       65%  Maine                           43%
    ------------------------------------------------------------------------
    Maryland                        44%  Massachusetts                   41%
    ------------------------------------------------------------------------
    Michigan                        46%  Minnesota                       43%
    ------------------------------------------------------------------------
    Mississippi                     64%  Missouri                        42%
    ------------------------------------------------------------------------
    Montana                         49%  Nebraska                        35%
    ------------------------------------------------------------------------
    Nevada                          64%  New Hampshire                   27%
    ------------------------------------------------------------------------
    New Jersey                      42%  New Mexico                      72%
    ------------------------------------------------------------------------
    New York                        51%  North Carolina                  54%
    ------------------------------------------------------------------------
    North Dakota                    33%  Ohio                            52%
    ------------------------------------------------------------------------
    Oklahoma                        60%  Oregon                          50%
    ------------------------------------------------------------------------
    Pennsylvania                    39%  Rhode Island                    50%
    ------------------------------------------------------------------------
    South Carolina                  60%  South Dakota                    50%
    ------------------------------------------------------------------------
    Tennessee                       54%  Texas                           54%
    ------------------------------------------------------------------------
    Utah                            31%  Vermont                         42%
    ------------------------------------------------------------------------
    Virginia                        31%  Washington                      49%
    ------------------------------------------------------------------------
    West Virginia                   48%  Wisconsin                       64%
    ------------------------------------------------------------------------
    Wyoming                         36%  United States                   N/A
    ------------------------------------------------------------------------
    Notes
    In the 2016 Kaiser Family Foundation Medicaid Budget Survey, States were
      asked to report the share of all births in the State that were
      financed by Medicaid in the most recent 12-month period for which data
      were available. States reported data from 2010-2016, which varied by
      calendar year, State fiscal year, and Federal fiscal year.

    Sources
    Vernon K. Smith, Kathleen Gifford, Eileen Ellis, and Barbara Edwards,
      Health Management Associates; and Robin Rudowitz, Elizabeth Hinton,
      Larisa Antonisse, and Allison Valentine, Kaiser Commission on Medicaid
      and the Uninsured. ``Implementing Coverage and Payment Initiatives:
      Results from a 50-State Medicaid Budget Survey for State Fiscal Years
      2016 and 2017,'' The Henry J. Kaiser Family Foundation, October 2016.

    Definitions
    N/A: Data not available.

                Prepared Statement of Hon. Bill Cassidy, M.D.,
                         a U.S. Senator From Louisiana
        My colleagues, it is a privilege to speak to the Graham-Cassidy-
    Heller-Johnson amendment to H.R. 1628, the American Health Care Act.

        Before being Senator Cassidy, I was Dr. Cassidy, caring for
    uninsured and Medicaid patients in Louisiana's public hospital system.
    My patients had terrible disease, multiple chronic conditions but could
    not receive care elsewhere. My life work has been to care for such
    fellow Americans. This bill continues this work by other means.

        The ACA promised affordable health-care coverage, freedom to keep
    your doctor and to bring health-care costs down. In reality, middle-
    class families have sky-
    rocketing premiums, individual mandates which Americans hate, $6,000
    deductibles in a failing individual market. The projected inflation
    rate of the exchange tax subsidies and the cost sharing reduction
    payments is 12.9% per year; doubling the expense every 6 years. The
    State match for the Medicaid Expansion increases to 10% in 2020. This
    can be in the millions and billions. Fifteen Democratic Senators
    recently declared Obamacare a failure while endorsing a single payer
    system. The problems of Obamacare require a path forward.

        Some today will bewail that Republicans won't give up attempts to
    repeal Obamacare. This Republican will continue to do so as long as
    premiums and deductibles for middle-class families grow 10% to 50% or
    even higher per year, destroying family budgets.

        As a positive, Senator Wyden recently praised the CHIP program. We
    agree. GCHJ passes a flexible block grant combining Medicaid Expansion,
    Obamacare tax credits, cost-sharing reduction subsidies and the basic
    health plan, and distributes this money through the CHIP program with
    CHIP requirements and protections. It is a mandatory appropriation. The
    CHIP program requires reauthorization. This does not mean it
    automatically goes away in 10 years as some absurdly state.

        States receive an allocation based on how many Americans between
    50% and 138% FPL live in the State. Over the course of years, the
    amount the Federal taxpayer provides per person equalizes so that no
    matter where the American lives, they benefit equally.

        Let me address the inevitable comment that we end Medicaid
    expansion. A State can continue to fund their expansion program as they
    have implemented. They have the flexibility. Despite pointing this out,
    it will be said.

        To help States, Medicaid Expansion match is waived. The flexible
    block grant functions like a combined section 1115/1332 waiver with
    guardrails providing States flexibility to innovate. We preserve
    patient protections such as mental health parity, guaranteed issue,
    prohibit charging women more for health insurance and no lifetime caps.
    States applying for waivers must prove that Americans with pre-existing
    conditions have access to affordable and adequate coverage--period, the
    end. I'm asked what is the definition of affordable. It means the
    patient can afford it.

        This raises an issue, many on the left are threatened that we give
    States and patients the power Obamacare usurped. Under this narrative,
    States are inept, corrupt Governors scheme to deprive his or her
    State's residents of protections, and patients only get better if told
    what to do. This amendment rejects that narrative.

        GCHJ repeals the individual mandate which ACA architect Jonathon
    Gruber, found does not increase enrollment. Regarding this, the IRS
    reports that 58% of those penalized have AGI of less than $50,000. We
    think these Americans should be helped, not penalized. GCHJ repeals the
    employer mandate, which data shows decreases full time employment
    opportunity for the lowest quintile of wage earners, those who can
    least afford.

        Today, I expect accusations that this is a partisan bill which
    drains Blue States for the sake of Red States. Totally false. Under the
    latest version, Virginia receives $4 billion more from 2020 to 2026,
    Missouri $5 billion more, and Florida $15 billion more than current
    law; increasing access to coverage for things like colonoscopies,
    mammograms and other screening tests for millions. Those opposing this
    amendment clearly don't care about Americans in these and similar
    States.

        I also expect pleas for regular order. Why don't we just have
    hearings. I don't defend this process, but I will say that no Democrat
    was interested in addressing the problems with Obamacare in my State
    when Susan Collins and I crafted a bill allowing States to keep
    Obamacare if it was working while allowing other States where Obamacare
    failed to try something else. There was no interest whatsoever. I
    wanted the effort to be bipartisan. But, if one side of the aisle
    refuses to help my State, I can't stop trying.

        We need to pass the Graham-Cassidy-Heller-Johnson amendment,
    returning power to patients and States while expanding access to
    coverage for millions. Thank you.

                                     ______

            Questions Submitted for the Record to Hon. Bill Cassidy
                  Question Submitted by Hon. Claire McCaskill
        Question. Do your calculations of the State-by-State impact of
    Graham-Cassidy-Heller-Johnson include the effect of lowering the
    provider tax safe harbor limit under the hold harmless rule to 4
    percent?

        If not, will you please provide a State-by-State calculation of
    reduction in State and Federal Medicaid dollars due to the lowering of
    the provider tax safe harbor limit under the hold harmless rule to 4
    percent, based on current utilization of the safe-harbor limit?

        Answer. The analysis on the latest version of Graham-Cassidy
    legislative text can be found on our website at https://
    www.cassidy.senate.gov/read-about-graham-cassidy-heller-johnson. You
    will have to contact OMB regarding the assumptions behind the model and
    whether lowering the cap on the provider tax was incorporated into
    their modeling on a State-by-State basis.

                                     ______

                  Questions Submitted by Hon. Robert Menendez
        Question. You dispute the analyses by several outside organizations
    about the impact of your proposal on coverage rates and funding to
    States. Can you provide your analysis on how New Jersey would fare
    under your proposal each year through 2036 in terms of premiums in the
    State, number of covered individuals using 2016 census data as a
    baseline, impact to the economy of the State, funding for New Jersey
    under your Medicaid block grant, funding under the Market-Based Health
    Care Block Grant, and the impact to hospitals in the State?

        Answer. No such analysis exists for this legislation, nor has it
    existed in such detail for any piece of legislation ever. Even CBO does
    not do analysis as detailed as you are requesting. Furthermore, the
    legislative text can only run through 2026 per reconciliation rules,
    therefore any analysis beyond 2026 on the block grant, premiums, and
    impact on hospitals is inaccurate and thoroughly misleading. Finally,
    States are given significant flexibility in determining how to best
    serve their patient populations, therefore trying to predict and
    measure these decisions and the impact on premiums and hospitals over a
    20-year period is purely speculative.

        OMB recently released a report of the dollars received under the
    Market-Based Health Care Grant Program (https://www.cassidy.senate.gov/
    read-about-graham-cassidy-heller-johnson) that indicates New Jersey
    would be held harmless compared with current law when taking into
    account that the State would no longer have to put up its 10% match for
    the Medicaid expansion population.

        Question. Can you provide detailed information on how you are
    modeling your impact data, including showing me the inputs,
    assumptions, and formulas you used to find the New Jersey numbers under
    your proposal through 2036 for each of the impact data points requested
    in Question 1 above?

        Answer. The analysis on the latest version of Graham-Cassidy
    legislative text can be found on our website at https://
    www.cassidy.senate.gov/read-about-graham-cassidy-heller-johnson. You
    will have to contact OMB regarding the assumptions behind their model.

        In our initial numbers, we based these numbers off of spending in
    2016 on CSRs, tax credits, and Medicaid expansion as provided by HHS/
    CMS/OMB and updated for any new data presented by State Medicaid
    directors where appropriate. These numbers were then grown by CPI-M
    each year until 2020 to determine the base rate. The formula then kicks
    in to grow and adjust the numbers as written in the legislative text.

        Question. The United States is facing a rapidly aging population.
    Medicaid pays for the long-term care needs of millions of seniors, a
    number that is expected to grow rapidly in the near future. How will
    your funding caps for Medicaid funding impact the ability of States to
    meet the needs of the elderly? In particular, can the needs of the
    growing number of individuals afflicted by Alzheimer's disease be met
    with your plan?

        Answer. We have asked OMB to provide an analysis of the per-capita
    cap on a State-by-State basis. It is important to note that this type
    of proposal was originally put forward by President Bill Clinton and
    endorsed by every Senate Democrat at the time, including three current
    Senators and the former Vice President. Our proposal provides a growth
    rate above medical inflation through 2024 and then a growth rate of
    medical inflation after that. Currently, long-term care is growing at a
    lower rate annually than this level. We believe the growing needs of
    the long-term care population, including those battling Alzheimer's can
    and would be addressed under this proposal.

        Question. Families who have children with special needs often face
    an uphill battle in accessing services. What protections does your bill
    offer them to ensure their children are not cut off from care for their
    conditions? How will you ensure that a young child isn't forced to go
    without care because they have hit an annual cap? A lifetime cap?

        Answer. The legislation does not change the prohibition on denying
    coverage for individuals with pre-existing conditions. It also does not
    alter the requirements of guaranteed issue, guaranteed renewability, or
    community rating. While it does give States the ability to alter the
    essential health benefits in its application for the block grant, it
    does not change the prohibition on annual or lifetime caps and it
    requires States to certify that they will ensure individuals with pre-
    existing conditions have access to adequate and affordable coverage.
    CRS has done a report certifying that granting flexibility on essential
    health benefits does not eliminate the prohibitions on annual and
    lifetime caps. This flexibility on essential health benefits is also
    envisioned under section 1332 of PPACA.

        Question. How will your plan ensure there is no massive disruption
    of the individual insurance market should it be enacted in the period
    of time before the
    Market-Based Health Care Block Grants (HCBG) are released to States?

        Answer. The bill provides $10 billion in 2019 and $15 billion in
    2020 for short-term market stabilization. Furthermore, I have
    cosponsored the Alexander-Murray proposal to stabilize the individual
    insurance market. My fellow authors and I have always made clear that
    short-term stabilization would be necessary under any proposal and that
    we support the need to do this as a bridge to our proposal.

        Question. Wrap-around services are of critical importance to many
    families who have children with disabilities and who earn too much to
    qualify for Medicaid. How will your proposal ensure these families
    don't lose access to critically important services for their children
    and family members?

        Answer. Under this proposal, up to 20% of the funds under the block
    grant can be used for optional benefits and wrap-around services under
    the traditional Medicaid program. This was specifically done to ensure
    that States can maintain successful wrap-around services and optional
    benefits with the implementation of a per-capita cap. We support giving
    States the flexibility and the funding to best serve the populations in
    their States.

        Question. The HCBS demonstration project funding is a positive
    addition; however as written, would States currently using those funds
    be able to use this funding for the same services they are providing
    today?

        Answer. This legislation creates a 4-year, $8-billion competitive
    demonstration project to fund home and community-based services.
    Participating States would have an FMAP of 100% for these services.
    Furthermore, a State may use up to 20% of its block grant dollars on
    wrap-around and optional services under the traditional Medicaid
    program, so a State would have the ability to use those dollars to
    create its own program for HCBS if it so chooses.

        Question. Does the innovation fund replace the amount of HCBS
    funding lost due to the repeal of the 1915(k) enhanced match?

        Answer. The combination of the dollars in the demonstration project
    and the 20% option in the block grant will more than cover the amount
    currently spent on HCBS.

        Question. Are States and CMS able to identify the children with
    autism eligible for Medicaid on the basis of income?

        Answer. I will defer to CMS on this question.

        Question. Will children with autism who are eligible for Medicaid
    on the basis of income be able to be excluded from the cap?

        Answer. Blind and disabled children are exempted from the per-
    capita cap. This is defined as children under age 19, who are eligible
    for Medicaid based on their disability. This determination is made on a
    State-by-State basis based on a medical diagnosis that fits the State's
    definition of being medically needy in an eligibility pathway. For some
    States, autism may be a medically needy pathway for Medicaid coverage,
    while it may not in others.

        Question. If those children with autism who are eligible for
    Medicaid on the basis of income are included in the cap, what do you
    anticipate will be the impact on States' ability to meet their
    obligations under Early and Periodic Screening, Diagnostic, and
    Treatment?

        Answer. There can be no cuts to EPSDT, so the full range of
    services would be built into the child-specific cap.

        Question. As of August 2017, NJ FamilyCare provides coverage for
    over 205,000 New Jerseyans with disabilities. For many people with
    disabilities, Medicaid is about more than simply medical care. Not only
    is it about life, but about liberty and the pursuit of happiness as
    well. This legislation stands to erode the great progress made in the
    nearly three decades since the passage of the Americans with
    Disabilities Act of 1990 on the ability of people with disabilities to
    integrate into the community. What would the impact of this legislation
    be on the ability of States to provide for home and community-based
    services for people with disabilities through Medicaid? What impact
    would the Medicaid per-capita caps and the end of consumer protections
    for essential health benefits have on the ability of people with
    disabilities to live independently and contribute to their communities?

        Answer. The growth rate for the per-capita cap for the disabled
    population is set above medical inflation through 2024 and then moves
    to medical inflation starting in 2025. This will give States
    significant resources to provide services to individuals with
    disabilities, including HCBS. Furthermore, there is a demonstration
    project with $8 billion for HCBS. Finally, up to 20% of the dollars
    under the block grant can be used for services like HCBS under
    traditional Medicaid. States will have significant and sufficient
    resources to help people with disabilities live independently and
    contribute to their communities.

        Question. What would the impact of this legislation be on the
    ability of States to provide for home and community-based services for
    people with disabilities through Medicaid?

        Answer. There is a demonstration project with $8 billion for HCBS.
    In addition, up to 20% of the dollars under the block grant can be used
    for services like HCBS under traditional Medicaid.

        Question. What impact would the Medicaid per-capita caps and the
    end of consumer protections for essential health benefits have on the
    ability of people with disabilities to live independently and
    contribute to their communities?

        Answer. The growth rate for the per-capita cap for the disabled
    population is set above medical inflation through 2024 and then moves
    to medical inflation starting in 2025. This will give States
    significant resources to provide services to individuals with
    disabilities. In addition, up to 20% of the dollars under the block
    grant can be used for services like HCBS under traditional Medicaid.
    States will have significant and sufficient resources to help people
    with disabilities live independently and contribute to their
    communities.

        Question. How will the changed funding to the Medicaid impact the
    program's ability to respond to catastrophic events like floods and
    hurricanes? Will States have the funding they need to respond to a
    spike in Medicaid need through your proposal?

        Answer. Spending attributed to a public health emergency would be
    exempted from the per-capita cap up to $5 billion from 2020-2024. A
    public health emergency is defined by a declaration by the Secretary
    pursuant to section 319 of the Public Health Service Act.

                                     ______

                    Questions Submitted by Hon. Bill Nelson
        Question. Eleven seniors in Florida died after being trapped in a
    nursing home in extreme temperatures after Hurricane Irma knocked out
    the facility's power. Most troubling is that there was a functioning
    hospital located directly across the street from the nursing home, and
    yet they weren't evacuated. There's an ongoing criminal investigation
    to determine what went wrong and who is to blame, but quite simply,
    this isn't acceptable.

        Nursing homes and other long-term care facilities are under
    tremendous pressure to provide quality care and take care of our loved
    ones, but they need the resources in order to do so.

        The Graham-Cassidy bill caps Medicaid, effectively cutting billions
    from the program. The cap would grow more slowly each year than the
    projected growth in State per-beneficiary costs, especially over time
    with an aging population. The cuts to Federal Medicaid funding would
    only deepen in 2025 as the annual adjustment becomes even more
    inadequate.

        This is especially problematic for Florida, as the rate of Medicaid
    enrollment for disabled persons and low-income seniors has risen faster
    than the national average over the last 10 years.

        Moreover, the cap would force States to make hard choices about
    cutting eligibility, benefits, and/or provider payments. Many States
    will be faced with no choice but to cut-home and community-based
    services, and other ``optional'' benefits.

        Do you believe the Graham-Cassidy bill would allow nursing homes,
    home health agencies, and other long-term care facilities to provide
    quality care to the Nation's seniors?

        Answer. Yes, the Graham-Cassidy bill would allow nursing homes,
    home health agencies, and other long-term care facilities to provide
    quality care to the Nation's seniors. The growth rate for the per-
    capita cap for the long-term care population is set above medical
    inflation through 2024 and then moves to medical inflation starting in
    2025. This will give States significant resources to provide services
    to individuals with disabilities. Currently, long-term care is growing
    at a lower rate annual than this level. In addition, up to 20% of the
    dollars under the block grant can be used for wrap-around and optional
    services under traditional Medicaid that could be used to serve the
    long-term care population.

        Question. Twenty-five percent of Florida's population or 5 million
    Floridians are 60 or older, making Florida the State with the largest
    population of seniors. Generally older adults have more health care
    needs, chronic conditions and co-morbidities than younger people. Many
    older Americans are also forced to tighten their belts to afford things
    like health coverage.

        Please tell me with a ``yes'' or ``no'' answer, does the Graham-
    Cassidy bill repeal the ACA's premium tax credits?

        Answer. The Graham-Cassidy bill repeals the ACA's premium tax
    credits in 2020 and replaces that funding with dollars given to States
    through a block grant. The amount of dollars in 2020 is based on the
    amount of money received by States or individuals in the State for tax
    credits, Medicaid expansion, cost-sharing reduction subsidies, and
    basic health program in 2017 grown by medical inflation until 2020.

        Question. Does the Graham-Cassidy bill eliminate cost-sharing
    reduction payments?

        Answer. The Graham-Cassidy bill repeals the ACA's cost-sharing
    reduction subsidies in 2020 and replaces that funding with dollars
    given to States through a block grant. The amount of dollars in 2020 is
    based on the amount of money received by States or individuals in the
    State for tax credits, Medicaid expansion, cost-sharing reduction
    subsidies, and basic health program spending in 2017 grown by medical
    inflation until 2020.

        Question. Does the Graham-Cassidy bill allow States to take us back
    to the days when insurers could charge older adults higher rates than
    under the existing law?

        Answer. States would have the flexibility to change age rating
    rules provided that individuals with pre-existing conditions have
    access to adequate and affordable coverage and the Secretary approves
    their application.

        Question. The opioid crisis is devastating families across the
    country. In Florida alone, 2,600 people died from opioids in the first
    half of 2016. Fentanyl was responsible for 704 of those deaths.

        The Affordable Care Act made great strides to increase access to
    substance abuse treatment. It ensured that newly covered individuals
    would receive mental health and substance use disorder services,
    including behavioral health treatment, under their health insurance
    plan as part of their essential health benefits.

        Is substance use disorder treatment a necessary component of
    efforts to prevent and treat opioid addiction?

        Answer. As a physican who has taken care of patients with substance
    abuse disorder, I know that treatment is an important part of
    preventing and treating opioid addiction.

        Question. Does the Graham-Cassidy bill allow States to waive
    essential health benefits, like coverage of mental health and substance
    use disorder services?

        Answer. States have the ability to apply to alter the essential
    health benefits in its application for the block grant. In order for an
    application to be approved, States must certify that individuals with
    pre-existing conditions have access to adequate and affordable
    coverage. This same flexibility on essential health benefits is also
    envisioned under section 1332 of PPACA.

        Question. By capping the Medicaid program and ending Medicaid
    expansion, the Graham-Cassidy bill cuts billions of dollars from
    Medicaid, the largest payer of substance use services in the country. A
    September 25th CBO report Stated that the Graham-Cassidy bill cuts $1
    trillion out of Medicaid over 10 years. If those cuts are made, how do
    you propose States like Florida provide the necessary services to help
    individuals with substance use disorders?

        Answer. This is a misleading statement. While the amount of money
    projected to be spent on Medicaid is reduced as compared to current
    law, much of this money is still given to States through the Market-
    Based Health Care Grant Program. In total more than $1.2 trillion is
    put into this block grant. Furthermore, the rate of growth for the per-
    capita caps are placed at medical inflation and medical inflation plus
    1% through 2024. For many States and categories of patients in the
    Medicaid population, this is above the current rate of spending
    projections.

        Question. Some have said that the public health emergency response
    fund could be used for the opioid epidemic; however, it is my
    understanding that this money was for disasters like Hurricane Irma.
    Does that mean flood victims and those suffering from opioid addiction
    will be pitted against each other?

        Answer. Spending attributed to a public health emergency would be
    exempted from the per-capita cap up to $5 billion from 2020-2024. A
    public health emergency is defined by a declaration by the Secretary
    pursuant to section 319 of the Public Health Service Act. In addition,
    up to 20% of the block grant can be used on the traditional Medicaid
    population, giving States significant flexibility and resources to help
    with health spending related to the opioid epidemic and Hurricane Irma.
    Furthermore, Congress usually passes supplemental appropriations to
    help with disaster spending that exceeds the current amount of money
    appropriated to the disaster fund.

                                     ______

                  Prepared Statement of Hon. Lindsey Graham,
                       a U.S. Senator From South Carolina
        Health care in the United States is in the throes of an unrelenting
    tailspin. Thrust upon us on Christmas Eve in 2009, Obamacare has been
    an unmitigated disaster. Premiums are growing at unsustainable rates;
    insurers are fleeing exchanges and dropping coverage, and patients
    across the country are in many cases down to a few, or in some cases
    zero options to purchase coverage.

        In my State of South Carolina, we are down to one carrier offering
    coverage in the exchange. In 2014, we had five carriers. Exchange based
    plans are relied on by around 200,000 people in South Carolina.
    Premiums are set to rise over 30% in South Carolina next year alone.

        Across the country, the situation is no better. Next year, it is
    expected that 45 percent of all counties in America will have either
    one or no carriers offering coverage--impacting coverage where 12
    million people live.

        Medicaid and health-care spending are on an unsustainable spending
    trajectory. Four high-spending States, California, New York, Maryland,
    and Massachusetts are receiving a disproportionate share of all
    Obamacare funds. They are receiving nearly 40% of all Obamacare
    spending, with only just over 20% of the country's population. This is
    not only inequitable, but unsustainable. Graham-Cassidy-Heller-Johnson
    restores parity among the States and reforms spending inefficiencies.

        Today we stand at a defining crossroads--with three options: (1)
    Prop up Obamacare; (2) Berniecare, as introduced by Senator Bernie
    Sanders, or (3) Graham-
    Cassidy-Heller-Johnson.

        Do we continue the march to single-payer through Obamacare, and now
    Berniecare, or do we empower the States to design patient-centered
    health care in the local communities where patients live?

        Graham-Cassidy-Heller-Johnson embraces federalism and takes the
    power and money to direct health care out of Washington and to the
    States. Our proposal is the last best chance to end the march to
    single-payer healthcare. It is single-payer's worst nightmare.

        We are in the defining fight for the future of health care in
    America. Obamacare has failed. Berniecare is the end of patient choice
    and innovation. Graham-Cassidy-Heller-Johnson is the last and best hope
    to empower patient-centered health care in America.

        It is supported by as wide a coalition as President Donald Trump,
    Governor Jeb Bush, Alan Greenspan, and Breitbart. Most importantly,
    Repeal and Replace is being demanded of us by the American people. We
    hear their call to action, and are ready to pass Graham-Cassidy-Heller-
    Johnson.

        My cosponsors and I, this band of brothers, are here to fight for
    health-care freedom, until Graham-Cassidy-Heller-Johnson becomes the
    law of the land.

                                     ______

                  Prepared Statement of Hon. Orrin G. Hatch,
                            a U.S. Senator From Utah
    WASHINGTON--Senate Finance Committee Chairman Orrin Hatch (R-Utah)
    today delivered the following opening statement at a hearing on the
    Graham-Cassidy-
    Heller-Johnson health-care proposal.

        I'd like to welcome everyone to this afternoon's hearing where we
    will discuss and examine the Graham-Cassidy-Heller-Johnson health-care
    proposal.

        Given the relatively unique circumstances we're facing with regard
    to health care generally and this proposal in particular, the Senate
    Republican leadership as well as members of the conference have asked
    for a hearing on this proposal so that we can all get a better sense of
    how it is intended to work.

        Toward that end, we have two distinguished panels of witnesses
    before us today.

        The first panel will feature statements from two of our
    distinguished Senate colleagues.

        The second panel will feature another one our colleagues, who is
    also a member of this committee. We'll hear from a friend and former
    Senate colleague on the second panel as well. Joining them at the table
    will be experts and stakeholders who are here to share their views on
    the proposal from Senators Graham, Cassidy, Heller, and Johnson.

        The purpose of a hearing is to respectfully discuss ideas and
    become better informed on particular issues. It does not mean that
    everyone shares the same views and opinions.

        In fact, I expect that quite a few disagreements will be expressed
    today. And that is okay.

        I've been in the Senate for 4 decades now. And in that time, I've
    been a part of some very difficult and contentious debates.

        Early on, I was part of a fierce debate over labor law reform.

        Over the years, I've participated in some of the most heated
    Supreme Court hearings in our Nation's history.

        I was here to take part in drafting, debating, and passing the
    Americans with Disabilities Act, one of my proudest accomplishments.

        I was around when the debate over the war in Iraq became extremely
    combative.

        And of course, I was here when we debated Obamacare before it
    passed, and I've been here for every debate we've had about it since
    that time.

        So I understand that there are some strong opinions about this
    issue. And more importantly, I understand why opinions are so strong.

        When we talk about health-care policy, we're not just talking about
    a theoretical concept or legislation that impacts a single isolated
    industry. This topic has a significant impact on the lives of every
    person in this country in ways that can make or break both their health
    and their livelihoods.

        Frankly, because this issue is so personal, everyone has strong
    feelings.

        To members of the committee, to those in the audience today, and to
    any person who may watch or read about today's hearing at some point in
    the future, let me say this: I respect your opinions on these issues.

        But, while I wish that expressions of goodwill could, on their own,
    fix our Nation's problems, that is just not the case. We have to do the
    work. And, on these issues, the work is particularly hard.

        Today, we're here to discuss the most recent health-care proposal
    drafted by some of our colleagues. I commend them for their efforts and
    their willingness to put forward ideas to address these problems.

        My hope is that we can spend our time today questioning our
    witnesses about substance and policy and not on scoring political
    points, particularly when we have distinguished colleagues and a former
    colleague at the witness table.

        I know that, for both sides of this debate, passionate
    demonstrations and righteous indignation--particularly when there are
    cameras in the room--make good fodder for Twitter and TV commercials,
    especially when the subject is health care. Our committee is generally
    regarded as being above such shenanigans, though we haven't been
    entirely immune to these types of theatrics in the past.

        For today, let me say this. If the hearing is going to devolve into
    a sideshow or a forum simply for putting partisan points on the board,
    there's no real reason for us to be here. I won't hesitate to adjourn
    the hearing if it gets to that point. I'm saying this for the benefit
    of my colleagues on the committee and everyone in the audience.

        Let's have a civil discussion.

        I have no objection to having a spirited debate on these issues. My
    hope is that, in the end, our efforts will generate more light and less
    heat than we've seen in the most recent episodes of the health-care
    debate. If we can't have that, we should all be spending our time on
    something more productive.

                                     ______

                  Prepared Statement of Hon. Mazie K. Hirono,
                           a U.S. Senator From Hawaii
        Chairman Hatch, Ranking Member Wyden, members of the committee,
    thank you for holding today's hearing. We may not agree on much when it
    comes to health care, but we all agree that the legislation we are
    considering today will have a tremendous impact on families in every
    State in this Nation.

        Nearly every health-care stakeholder--insurers, doctors, hospitals,
    patient groups, state governments, and others--has raised serious
    concerns about, or outright opposes this bill. Its details are
    complicated, its impact is very broad, and it's ridiculous that this
    will be the only hearing on this bill before the Senate votes on it.

        I urge my colleagues: let's do what's right for the millions of our
    constituents and their families, set this bill aside, and work together
    to find bipartisan agreement to strengthen the Affordable Care Act.

                                     ______

     Prepared Statement of Cindy Mann,\1\ Former Deputy Administrator and
      Director of the Center for Medicaid and CHIP Services, Centers for
    Medicare and Medicaid Services, Department of Health and Human Services
    ---------------------------------------------------------------------------
        \1\ Application for admission to the District of Columbia Bar
    pending. Practicing under the supervision of Jill DeGraff, a member of
    the District of Columbia Bar. Admitted to practice in New York and
    Massachusetts.
    ---------------------------------------------------------------------------
        Good morning Chairman Hatch, Senator Wyden, and distinguished
    members of committee. Thank you for the invitation to participate in
    this hearing on the
    Graham-Cassidy-Heller-Johnson legislative proposal (referred to
    hereafter as
    ``Graham-Cassidy'').

        I am Cindy Mann, a partner at Manatt, Phelps, and Phillips. At
    Manatt, I work with States, health-care providers and provider
    organizations, foundations, and consumer organizations, on matters
    relating to health-care coverage, delivery system reform, and
    financing, focusing primarily on publicly financed coverage and
    particularly, Medicaid and the Children's Health Insurance Program
    (CHIP). I also currently serve as an advisor to the Bipartisan Policy
    Center on the future of health care. Prior to joining Manatt, from June
    2009 through January 2015, I served as Deputy Administrator for the
    Centers for Medicare and Medicaid Services (CMS) and as Director of the
    Center for Medicaid and CHIP Services. In that capacity, I was
    responsible for Federal policy and oversight of Medicaid and CHIP and
    for supporting State implementation of those programs. While at CMS,
    much of my focus was working with States as they implemented provisions
    of the Affordable Care Act. Prior to joining CMS, I was a research
    professor at Georgetown University's Health Policy Institute and
    founded the Center for Children and Families, a research and policy
    organization focused on children's coverage. I also served as the
    Director of the Family and Children's Health Programs Group at the
    Health Care Financing Administration (now CMS), where I directed
    Federal implementation of CHIP and Medicaid with respect to children,
    families and pregnant women from 1999 to 2001. I have over 30 years of
    experience in these matters both at the Federal level and in States.

        My testimony today highlights the impact of the legislative
    proposal introduced by Senators Graham, Cassidy, Heller, and Johnson to
    repeal and replace the Affordable Care Act, focusing particularly on
    the impact on Medicaid and the 74 million people served by the Medicaid
    program. My testimony draws, in part, on an analysis of the Graham-
    Cassidy proposal prepared by Manatt Health on behalf of the Robert Wood
    Johnson State Health and Value Strategies Project; that report is
    attached.

        The Graham-Cassidy proposal would create new and far-reaching risks
    for people, States and the health-care system.

          Through funding reductions and caps, it puts coverage at risk
    for virtually every group of individuals covered through
    ``traditional'' Medicaid, including one out of three children in the
    Nation as well as millions of elderly and people with disabilities
    whose long-term care services are covered by Medicaid.
          It will also harm--and in some cases pose life-threatening
    harm--to the 23 million people projected to be covered through the
    Medicaid expansion and the Marketplace in 2019, who, by the terms of
    this proposal, will lose their coverage on December 31, 2019.
          And for those purchasing coverage in the individual and small
    group market, Graham-Cassidy will trigger in the very short term new
    levels of destabilization and higher premiums by maintaining guaranteed
    issue while ending the individual mandate without any replacement
    mechanism to promote enrollment of healthier individuals.

        These and many additional issues are an unequivocal sign that we
    must devise a better approach, rooted in a bi-partisan process in
    Congress with input from States, consumers, and health-care providers.
                 graham-cassidy builds on a deeply flawed bill
        Graham-Cassidy builds on and incorporates most of the provisions of
    the Better Care Reconciliation Act (BCRA), which the Senate rejected
    this summer. Although some provisions have been modified, Graham-
    Cassidy largely adopts BCRA's general framework and, in particular, the
    far-reaching changes it proposed to Medicaid--changes that go far
    beyond repealing and replacing the Affordable Care Act. Like BCRA,
    Graham-Cassidy would cut Federal Medicaid funding deeply and
    fundamentally restructure Medicaid financing for the ``traditional''
    (pre-expansion) Medicaid population. In addition, Graham-Cassidy takes
    a step beyond BCRA by terminating not only the enhanced funding for the
    Medicaid expansion but also the legal authority for States to cover
    low-income parents and other adults even with regular matching
    payments.\2\
    ---------------------------------------------------------------------------
        \2\ An exception is made for previously covered Native Americans
    under certain circumstances.

    ---------------------------------------------------------------------------
        More specifically, Graham-Cassidy would:

          Impose deep cuts to Medicaid that grow over time. While there is
    no score yet for the Graham-Cassidy proposal, the Congressional Budget
    Office (CBO) projected that the rejected BCRA bill upon which Graham-
    Cassidy is based would have cut Medicaid by $756 billion over 10
    years.\3\ The cuts grow over time as the trend rates used to make the
    annual adjustments to the per-capita caps drop beginning in 2025.
    Although Graham-Cassidy provides a modestly more generous trend rate
    than BCRA, under both proposals, the deepest cuts occur just beyond the
    CBO's 10-year budget scoring window.
    ---------------------------------------------------------------------------
        \3\ Congressional Budget Office letter to the Honorable Mike Enzi
    re: H.R. 1628, the Better Care Reconciliation Act of 2017: An Amendment
    in the Nature of a Substitute [ERN17500], as posted on the website of
    the Senate Committee on the Budget on July 20, 2017, available at:
    https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/
    52941-hr1628bcra.
    pdf.
    ---------------------------------------------------------------------------
          Fundamentally change financing for most of the Medicaid program.
    Graham-Cassidy would eliminate the Federal Government's guarantee to
    share with States the cost of all qualifying Medicaid expenditures by
    imposing per-capita caps on Federal spending for nearly all
    populations. Since Graham-
    Cassidy ends the Medicaid expansion, the consequences of this major
    change in financing falls solely on those enrolled in the
    ``traditional'' Medicaid program: newborns and other children, very
    low-income parents, pregnant women, and low-income seniors and people
    with disabilities.
          Shift all of the risk of higher costs onto States. Under the
    proposal, States would bear the full risk of all costs that exceed the
    trend rates, which are set below expected levels of health-care
    spending in order to achieve Federal savings. By contrast, under
    current law, States and the Federal Government share the risk of
    unanticipated costs due, for example, to higher drug costs, new cancer
    treatments, or health emergencies like the opioid crises. States that
    are not able to shoulder significant new costs will need to reduce
    provider payment rates and benefits, increase beneficiary costs, or
    reduce eligibility.
                         marketplace health-care grants
        The Graham-Cassidy proposal makes further structural changes to the
    health coverage landscape--beyond BCRA--by ending the tax credits and
    cost sharing subsidies available to people to purchase coverage in the
    marketplace. In place of these subsidies and the funding for Medicaid
    expansion, Graham-Cassidy establishes a ``Market-Based Health Care
    Grant'' block grant. Like other block grants, the total amount of
    Federal funding for this block grant is not adjusted overt time to
    reflect changes in enrollment, use of services, or cost of care. In
    addition, the block grant would be temporary; funding is available only
    through 2026. States would be at full risk for any costs above the
    block grant funding--should they take on the massive new
    responsibilities that the Federal Government sends their way--and for
    all costs when the block grant ends in 2026. There is no guarantee
    whether and at what level Federal funding would be available beginning
    in 2027.

        Manatt Health analyzed the Graham-Cassidy proposal on behalf of the
    Robert Wood Johnson Foundation's State Health and Value Strategies
    Project.\4\ While there are various analyses estimating the impact of
    the block grant component of the proposal, all estimates to date point
    in the same direction: the majority of States will lose Federal funding
    under Graham-Cassidy, with some experiencing particularly large losses.
    ---------------------------------------------------------------------------
        \4\ We conducted two analyses. First we calculated unadjusted block
    grant allotments based on the basic formulas in the bill to show the
    State-by-State distribution of funding under the proposal. Given the
    amount of discretion that is included in the proposal for the Secretary
    of HHS to adjust the allotments, we also calculated illustrative State-
    by-State allotments using a Medicare price index to adjust allotments
    to account for differences in wages, input costs, and similar factors
    that impact health care spending. While our assumptions are necessarily
    uncertain, the analysis demonstrates that adjustments could result in
    significant--and unknowable--changes to a State's allocation. ``Update:
    State Policy and Budget Impacts of New Graham-Cassidy Repeal and
    Replace Proposal'' (September 19, 2017), available at: http://
    www.statenetwork.org/resource/update-state-policy-and-budget-impacts-
    of-new-graham-cassidy-repeal-and-replace-proposal/.

    ---------------------------------------------------------------------------
    Key takeaways from Manatt's analysis are noted here:

          Total funding is below current law levels with much deeper cuts
    for some States.
              Over the 2020 to 2026 period, the block grant
    would provide 6.4% less Federal funding than under current law with the
    gap growing over time; in 2026, national funding for the block grant is
    nearly 9 percent below current law spending projections.
              The proposal radically alters the allocation of
    funding relative to current law, leaving many States with very deep
    cuts in funding. Over the 2020 to 2026 period, 29 States receive less
    in Federal funding with an average reduction of 19 percent. Some States
    will see their funding cut by half.
          No State is a ``winner.''
              The overall level of the block grant does not
    adjust for actual costs or enrollment; some States may receive
    adjustments in their allocations but at the expense of other States and
    all States are at risk for costs over the capped.
              Notably, these block grant allocations are in
    addition to other deep funding reductions in the proposal.
          The time-limited funding creates added risks for States. Under
    the proposal, the block grant ends in 2026, leaving States to take on
    substantial obligations with no guarantee of future funding.

        States will be granted broad flexibility on how they use these
    funds. The funds can be used for many purposes in addition to coverage,
    and States will inevitably be faced with many competing pressures for
    how to spend these funds. Individuals who have gained coverage through
    Medicaid expansions and subsidized marketplace coverage have no
    assurance that they will receive any coverage, never mind coverage that
    is as affordable or comprehensive as that which is guaranteed under
    current law.
                           implementation challenges
        Beyond the precipitous drop in funding and the sweeping
    programmatic changes advanced by this proposal, it is critical to
    consider the enormity of the responsibilities that will be shifted to
    States. States will have a very short time to consider how they will
    proceed and to then actually implement changes to launch new coverage
    and initiatives. It is no exaggeration to say that the Graham-Cassidy
    proposal will result in chaos for our health-care system and most
    notably for the millions of people who have coverage through Medicaid
    and the marketplaces today.

                                     ______

                                   attachment

     Update: State Policy and Budget Impacts of New Graham-Cassidy Repeal
                              and Replace Proposal

    Authored by Manatt Health

    A grantee of the Robert Wood Johnson Foundation

    September 2017
    _______________________________________________________________________

    IN THIS BRIEF

    3  After 2019, the Graham-Cassidy proposal would eliminate federal
    funding and authority for Medicaid expansion, as well as federal tax
    credit and cost-sharing reduction subsidies for Marketplace coverage.

    3  In 2020-2026, states instead would receive a block grant, referred
    to as a
    Market-Based Health Care allotment, which could be used for coverage,
    payments to providers, or other purposes.

    3  Over the 2020 to 2026 period, the block grant would provide 6.4
    percent less federal funding than under current law. The size of the
    gap between current law funding and the block grant appropriation would
    be 8.9 percent by 2026.

    3  Depending on the year, between 25 and 38 states would have
    unadjusted allotments that provide less funding than under current law,
    and some of these states would see reductions of 50 percent or more in
    federal resources to support health coverage for low-income
    individuals.

    3  More than 23 million \1\ people are projected to have subsidized
    coverage through Medicaid expansion or the Marketplace in 2019. Under
    Graham-Cassidy, Medicaid expansion coverage and the federal
    infrastructure for Marketplace subsidies would end, and states would
    have full responsibility for addressing the health care needs of low-
    income people without affordable coverage.
    ---------------------------------------------------------------------------
        \1\ Table 1, page 4, https://www.cbo.gov/system/files/115th-
    congress-2017-2018/reports/53091-fshic.pdf.

    3  States would have broad latitude to obtain waivers of ACA
    provisions, including waivers of ACA benefit and rating requirements.
    In states that obtain waivers, individuals with pre-existing conditions
    could face substantially higher premiums or find their policies do not
    ---------------------------------------------------------------------------
    cover essential services.

    3  States would have far more flexibility to decide how to deploy
    federal resources, although the broad flexibility accompanying the new
    Market-Based Health Care allotments could leave them vulnerable to
    federal cuts in the future.

    _______________________________________________________________________

    Introduction

    This brief provides an overview of the proposal released on September
    13th by Senators Lindsey Graham (R-SC) and Bill Cassidy (R-LA)--along
    with Senators Dean Heller (R-NV) and Ron Johnson (R-WI) and former
    Senator Rick Santorum (R-PA)--to ``repeal and replace'' the Affordable
    Care Act (ACA). This is an updated version of the proposal that
    Senators Graham and Cassidy filed on July 27th. The Graham-Cassidy ACA
    repeal and replace legislation would retain many features of the Better
    Care Reconciliation Act (BCRA) voted down by the Senate on July 25th,
    including per-capita caps on Medicaid spending \2\ and elimination of
    the individual and employer mandates. However, it also goes beyond that
    proposal by converting Marketplace and Medicaid expansion federal
    funding into a block grant.
    ---------------------------------------------------------------------------
        \2\ The new legislation changes the growth rate for elderly and
    disabled in 2025 and beyond as compared to BCRA, and includes a delay
    of the per-capita cap for certain rural states meeting specified
    conditions.
    ---------------------------------------------------------------------------

    OVERVIEW OF PROPOSAL

    Graham-Cassidy would eliminate federal funding for Marketplace and
    Medicaid expansion coverage after 2019 and replace it with a capped
    allotment distributed to states in the form of ``Market-Based Health
    Care'' block grants. The national amounts available for state
    allotments would not vary based on actual costs or enrollment, and
    would be less than estimated current law federal spending on
    Marketplace and Medicaid expansion coverage. States would have
    significant flexibility to use their block grant funds for coverage,
    payments to providers, or other health care-related purposes. As
    explained in the appendix and as illustrated by the state-by-state
    estimates provided in Tables 1A, 1B and 2 of this analysis, the
    proposal also alters the distribution of federal funds among states,
    sending dollars from expansion states and other states that receive a
    relatively significant share of current law federal subsidies for
    Marketplace coverage to non-expansion states and those with lower
    Marketplace participation and/or costs. No state match would be
    required. The block grant would end after 2026.

    For coverage funded with block grant dollars, states would be granted
    waivers, upon request, of various federal rules governing coverage;
    these include restrictions on premium variation, rating rules based on
    health status, essential health benefit requirements, and minimum
    medical loss ratios. While these provisions apply only to insurance
    coverage funded under the allotment, by financing even a small coverage
    program with allotment dollars, it appears a state could make the new
    rules apply to the entire individual and small group markets.

    Following is a summary of key issues and implications of the Graham-
    Cassidy proposal for states, consumers, and other stakeholders.

    Market-Based Health Care Grant Program--The Market-Based Health Care
    Grant Program is the block grant that replaces federal funding for
    Marketplace subsidies and Medicaid expansion coverage after 2019.
    States would have significant flexibility to use their block grant
    funds for coverage, payments to providers, or other health care-related
    purposes. In 2020, the available block grant funds are distributed
    among states based on their historic spending patterns for Marketplace,
    Basic Health Program (BHP), and Medicaid expansion coverage. Over time,
    however, the block grant formula increasingly distributes federal
    dollars based on each state's share of low-income (between 45 percent
    and 133 percent of the federal poverty level (FPL)) individuals
    nationwide, adjusted to reflect the risk profile of the state's low-
    income population, the actuarial value of coverage funded by the state
    with block grant dollars, and a discretionary state-specific adjustment
    by the Secretary of Health and Human Services (HHS). These adjustments
    do not add any new dollars to the block grant, but can result in
    changes in the distribution of block grant funds among states. In the
    case of the Secretary's state-specific adjustment, the size of and
    specifications for the adjustment are open-ended. In 2020 and 2021, an
    additional contingency fund appropriation is available to increase
    allotments for states with low population densities (Alaska, Montana,
    North Dakota, South Dakota, and Wyoming) and those that did not expand
    Medicaid under the ACA.

    Manatt's estimates indicate the block grant program would provide a
    lower level of funding at the national level relative to current law
    and result in a substantial redistribution of the remaining resources
    among states.\3\
    ---------------------------------------------------------------------------
        \3\ Unless otherwise noted, the estimates presented here do not
    reflect potential adjustments to the allotments of individual states
    since it is unclear how they would be deployed by the Secretary of HHS
    and cannot be used to increase the national funding level available for
    state allotments.

      Over 2020 to 2026, the block grant would provide states
    with $81.6 billion less in federal funding than would be available
    under current law, a reduction of 6.4 percent. In 2026, national
    funding for the block grant is 8.9 percent below current law spending
    ---------------------------------------------------------------------------
    projections.

      Most states would receive less funding under the block
    grant than under current law. As shown in Table 1A, 32 states would
    receive less federal funding in 2020 under the unadjusted amount of the
    block grant. By 2026, some states fare better, but the majority (27
    states) continue to face a loss of federal funding. Over the 2020 to
    2026 period, 29 states receive less in federal funding with an average
    reduction of 19 percent.

      In some states, the loss of federal funding is
    significantly higher, reflecting the disparate impact of the Graham-
    Cassidy proposal on states that have expanded Medicaid and/or generally
    have higher-cost care. States such as Alaska, Connecticut, Delaware,
    New Hampshire, New Mexico, New York, Oregon, Vermont, and Washington
    would see reductions of 25 percent or more over the 2020 to 2026 period
    under the Graham-Cassidy unadjusted allotments relative to current law.

      Over 2020 to 2026, 22 states would receive more federal
    funding under their unadjusted block grant amount than under current
    law, although they still would face cuts as a result of the Medicaid
    per-capita cap included in the Graham-
    Cassidy proposal.\4\ This group of states is dominated by non-expansion
    states, but also includes some expansion states with relatively low
    Medicaid and/or Marketplace expenditures per person.
    ---------------------------------------------------------------------------
        \4\ Although not shown here, our earlier analysis indicated that
    the per-capita cap included in BCRA, the earlier Senate legislation to
    repeal and replace the Affordable Care Act that was voted down by the
    Senate on July 25th, would result in an $189.2 billion reduction in
    federal Medicaid expenditures between fiscal year 2020 and fiscal year
    2026. We will be updating these estimates to reflect interactions
    between Graham-Cassidy's modified version of the BCRA per-capita cap in
    the near future.

      Allowable adjustments to the block grant amounts could
    result in significant changes in the distribution of federal resources
    among states. For example, if the Secretary elects to take the
    geographic cost of providing services into account using a Medicare
    price index, 33 states see a decrease in their 2020 to 2026 federal
    funding from the adjustment while the remaining states see an increase.
    This is because the Secretary can only increase funding for higher cost
    states by reducing the federal funding available for lower cost states.
    With the price adjustment, the number of states receiving less 2020 to
    ---------------------------------------------------------------------------
    2026 federal funding relative to current law increases from 29 to 31.

    See Table 1A for estimates of state-by-state federal funding for
    unadjusted allotments under the Market-Based Health Care Grant Program.
    To illustrate the potential impact of the adjustments, Table 1B
    provides illustrative estimates that assume the Secretary of HHS
    adjusts each state's allotment to reflect a state-specific measure of
    the cost of providing care. Table 2 provides additional detail on
    current law federal expenditures for Marketplace, BHP, and Medicaid
    expansion coverage.

    State Responsibility for Coverage--More than 23 million \5\ people are
    projected to have subsidized coverage through the Medicaid expansion or
    Marketplace in 2019. Under Graham-Cassidy, Medicaid expansion coverage
    and the federal infrastructure for Marketplace subsidies would end, and
    as of January 1, 2020, states would assume full responsibility for
    addressing health-care needs for low-income individuals who do not have
    affordable insurance. The block grant, however, provides states with
    less funding to do so as compared to current law funding levels.
    ---------------------------------------------------------------------------
        \5\ https://www.cbo.gov/system/files/115th-congress-2017-2018/
    reports/53091-fshic.pdf.

          Graham-Cassidy would provide new state flexibility,
    including to repurpose federal dollars away from coverage to payments
    to providers or other health care-related initiatives. However, the
    lack of a clear connection to coverage and minimal federal requirements
    ---------------------------------------------------------------------------
    may put the funding at greater risk for reductions in the future.

          In addition to determining how best to use block grant
    funds to address lack of coverage, stabilize the market and reduce
    premiums and other out-of-pocket costs, state policymakers may face
    pressure to use some of these funds to address state budget issues,
    heightened by other components of the bill, including the per-capita
    cap on federal Medicaid payments \6\ and the bill's restriction on
    states' use of provider taxes and assessments.\7\
    ---------------------------------------------------------------------------
        \6\ As noted, the Graham-Cassidy proposal would impose per person
    caps on federal funding for almost all Medicaid populations, including
    children, seniors, and people with disabilities and on virtually all
    services, including acute care, preventive care, and nursing home and
    other long-term care services. The trend rates for the caps tighten
    considerably in 2025; they are set at the medical CPI for the elderly
    and disabled populations and at CPI for all other beneficiaries. While
    the trend rate for elderly and disabled enrollees is more generous than
    was provided under BCRA, these trend rates are below CBO projections
    for the growth of health care and long-term care costs.
        \7\ Graham-Cassidy tightens the proposal first advanced in BCRA to
    reduce states' ability to rely on provider taxes and assessments to
    finance Medicaid or other State priorities. The constraints begin in
    2021 and by 2025, the current 6 percent limit that guides CMS in
    determining what is and is not an acceptable tax is reduced to 4
    percent. See HR1628, section 123.

          States will be at full financial risk for funding
    coverage programs and services developed under the block grant when the
    grant ends in 2026; there is no guarantee of whether and at what level
    ---------------------------------------------------------------------------
    federal funding would be available beginning in 2027.

    Waiver Authority and Effects on Individuals with Pre-Existing
    Conditions--The proposal gives states broad latitude to obtain waivers
    (under new authority) of the ACA's consumer protection and insurance
    regulation provisions for individual or small group coverage funded
    through the Market-Based Health Care Grant Program. States would have
    the flexibility to eliminate the essential health benefit or any other
    benefit rule; allow insurers to vary premiums based on health, age, or
    any factor other than sex or membership in a protected class; and
    eliminate requirements for a minimum medical loss ratio. In states that
    obtain waivers, individuals with pre-existing conditions could face
    substantially higher premiums in the individual and small group
    markets, or find their policies do not cover essential services. While
    coverage must be available on a guaranteed-issue basis, states could
    obtain waivers to permit insurers to increase premiums or contributions
    based on health status, or carve out or limit coverage for the specific
    treatments they need. Unlike under the ACA's Section 1332 waivers,
    there are no coverage ``guardrails'' limiting the waivers. Instead,
    states must describe in their waiver applications how individuals with
    pre-existing conditions will have ``adequate'' and ``affordable''
    coverage.

    Implications for Individual Market/Marketplace Coverage--The proposal
    eliminates the individual and employer mandates, the premium tax credit
    and cost-sharing subsidies, and permits a broader range of individuals
    to purchase catastrophic coverage, but leaves many of the other current
    law (ACA) requirements for individual market and Marketplace plans in
    place unless a state seeks a waiver. Without state action, premiums in
    this market would likely increase substantially, potentially
    destabilizing the market.

    Other Key Medicaid Provisions--As noted, Graham-Cassidy not only
    establishes the Market-Based Health Care allotments, but also
    permanently terminates the state option to expand Medicaid; beginning
    in 2020, states would no longer have the option to cover expansion
    populations, even at the regular match (with the exception of
    grandfathered Native American populations, under certain
    circumstances). In addition, it converts Medicaid funding to a per-
    capita cap (although the current draft includes a more favorable trend
    rate for elderly and disabled populations than earlier versions of
    Senate repeal and replace legislation and for frontier states with low
    Market-Based Health Care allotments, the proposed legislation delays
    implementation of the per-capita cap). States with allotments that
    grow, relative to a base year, by less than the medical component of
    the Consumer Price Index (CPI) would be eligible for a proportionate
    reduction in their otherwise applicable Medicaid disproportionate share
    hospital (DSH) cuts, but would need to provide the non-federal share to
    draw down these dollars. However, Graham-Cassidy no longer delays
    pending Medicaid DSH reductions for non-expansion states (or states
    that drop their expansion), meaning that all states will experience DSH
    reductions in federal fiscal year (FFY) 2018. Both hospitals and states
    also will see an impact from the bill's provision that restricts
    states' abilities to rely on provider taxes, phasing down the allowable
    tax safe harbor from 6 percent to 4 percent in FFY 2025 and beyond.
    Graham-Cassidy also modifies longstanding Medicaid retroactive
    eligibility authority for most Medicaid beneficiaries to provide only
    two (not three) months of coverage; three months of retroactive
    coverage would continue to be available for recipients who are 65 or
    older and who are eligible for Medicaid on the basis of being blind or
    disabled at the time the application is made. Finally, the legislation
    no longer includes an earlier BCRA provision that appropriated $45
    billion for substance use disorder treatment and recovery services,
    plus $252 million for research.

                                   CONCLUSION

    The Graham-Cassidy proposal would have major implications for states
    and their residents given the smaller pool of federal funding that
    would be available for coverage as compared to funding under current
    law, the redistribution of the reduced federal funds among states, the
    major restructuring of federal financing for state Medicaid programs
    overall, and the ability for states to waive key consumer protections
    of the ACA. Particularly in the long term, given that national amounts
    for the new block grants would be indexed at a rate below general
    inflation and then terminated after 2026, coupled with the
    establishment of per-capita caps for all non-
    expansion populations in the Medicaid program, the legislation could
    create significant fiscal and political pressure on state policymakers.
    Finally, the proposal provides states with significant flexibility to
    determine how to use their federal block grant dollars, but it also
    provides the Secretary of HHS with substantial flexibility to decide
    how to distribute federal block grant funds among states.

                 Table 1A. Estimated Federal Spending for Marketplace and Medicaid Expansion Under Current Law Versus Unadjusted Allotments PUnder Graham-Cassidy, 2020-2026 (millions)
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                            Marketplace, BHP, and Medicaid expansion under                                    Graham-Cassidy unadjusted allotment \2\
                                                            current law \1\                  -------------------------------------------------------------------------------------------------------
                    State                ----------------------------------------------------                       Amount                                  Change relative to current law
                                                                                             -------------------------------------------------------------------------------------------------------
                                              2020         2021         2026      2020-2026       2020         2021         2026      2020-2026       2020         2021         2026      2020-2026
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    United States.......................     $155,932     $164,363     $208,636   $1,268,550     $152,000     $151,000     $190,000   $1,187,000     $(3,932)    $(13,363)    $(18,636)    $(81,550)
    Alabama.............................       $1,481       $1,550       $1,802      $11,493       $1,284       $1,601       $3,564      $16,842       $(197)          $51       $1,762       $5,349
    Alaska..............................         $579         $610         $767       $4,694         $928         $772         $281       $3,534         $349         $162       $(486)     $(1,160)
    Arizona.............................       $4,201       $4,469       $5,972      $35,315       $4,106       $4,041       $4,936      $31,619        $(95)       $(428)     $(1,036)     $(3,696)
    Arkansas............................       $1,709       $1,803       $2,337      $14,060       $1,737       $1,734       $2,246      $13,938          $28        $(69)        $(91)       $(122)
    California..........................      $26,390      $27,812      $35,486     $215,291      $25,688      $24,233      $24,263     $174,185       $(702)     $(3,579)    $(11,223)    $(41,106)
    Colorado............................       $2,454       $2,589       $3,328      $20,117       $2,437       $2,317       $2,418      $16,939        $(17)       $(272)       $(910)     $(3,178)
    Connecticut.........................       $2,085       $2,198       $2,806      $17,025       $2,026       $1,844       $1,486      $12,213        $(59)       $(354)     $(1,320)     $(4,812)
    Delaware............................         $777         $820       $1,058       $6,381         $780         $696         $483       $4,383           $3       $(124)       $(575)     $(1,998)
    District of Columbia................         $380         $402         $530       $3,159         $406         $385         $395       $2,792          $26        $(17)       $(135)       $(367)
    Florida.............................      $10,211      $10,660      $12,357      $78,868       $8,902       $9,258      $14,188      $79,040     $(1,309)     $(1,402)       $1,831         $172
    Georgia.............................       $2,730       $2,850       $3,302      $21,082       $2,380       $3,047       $7,056      $32,834       $(350)         $197       $3,754      $11,752
    Hawaii..............................         $654         $690         $897       $5,387         $670         $627         $604       $4,441          $16        $(63)       $(293)       $(946)
    Idaho...............................         $549         $573         $663       $4,237         $479         $544       $1,024       $5,187        $(70)        $(29)         $361         $950
    Illinois............................       $4,580       $4,824       $6,086      $37,154       $4,328       $4,440       $6,334      $37,368       $(252)       $(384)         $248         $214
    Indiana.............................       $2,703       $2,848       $3,665      $22,136       $2,707       $2,834       $4,324      $24,662           $4        $(14)         $659       $2,526
    Iowa................................         $872         $919       $1,164       $7,091         $828         $892       $1,482       $8,111        $(44)        $(27)         $318       $1,020
    Kansas..............................         $553         $579         $671       $4,289         $479         $688       $1,851       $8,153        $(74)         $109       $1,180       $3,864
    Kentucky............................       $4,023       $4,247       $5,564      $33,293       $4,200       $3,897       $3,560      $27,025         $177       $(350)     $(2,004)     $(6,268)
    Louisiana...........................       $2,624       $2,763       $3,493      $21,296       $2,500       $2,543       $3,526      $21,111       $(124)       $(220)          $33       $(185)
    Maine...............................         $489         $512         $594       $3,793         $423         $468         $835       $4,333        $(66)        $(44)         $241         $540
    Maryland............................       $2,228       $2,347       $2,992      $18,156       $2,174       $2,132       $2,565      $16,568        $(54)       $(215)       $(427)     $(1,588)
    Massachusetts.......................       $2,935       $3,087       $3,948      $23,908       $2,906       $2,820       $3,241      $21,474        $(29)       $(267)       $(707)     $(2,434)
    Michigan............................       $5,629       $5,934       $7,640      $46,134       $5,623       $5,289       $5,214      $37,779         $(6)       $(645)     $(2,426)     $(8,355)
    Minnesota...........................       $2,533       $2,674       $3,462      $20,855       $2,588       $2,416       $2,284      $16,975          $55       $(258)     $(1,178)     $(3,880)
    Mississippi.........................         $507         $529         $614       $3,916         $442         $803       $2,661      $10,942        $(65)         $274       $2,047       $7,026
    Missouri............................       $1,501       $1,571       $1,824      $11,640       $1,301       $1,473       $2,758      $14,007       $(200)        $(98)         $934       $2,367
    Montana.............................       $1,022       $1,077       $1,362       $8,303       $1,669       $1,416         $613       $6,747         $647         $339       $(749)     $(1,556)
    Nebraska............................         $679         $712         $829       $5,288         $586         $621         $999       $5,435        $(93)        $(91)         $170         $147
    Nevada..............................       $1,526       $1,623       $2,171      $12,834       $1,515       $1,498       $1,864      $11,820        $(11)       $(125)       $(307)     $(1,014)
    New Hampshire.......................         $541         $570         $730       $4,421         $530         $491         $441       $3,381        $(11)        $(79)       $(289)     $(1,040)
    New Jersey..........................       $5,020       $5,290       $6,768      $41,002       $4,937       $4,654       $4,643      $33,405        $(83)       $(636)     $(2,125)     $(7,597)
    New Mexico..........................       $2,109       $2,227       $2,918      $17,460       $2,199       $1,986       $1,520      $12,920          $90       $(241)     $(1,398)     $(4,540)
    New York............................      $17,024      $18,194      $25,537     $147,102      $17,151      $15,487      $11,833     $100,712         $127     $(2,707)    $(13,704)    $(46,390)
    North Carolina......................       $4,917       $5,148       $5,986      $38,183       $4,256       $4,403       $6,653      $37,323       $(661)       $(745)         $667       $(860)
    North Dakota........................         $280         $296         $374       $2,280         $460         $445         $382       $2,641         $180         $149           $8         $361
    Ohio................................       $5,054       $5,331       $6,913      $41,587       $5,140       $5,135       $6,658      $41,290          $86       $(196)       $(255)       $(297)
    Oklahoma............................       $1,252       $1,312       $1,527       $9,739       $1,081       $1,315       $2,812      $13,506       $(171)           $3       $1,285       $3,767
    Oregon..............................       $4,317       $4,562       $6,011      $35,824       $4,403       $3,834       $2,145      $22,668          $86       $(728)     $(3,866)    $(13,156)
    Pennsylvania........................       $6,067       $6,389       $8,043      $49,157       $5,699       $5,527       $6,330      $42,028       $(368)       $(862)     $(1,713)     $(7,129)
    Rhode Island........................         $520         $548         $703       $4,250         $519         $499         $546       $3,718         $(1)        $(49)       $(157)       $(532)
    South Carolina......................       $1,434       $1,499       $1,743      $11,112       $1,245       $1,468       $2,972      $14,597       $(189)        $(31)       $1,229       $3,485
    South Dakota........................         $216         $226         $264       $1,680         $302         $362         $508       $2,658          $86         $136         $244         $978
    Tennessee...........................       $1,825       $1,912       $2,224      $14,189       $1,576       $1,976       $4,433      $20,883       $(249)          $64       $2,209       $6,694
    Texas...............................       $5,688       $5,944       $6,898      $44,016       $4,946       $6,835      $17,530      $78,513       $(742)         $891      $10,632      $34,497
    Utah................................         $739         $772         $895       $5,714         $642         $757       $1,536       $7,539        $(97)        $(15)         $641       $1,825
    Vermont.............................         $526         $555         $709       $4,297         $518         $462         $319       $2,905         $(8)        $(93)       $(390)     $(1,392)
    Virginia............................       $1,982       $2,071       $2,402      $15,329       $1,725       $2,022       $4,051      $19,983       $(257)        $(49)       $1,649       $4,654
    Washington..........................       $4,861       $5,140       $6,822      $40,481       $5,010       $4,527       $3,476      $29,486         $149       $(613)     $(3,346)    $(10,995)
    West Virginia.......................       $1,326       $1,399       $1,806      $10,893       $1,331       $1,265       $1,318       $9,244           $5       $(134)       $(488)     $(1,649)
    Wisconsin...........................       $1,427       $1,494       $1,734      $11,071       $1,956       $1,942       $2,590      $15,475         $529         $448         $856       $4,404
    Wyoming.............................         $203         $212         $245       $1,568         $284         $279         $252       $1,668          $81          $67           $7         $100
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    Source: Manatt Health analysis.

    Notes: Amounts assume that the entire 2020 allotment amount of $146 billion is distributed to states, including the $10 billion reserve fund. In addition, amounts shown here include $6 billion
      in 2020 and $5 billion in 2021 to increase allotments for low-density (AK, MT, ND, SD, WY) and non-expansion states.

     \1\  Amounts are for federal fiscal years. See Table 2 for additional detail.
    \2\ Estimates assume that states will choose 2017 as their base year for use in allotment calculations. As a result, amounts differ from those provided on Senator Cassidy's website (https://
      www.cassidy.senate.gov/read-about-graham-cassidy-heller-johnson), which use 2016 as the base year.

                  Table 1B. Estimated Federal Spending for Marketplace and Medicaid Expansion Under Current Law Versus Adjusted Allotments  Under Graham-Cassidy, 2020-2026 (millions)
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                            Marketplace, BHP, and Medicaid expansion under                        Graham-Cassidy allotment with illustrative price adjustment \2\
                                                            current law \1\                  -------------------------------------------------------------------------------------------------------
                    State                ----------------------------------------------------                       Amount                                  Change relative to current law
                                                                                             -------------------------------------------------------------------------------------------------------
                                              2020         2021         2026      2020-2026       2020         2021         2026      2020-2026       2020         2021         2026      2020-2026
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    United States.......................     $155,932     $164,363     $208,636   $1,268,550     $152,000     $151,000     $190,000   $1,187,000     $(3,932)    $(13,363)    $(18,636)    $(81,550)
    Alabama.............................       $1,481       $1,550       $1,802      $11,493       $1,284       $1,361       $3,059      $14,523       $(197)       $(189)       $1,257       $3,030
    Alaska..............................         $579         $610         $767       $4,694         $928         $863         $345       $4,013         $349         $253       $(422)       $(681)
    Arizona.............................       $4,201       $4,469       $5,972      $35,315       $4,106       $3,901       $4,902      $31,092        $(95)       $(568)     $(1,070)     $(4,223)
    Arkansas............................       $1,709       $1,803       $2,337      $14,060       $1,737       $1,486       $1,979      $12,359          $28       $(317)       $(358)     $(1,701)
    California..........................      $26,390      $27,812      $35,486     $215,291      $25,688      $27,581      $28,409     $197,306       $(702)       $(231)     $(7,077)    $(17,985)
    Colorado............................       $2,454       $2,589       $3,328      $20,117       $2,437       $2,223       $2,386      $16,563        $(17)       $(366)       $(942)     $(3,554)
    Connecticut.........................       $2,085       $2,198       $2,806      $17,025       $2,026       $2,007       $1,664      $13,276        $(59)       $(191)     $(1,142)     $(3,749)
    Delaware............................         $777         $820       $1,058       $6,381         $780         $689         $492       $4,400           $3       $(131)       $(566)     $(1,981)
    District of Columbia................         $380         $402         $530       $3,159         $406         $417         $440       $3,032          $26          $15        $(90)       $(127)
    Florida.............................      $10,211      $10,660      $12,357      $78,868       $8,902       $8,526      $13,322      $74,073     $(1,309)     $(2,134)         $965     $(4,795)
    Georgia.............................       $2,730       $2,850       $3,302      $21,082       $2,380       $2,748       $6,472      $30,054       $(350)       $(102)       $3,170       $8,972
    Hawaii..............................         $654         $690         $897       $5,387         $670         $696         $690       $4,917          $16         $(6)       $(207)       $(470)
    Idaho...............................         $549         $573         $663       $4,237         $479         $505         $972       $4,901        $(70)        $(68)         $309         $664
    Illinois............................       $4,580       $4,824       $6,086      $37,154       $4,328       $4,246       $6,232      $36,448       $(252)       $(578)         $146       $(706)
    Indiana.............................       $2,703       $2,848       $3,665      $22,136       $2,707       $2,594       $4,071      $23,140           $4       $(254)         $406       $1,004
    Iowa................................         $872         $919       $1,164       $7,091         $828         $831       $1,421       $7,732        $(44)        $(88)         $257         $641
    Kansas..............................         $553         $579         $671       $4,289         $479         $619       $1,692       $7,432        $(74)          $40       $1,021       $3,143
    Kentucky............................       $4,023       $4,247       $5,564      $33,293       $4,200       $3,447       $3,239      $24,690         $177       $(800)     $(2,325)     $(8,603)
    Louisiana...........................       $2,624       $2,763       $3,493      $21,296       $2,500       $2,206       $3,146      $18,905       $(124)       $(557)       $(347)     $(2,391)
    Maine...............................         $489         $512         $594       $3,793         $423         $451         $824       $4,240        $(66)        $(61)         $230         $447
    Maryland............................       $2,228       $2,347       $2,992      $18,156       $2,174       $2,376       $2,940      $18,471        $(54)          $29        $(52)         $315
    Massachusetts.......................       $2,935       $3,087       $3,948      $23,908       $2,906       $3,100       $3,665      $23,641        $(29)          $13       $(283)       $(267)
    Michigan............................       $5,629       $5,934       $7,640      $46,134       $5,623       $5,044       $5,116      $36,765           $6       $(890)     $(2,524)     $(9,369)
    Minnesota...........................       $2,533       $2,674       $3,462      $20,855       $2,588       $2,428       $2,361      $17,268          $55       $(246)     $(1,101)     $(3,587)
    Mississippi.........................         $507         $529         $614       $3,916         $442         $695       $2,331       $9,563        $(65)         $166       $1,717       $5,647
    Missouri............................       $1,501       $1,571       $1,824      $11,640       $1,301       $1,339       $2,552      $12,943       $(200)       $(232)         $728       $1,303
    Montana.............................       $1,022       $1,077       $1,362       $8,303       $1,669       $1,382         $605       $6,629         $647         $305       $(757)     $(1,674)
    Nebraska............................         $679         $712         $829       $5,288         $586         $585         $963       $5,208        $(93)       $(127)         $134        $(80)
    Nevada..............................       $1,526       $1,623       $2,171      $12,834       $1,515       $1,512       $1,935      $12,080        $(11)       $(111)       $(236)       $(754)
    New Hampshire.......................         $541         $570         $730       $4,421         $530         $498         $460       $3,466        $(11)        $(72)       $(270)       $(955)
    New Jersey..........................       $5,020       $5,290       $6,768      $41,002       $4,937       $4,939       $5,068      $35,610        $(83)       $(351)     $(1,700)     $(5,392)
    New Mexico..........................       $2,109       $2,227       $2,918      $17,460       $2,199       $1,911       $1,505      $12,667          $90       $(316)     $(1,413)     $(4,793)
    New York............................      $17,024      $18,194      $25,537     $147,102      $17,151      $17,080      $13,426     $110,645         $127     $(1,114)    $(12,111)    $(36,457)
    North Carolina......................       $4,917       $5,148       $5,986      $38,183       $4,256       $4,070       $6,272      $35,101       $(661)     $(1,078)         $286     $(3,082)
    North Dakota........................         $280         $296         $374       $2,280         $460         $427         $367       $2,538         $180         $131         $(7)         $258
    Ohio................................       $5,054       $5,331       $6,913      $41,587       $5,140       $4,706       $6,277      $38,809          $86       $(625)       $(636)     $(2,778)
    Oklahoma............................       $1,252       $1,312       $1,527       $9,739       $1,081       $1,164       $2,525      $12,136       $(171)       $(148)         $998       $2,397
    Oregon..............................       $4,317       $4,562       $6,011      $35,824       $4,403       $3,926       $2,260      $23,358          $86       $(636)     $(3,751)    $(12,466)
    Pennsylvania........................       $6,067       $6,389       $8,043      $49,157       $5,699       $5,313       $6,260      $41,177       $(368)     $(1,076)     $(1,783)     $(7,980)
    Rhode Island........................         $520         $548         $703       $4,250         $519         $521         $586       $3,913         $(1)        $(27)       $(117)       $(337)
    South Carolina......................       $1,434       $1,499       $1,743      $11,112       $1,245       $1,324       $2,727      $13,381       $(189)       $(175)         $984       $2,269
    South Dakota........................         $216         $226         $264       $1,680         $302         $352         $497       $2,590          $86         $126         $233         $910
    Tennessee...........................       $1,825       $1,912       $2,224      $14,189       $1,576       $1,716       $3,897      $18,400       $(249)       $(196)       $1,673       $4,211
    Texas...............................       $5,688       $5,944       $6,898      $44,016       $4,946       $6,255      $16,346      $72,913       $(742)         $311       $9,448      $28,897
    Utah................................         $739         $772         $895       $5,714         $642         $701       $1,451       $7,092        $(97)        $(71)         $556       $1,378
    Vermont.............................         $526         $555         $709       $4,297         $518         $482         $343       $3,045         $(8)        $(73)       $(366)     $(1,252)
    Virginia............................       $1,982       $2,071       $2,402      $15,329       $1,725       $1,884       $3,853      $18,920       $(257)       $(187)       $1,451       $3,591
    Washington..........................       $4,861       $5,140       $6,822      $40,481       $5,010       $4,600       $3,634      $30,246         $149       $(540)     $(3,188)    $(10,235)
    West Virginia.......................       $1,326       $1,399       $1,806      $10,893       $1,331       $1,134       $1,215       $8,532           $5       $(265)       $(591)     $(2,361)
    Wisconsin...........................       $1,427       $1,494       $1,734      $11,071       $1,956       $1,862       $2,544      $15,084         $529         $368         $810       $4,013
    Wyoming.............................         $203         $212         $245       $1,568         $284         $282         $264       $1,714          $81          $70          $19         $146
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    Source: Manatt Health analysis.

     Notes: Amounts assume that the entire 2020 allotment amount of $146 billion is distributed to states, including the $10 billion reserve fund. In addition, amounts shown here include $6
      billion in 2020 and $5 billion in 2021 to increase allotments for low-density (AK, MT, ND, SD, WY) and non-expansion states.

     \1\ Amounts are for federal fiscal years. See Table 2 for additional detail.
    \2\ The Graham-Cassidy proposal includes state-level allotment adjustments for population risk, actuarial value of coverage, and, at the Secretary of HHS's discretion, state-specific factors
      (e.g., wage rates). For illustrative purposes, amounts shown here include a state-specific adjustment based on a price index constructed using actual and standardized Medicare costs per
      capita for 2015 (https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Geographic-Variation/GV_PUF.html).

                                                     Table 2. Detail on Estimated Federal Spending for Marketplace and Medicaid Expansion Coverage PUnder Current Law, 2020-2026 (millions)
    ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                              2020                                         2021                                         2026                                      2020-2026
                                                         -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                            State                         Marketplace \1\     Medicaid                 Marketplace \1\     Medicaid                 Marketplace \1\     Medicaid                 Marketplace \1\     Medicaid
                                                            and BHP \2\    expansion \3\     Total       and BHP \2\    expansion \3\     Total       and BHP \2\    expansion \3\     Total       and BHP \2\    expansion \3\     Total
    ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    United States.......................................        $69,910         $86,022      $155,932        $73,396         $90,967      $164,363        $87,672        $120,964      $208,636       $550,477        $718,073    $1,268,550
    Alabama.............................................         $1,481              $-        $1,481         $1,550              $-        $1,550         $1,802              $-        $1,802        $11,493              $-       $11,493
    Alaska..............................................           $242            $337          $579           $254            $356          $610           $296            $471          $767         $1,888          $2,806        $4,694
    Arizona.............................................         $1,201          $3,000        $4,201         $1,262          $3,207        $4,469         $1,471          $4,501        $5,972         $9,382         $25,933       $35,315
    Arkansas............................................           $293          $1,416        $1,709           $306          $1,497        $1,803           $356          $1,981        $2,337         $2,269         $11,791       $14,060
    California..........................................         $7,990         $18,400       $26,390         $8,369         $19,443       $27,812         $9,739         $25,747       $35,486        $62,104        $153,187      $215,291
    Colorado............................................           $585          $1,869        $2,454           $614          $1,975        $2,589           $714          $2,614        $3,328         $4,559         $15,558       $20,117
    Connecticut.........................................           $636          $1,449        $2,085           $667          $1,531        $2,198           $779          $2,027        $2,806         $4,960         $12,065       $17,025
    Delaware............................................           $162            $615          $777           $170            $650          $820           $197            $861        $1,058         $1,259          $5,122        $6,381
    District of Columbia................................             $4            $376          $380             $4            $398          $402             $4            $526          $530            $28          $3,131        $3,159
    Florida.............................................        $10,211              $-       $10,211        $10,660              $-       $10,660        $12,357              $-       $12,357        $78,868              $-       $78,868
    Georgia.............................................         $2,730              $-        $2,730         $2,850              $-        $2,850         $3,302              $-        $3,302        $21,082              $-       $21,082
    Hawaii..............................................            $98            $556          $654           $102            $588          $690           $119            $778          $897           $757          $4,630        $5,387
    Idaho...............................................           $549              $-          $549           $573              $-          $573           $663              $-          $663         $4,237              $-        $4,237
    Illinois............................................         $1,785          $2,795        $4,580         $1,871          $2,953        $4,824         $2,177          $3,909        $6,086        $13,887         $23,267       $37,154
    Indiana.............................................           $593          $2,110        $2,703           $619          $2,229        $2,848           $715          $2,950        $3,665         $4,573         $17,563       $22,136
    Iowa................................................           $328            $544          $872           $344            $575          $919           $403            $761        $1,164         $2,561          $4,530        $7,091
    Kansas..............................................           $553              $-          $553           $579              $-          $579           $671              $-          $671         $4,289              $-        $4,289
    Kentucky............................................           $335          $3,688        $4,023           $350          $3,897        $4,247           $406          $5,158        $5,564         $2,591         $30,702       $33,293
    Louisiana...........................................           $970          $1,654        $2,624         $1,015          $1,748        $2,763         $1,180          $2,313        $3,493         $7,525         $13,771       $21,296
    Maine...............................................           $489              $-          $489           $512              $-          $512           $594              $-          $594         $3,793              $-        $3,793
    Maryland............................................           $668          $1,560        $2,228           $698          $1,649        $2,347           $810          $2,182        $2,992         $5,168         $12,988       $18,156
    Massachusetts.......................................           $776          $2,159        $2,935           $806          $2,281        $3,087           $929          $3,019        $3,948         $5,935         $17,973       $23,908
    Michigan............................................         $1,269          $4,360        $5,629         $1,327          $4,607        $5,934         $1,542          $6,098        $7,640         $9,836         $36,298       $46,134
    Minnesota...........................................           $915          $1,618        $2,533           $965          $1,709        $2,674         $1,200          $2,262        $3,462         $7,389         $13,466       $20,855
    Mississippi.........................................           $507              $-          $507           $529              $-          $529           $614              $-          $614         $3,916              $-        $3,916
    Missouri............................................         $1,501              $-        $1,501         $1,571              $-        $1,571         $1,824              $-        $1,824        $11,640              $-       $11,640
    Montana.............................................           $375            $647        $1,022           $393            $684        $1,077           $457            $905        $1,362         $2,917          $5,386        $8,303
    Nebraska............................................           $679              $-          $679           $712              $-          $712           $829              $-          $829         $5,288              $-        $5,288
    Nevada..............................................           $372          $1,154        $1,526           $389          $1,234        $1,623           $450          $1,721        $2,171         $2,877          $9,957       $12,834
    New Hampshire.......................................           $155            $386          $541           $162            $408          $570           $190            $540          $730         $1,205          $3,216        $4,421
    New Jersey..........................................         $1,373          $3,647        $5,020         $1,436          $3,854        $5,290         $1,668          $5,100        $6,768        $10,641         $30,361       $41,002
    New Mexico..........................................           $185          $1,924        $2,109           $194          $2,033        $2,227           $227          $2,691        $2,918         $1,442         $16,018       $17,460
    New York............................................         $4,978         $12,046       $17,024         $5,466         $12,728       $18,194         $8,691         $16,846       $25,537        $46,825        $100,277      $147,102
    North Carolina......................................         $4,917              $-        $4,917         $5,148              $-        $5,148         $5,986              $-        $5,986        $38,183              $-       $38,183
    North Dakota........................................            $99            $181          $280           $104            $192          $296           $120            $254          $374           $769          $1,511        $2,280
    Ohio................................................           $847          $4,207        $5,054           $886          $4,445        $5,331         $1,030          $5,883        $6,913         $6,567         $35,020       $41,587
    Oklahoma............................................         $1,252              $-        $1,252         $1,312              $-        $1,312         $1,527              $-        $1,527         $9,739              $-        $9,739
    Oregon..............................................           $674          $3,643        $4,317           $707          $3,855        $4,562           $824          $5,187        $6,011         $5,253         $30,571       $35,824
    Pennsylvania........................................         $2,472          $3,595        $6,067         $2,591          $3,798        $6,389         $3,016          $5,027        $8,043        $19,233         $29,924       $49,157
    Rhode Island........................................           $120            $400          $520           $125            $423          $548           $143            $560          $703           $918          $3,332        $4,250
    South Carolina......................................         $1,434              $-        $1,434         $1,499              $-        $1,499         $1,743              $-        $1,743        $11,112              $-       $11,112
    South Dakota........................................           $216              $-          $216           $226              $-          $226           $264              $-          $264         $1,680              $-        $1,680
    Tennessee...........................................         $1,825              $-        $1,825         $1,912              $-        $1,912         $2,224              $-        $2,224        $14,189              $-       $14,189
    Texas...............................................         $5,688              $-        $5,688         $5,944              $-        $5,944         $6,898              $-        $6,898        $44,016              $-       $44,016
    Utah................................................           $739              $-          $739           $772              $-          $772           $895              $-          $895         $5,714              $-        $5,714
    Vermont.............................................           $140            $386          $526           $147            $408          $555           $169            $540          $709         $1,084          $3,213        $4,297
    Virginia............................................         $1,982              $-        $1,982         $2,071              $-        $2,071         $2,402              $-        $2,402        $15,329              $-       $15,329
    Washington..........................................           $613          $4,248        $4,861           $640          $4,500        $5,140           $741          $6,081        $6,822         $4,734         $35,747       $40,481
    West Virginia.......................................           $274          $1,052        $1,326           $287          $1,112        $1,399           $335          $1,471        $1,806         $2,134          $8,759       $10,893
    Wisconsin...........................................         $1,427              $-        $1,427         $1,494              $-        $1,494         $1,734              $-        $1,734        $11,071              $-       $11,071
    Wyoming.............................................           $203              $-          $203           $212              $-          $212           $245              $-          $245         $1,568              $-       $1,568
    ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    Source: Manatt Health analysis.

    Notes: Amounts are for federal fiscal years.

    \1\ Reflects national growth as projected by CBO, applied to state-level amounts. Estimate based on:
     2017 tax credit data for all states (https://downloads.cms.gov/files/effectuated-enrollment-snapshot-report-06-12-17.pdf);
     2016 cost-sharing reduction (CSR) data for 38 HealthCare.gov states (https://aspe.hhs.gov/health-insurance-marketplace-cost-sharing-reduction-subsidies-zip-code-and-county-2016), with national average applied to CSR enrollees in
      remaining states (https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/Effectuated_QuarterlyP_Snapshots.html);
     September 2017 CBO projections for national totals (https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53091-fshic.pdf). Because CBO recently revised its projections, current law estimates shown here differ from a
      previous publication describing an earlier version of the Graham-Cassidy proposal (http://www.statenetwork.org/wp-content/uploads/2017/08/SHVS_Repeal-and-Replace_Final.pdf).
    \2\ MN and NY provide BHP coverage for certain individuals who would otherwise be eligible for subsidies through the Marketplace. Estimates of federal funding reflect projections in state budget documents, with amounts extended out
      to 2026 using 2021 growth rate (https://mn.gov/dhs/general-public/publications-forms-resources/reports/financial-reports-and-forecasts.jsp; https://www.budget.ny.gov/pubs/archive/fy18archive/enactedfy18/FY2018EnactedFP.pdf).
    \3\ Estimate based on Manatt Medicaid Financing Model for background, see (http://www.statenetwork.org/resource/understanding-the-senates-better-care-reconciliation-act-of-2017-bcra-key-implications-for-medicaid/). Note that the
      national figure differs from CBO baseline for ACA subsidies (https://www.cbo.gov/sites/default/files/recurringdata/51298-2017-01-healthinsurance.pdf) in part because CBO: (1) only breaks out federal spending on Medicaid expansion
      for individuals who were made eligible by the ACA; (2) assumes that additional states have expanded by 2020. Spending from the Manatt Medicaid Financing Model includes newly eligible individuals in the expansion adult group but
      also those who were eligible under pre-ACA rules, for whom states may receive enhanced federal match (AZ, DE, HI, MA, MN, NY, VT, WA) and/or regular federal match (AR, CO, CT, IL, IN, IA, MI, NH, NY, ND, OH, OR, PA; in all but IN,
      NY, and OR the estimated share of expansion group enrollees at regular match is less than 10 percent).

      Appendix: Additional Details on the Market-based Health Care Grant
                                    Program

    National Funding Levels

      2020: $146 billion (with $10 billion out of 2020
    appropriation reserved for an increase in 2020 allotments of up to 5
    percent for each state, with any unspent amount added to 2026
    allotments)

      2021: $146 billion

      2022: $157 billion

      2023: $168 billion

      2024: $179 billion

      2025: $190 billion

      2026: $190 billion

      2027 and beyond: No allocation

    In addition, in 2020 and 2021, a ``contingency fund'' of $6 billion and
    $5 billion, respectively, is available for states with fewer than 15
    residents per square mile (25 percent) and non-expansion states (75
    percent).

    Uses of Funds

      Allowable uses of funds include:

          Stabilizing premiums and promoting issuer participation in the
    individual market;

          Paying providers directly for health-care services;

          Funding assistance to reduce out-of-pocket costs for people in
    the individual market;

          Helping people buy coverage, including by paying individual
    market premiums; and

          Providing health insurance coverage for Medicaid-eligible
    individuals by establishing and maintaining relationships with health
    insurance issuers, but limited to 15 percent of the state's allotments.

      Funds can be used for up to 2 years after the year for
    which they were appropriated (e.g., 2020 funds could be used in 2020,
    2021, and 2022).

      No state matching requirement.

      State-specific allotments are prorated as needed to match
    the national allotments.

    Distribution Formula

    The formula for distributing funds among states changes over time. In
    2020 it is based on a state's historic spending on Medicaid expansion,
    Marketplace coverage, and the BHP, indexed forward from a base period.
    Over time, allotments increasingly are based on a state's share of low-
    income individuals between 45 percent and 133 percent of the FPL.
    Beginning in 2021, state allotments also may be adjusted based on the
    risk profile of the state's low-income population, the actuarial value
    of coverage funded by the state with block grant dollars, and a
    discretionary state-specific adjustment by the Secretary of HHS that
    accounts for additional factors (e.g., wage rates) that impact health-
    care expenditures in a state.
    2020 Allotment
      Based on the following sum of federal expenditures in a
    state during a base period (selected by a state from four consecutive
    quarters between first quarter of fiscal year 2014 and first quarter of
    2018):

          Medicaid expansion, indexed by MACPAC projections through
    November 2019;

          BHP, indexed by medical CPI;

          Advanced premium tax credits, indexed by medical CPI; and

          Cost-sharing reductions, indexed by medical CPI.

      In 2020, states may request a share of up to $10 billion
    that is reserved for an advance payment to increase their 2020
    allotments.
    2021 to 2025 Allotments
      During this period, each state's allotment is based on its
    prior year allotment taking into account special adjustments (see
    below) plus or minus one-sixth of the difference between the state's
    prior year allotment and its projected 2026 allotment. (As described
    below, the 2026 allotment is based on each state's share of low-
    income people.)

      The following adjustments may be applied to a state's
    allotment, depending on the year and state circumstances:

          Population risk adjustment

            A risk adjustment factor based on the clinical risk
    categories into which the low-income individuals in each state are
    classified in accordance with a methodology to be developed by the
    Secretary

            Applies to 2021 to 2026, but phased in between 2021
    (25 percent), 2022 (50 percent), 2023 (75 percent)

            In all years, limited to increasing/decreasing a
    state's allotment by no more than 10 percent

          Coverage value adjustment

            Applies to 2024, 2025, and 2026, but phased in at 25
    percent in 2024, 50 percent in 2025, and 75 percent in 2026

            Reduces a state's allotment in proportion to the
    extent to which it offers coverage valued at less than the amount
    required for targeted low-income children in the Children's Health
    Insurance Program (CHIP)

            The proposal provides specific rules for how to
    ``value'' the coverage of selected individuals (e.g., individuals
    served by the block grant who are not receiving any coverage must be
    assigned an actuarial value of 0 percent)

          State-specific population adjustment

            Secretary's discretion to adjust allotments according
    to a ``population adjustment factor''

            Must take into account ``legitimate factors'' that
    impact health expenditures beyond clinical characteristics of low-
    income individuals

            May include demographics, wage rates, income levels,
    and other factors
    2026 Allotment
      In 2026, each state receives a share of the available
    national allotment ($190 billion) based on its share of low-income
    individuals between 45 percent and 133 percent of FPL.

      The adjustments described above under the formula for 2021
    to 2025 continue to apply in 2026.

                                     ______

                Questions Submitted for the Record to Cindy Mann
                  Questions Submitted by Hon. Robert Menendez
        Question. Families who have children with special needs often face
    an uphill battle in accessing services. What protections does the
    Graham-Cassidy-Heller-Johnson bill offer them to ensure their children
    are not cut off from care for their conditions? That a young child
    isn't forced to go without care because they have hit an annual cap? A
    lifetime cap?

        Answer. Graham-Cassidy would cap Federal Medicaid spending
    beginning in fiscal year 2020. Even though spending for a few
    populations--including children eligible for Medicaid based on
    disability--is exempt from the per-capita cap, the proposal creates an
    aggregate cap on Federal spending that is computed based on those caps.
    That aggregate cap is what sets the limit on Federal spending on the
    program, constraining spending in the Medicaid program, not just for
    the populations subject to the per-capita cap. For this reason the caps
    will have ramifications across the program and impact even those
    populations that the legislation appears to protect. In order to keep
    funding under the aggregate cap, States may be forced to reduce
    provider rates or optional benefits, potentially jeopardizing care for
    children with disabilities. States might seek to reduce spending by
    reducing or eliminating eligibility for high cost enrollees, which
    could put high-needs children covered under optional Medicaid
    eligibility groups at risk.

        In addition, Graham-Cassidy would allow States to adjust the scope
    of Essential Health Benefits to people who receive care on the
    individual market. This could mean that coverage could be less robust,
    with the scope of benefits reduced relative to current laws. Before the
    ACA was enacted, Medicaid often picked up the costs for high needs kids
    who hit the private insurance benefits caps. Graham-Cassidy introduces
    the possibility that such need could arise again, but in a capped
    funding environment, there would be less Federal financial support for
    Medicaid to meet this important need.

        Question. Wrap-around services are of critical importance to many
    families who have children with disabilities and who earn too much to
    qualify for Medicaid. How will Senator Cassidy's proposal ensure these
    families don't lose access to critically important services for their
    children and family members?

        Answer. Graham-Cassidy does not protect wrap-around services for
    children with disabilities and their families and in fact jeopardizes
    the continued availability of these critical services. Even though
    children eligible based on disability are not subject to the per-capita
    cap under the proposal, the computations based on the per-capita caps
    build up to an aggregate cap, and the aggregate cap will drive
    programmatic cuts that will ripple across the Medicaid program. Through
    funding reductions and caps, the proposal puts coverage at risk for
    virtually every group of individuals covered through ``traditional''
    Medicaid, including one out of three children in the Nation as well as
    millions of elderly people and both adults and children with
    disabilities whose long term care services are covered by Medicaid. In
    addition, some services that children with disabilities rely upon--
    including home and community based services--are optional Medicaid
    services and could be cut in an environment in which States are seeking
    to manage their programs to ensure they do not exceed capped
    allotments.

        Question. If States use the Market-Based Health Care Block Grant to
    establish high-risk pools, do you think there is sufficient funding in
    the grants to ensure States are able to operate the pool in a manner
    that will cover as many people as are currently covered under the
    Affordable Care Act?

        Answer. No. Graham-Cassidy would eliminate Federal funding for
    Marketplace and Medicaid expansion coverage after 2019 and replace it
    with a capped allotment distributed to States in the form of ``Market-
    Based Health Care'' block grants. The block grant ends in 2026, leaving
    States with no funding to continue block grant initiatives, unless the
    program is reauthorized. The national amounts available from 2020-2026
    for State allotments would not vary based on actual costs or enrollment
    and would be less than estimated current law Federal spending on
    Marketplace and Medicaid expansion coverage. As such, there is not
    sufficient funding in the grants to cover the same number of people
    with the same or similar scope of benefits as are covered today.
    Furthermore, under Graham-Cassidy, States would have flexibility to use
    their block grants for many purposes, including but not limited to
    coverage; there will be many competing demands for these dollars. A
    State that chose to use some of its block grant funds to establish a
    high risk pool would have even less funding to provide comprehensive
    coverage for those losing Medicaid and Marketplace coverage. At the
    same time, given competing demands, States would likely find funding
    insufficient to meet needs in such a high risk pool, which are
    typically designed to serve sicker and more expensive patients.
                               medicaid expansion
        Question. The legislation introduced by Senators Bill Cassidy,
    Lindsay Graham, Dean Heller, and Ron Johnson (Graham-Cassidy-Heller-
    Johnson) proposes to make radical changes to Medicaid beginning in
    2020. First, the bill would impose per-capita caps on the traditional
    program, which covers over 60 million low-income children, pregnant
    women, seniors, and individuals with disabilities. Second, the bill
    would eliminate the Affordable Care Act's (ACA) optional Medicaid
    expansion, which today covers over 11 million low-income adults across
    31 States and the District of Columbia.

        While these proposals echo the caps proposed by Senate Republicans
    earlier this summer, Graham-Cassidy's proposed changes to Medicaid
    expansion would be more severe than any proposal introduced thus far.
    This is because Graham-Cassidy ends both the Federal match for Medicaid
    expenditures under the program as well as the Medicaid expansion
    eligibility pathway. As a result, in 2020, all individuals covered
    under the Medicaid expansion would lose their coverage.

        During the September 25th hearing before the U.S. Senate Finance
    Committee, there was confusion created over what happens to the
    Medicaid expansion program and its beneficiaries under the Graham-
    Cassidy bill. For example, when Senator Heller asked Senator Cassidy,
    ``Could an expanded State like Nevada use the money to replicate their
    current Medicaid expansion system?'' Senator Cassidy responded with:
    ``Absolutely.'' Could you please clarify whether States would be
    permitted to continue providing Medicaid coverage to the expansion
    population under Graham-Cassidy as they do today? Is it correct that
    this eligibility pathway is terminated in 2020 for expansion States and
    as of September 1, 2017 for non-expansion States? Is it correct that a
    State would no longer be eligible for enhanced Federal funding under
    the expansion FMAP?

        Answer. States like Nevada could not replicate their current
    Medicaid expansion system under the Cassidy-Graham legislation. They
    could not maintain their Medicaid expansion because the Graham-Cassidy
    legislation eliminates the eligibility pathway that allows States the
    flexibility to expand--upon enactment for States that haven't yet
    expanded and in 2020, for States that have already expanded. This means
    that States could not receive even the regular Federal match to cover
    the Medicaid expansion population. While some States might pursue 1115
    waivers to retain Medicaid coverage for expansion populations, Federal
    budget neutrality rules could make it very difficult--if not
    impossible--to continue coverage for expansion adults.

        Although the block grant funding could be used by States to
    establish alternative coverage programs, the Congressional Budget
    Office's (CBO's) preliminary analysis of the Graham-Cassidy legislation
    still concludes that ``millions'' would lose coverage under the
    proposed legislation. In particular, CBO indicates that by 2026, the
    amount of block grant funding received by expansion States would be
    enough to cover only a population that is similar in size and cost to
    its current law Medicaid expansion population. In other words, there
    would be no Federal funding available to serve those who would have had
    Marketplace coverage under current law. While States could choose to
    use their block grant funds to subsidize a population that differs from
    the expansion group, the end result is the same--millions of people
    losing coverage.\1\
    ---------------------------------------------------------------------------
        \1\ Congressional Budget Office, ``Preliminary Analysis of
    Legislation That Would Replace Subsidies for Health Care With Block
    Grants,'' September 2017, available at: https://www.cbo.gov/
    publication/53126. CBO based its analysis on Version LYN17744 of the
    proposed legislation, available here: https://www.cassidy.senate.gov/
    imo/media/doc/LYN177444.pdf.

        Question. Even if States attempted to replicate their previous
    expansion coverage with block grant funds and ignored other competing
    demands for the dollars, the block grant is no replacement for
    Medicaid. The total amount of Federal funding available to States does
    not adjust based on enrollment or costs as it does under Medicaid; and
    to keep the cost of coverage from exceeding the block grant funds,
    States would likely impose enrollment caps and potentially waiting
    lists. In addition, the block grant ends in 2026, leaving States with
    no funding to continue block grant initiatives--including replacement
    coverage for the Medicaid expansion population--unless the program is
    reauthorized. The expiration of the funding not only jeopardizes
    coverage post 2026 but will make States understandably reluctant to
    take on substantial coverage responsibilities for fear of ``holding the
    ---------------------------------------------------------------------------
    bag'' once the block grant funds expire.

        There was also confusion created around whether States who have
    expanded their Medicaid programs would receive more or fewer Federal
    dollars than under current law. Senator Cassidy claimed that some
    expansion States would benefit from the block grant because they would
    no longer be required to provide a 10-percent State match to receive
    Federal expansion funding. For example, Senator Heller claimed that
    without this 10-percent match, Nevada would save $1.16 billion. Can you
    please explain, briefly, whether States that picked up the Medicaid
    expansion would receive more or fewer Federal dollars to assist low-
    income residents with health insurance coverage under the Graham-
    Cassidy proposal? In your view, would States that have not expanded
    receive more Federal support than they would have otherwise had access
    to if they choose to expand their Medicaid programs?

        Answer. Over time, nearly all States that expanded Medicaid will
    receive fewer Federal dollars under Graham-Cassidy than they would
    under current law. While Senator Heller is correct that the 10-percent
    State match that the State will provide to draw down Federal Medicaid
    matching funds to support the Medicaid expansion would no longer be
    required, all but a handful of expansion States would receive far less
    Federal support under Graham-Cassidy than they do today and would have
    to spend more--not less--to maintain coverage at current levels.

        In general, Manatt's analysis of the September 13th version of the
    Graham-
    Cassidy legislation indicates that States that expanded Medicaid would
    receive fewer Federal dollars to assist low-income residents with
    health insurance coverage. For example, according to Manatt's analysis
    of the September 13th legislation, Nevada stands to lose as much as a
    billion dollars, relative to current law.\2\ However, there were
    subsequent adjustments to the legislation that would benefit specific
    States (including Nevada), through an expansion of the low-density
    definition, the addition of contingency funds for expansion States, and
    targeted increases for other States, which could reduce this loss to
    some extent.\3\
    ---------------------------------------------------------------------------
        \2\ ``Update: State Policy and Budget Impacts of the New Graham-
    Cassidy Repeal and Replace Proposal,'' prepared by Manatt Health for
    the Robert Wood Johnson Foundation, State Health and Value Strategies,
    September 2017, available at: http://www.statenetwork.org/wp-content/
    uploads/2017/09/SHVS_Graham-Cassidy-Sept-2017_Final.pdf.
        \3\ The September 25th updated version of the legislation also
    would allot 5 percent of Short Term Assistance funds to low-density
    States, like Nevada, with fewer than 30 people per square mile
    (previously defined as those with fewer than 15 people per square
    mile).

        There is no basis for saying that non-expansion States would
    categorically receive more Federal funding under the block grant than
    if they expanded under current law. First, the block grant is capped
    nationwide and is not adjusted based on the actual cost of care or the
    number of people who might enroll. By contrast, if a State expands
    coverage under Medicaid it is guaranteed Federal dollars to cover no
    less than 90 percent of the cost of care for all eligible people who
    enroll. If costs rise due to an epidemic like the opioid crisis, or
    because of rising drug costs, or if enrollment grows due to a recession
    or a natural disaster that puts people out of work, under current law
    Medicaid funding will adjust but the total block grant funds would not.
    Second, even if a given State does not experience higher costs or
    enrollment, another State might, and Graham-Cassidy allows the
    Secretary to increase one State's allocation at the expense of another
    ---------------------------------------------------------------------------
    State. That too undermines any certainty for States.

        In addition, an added danger for individuals who might have been
    eligible for Medicaid under an expansion is that the Market-Based
    Health Care Grants can be used for any number of initiatives, meaning
    that although the funds could be available to help support coverage for
    the Medicaid population, it is just as likely that the funding would be
    used to cover the costs of coverage for individuals at higher income
    levels.

                                     ______

                      Question Submitted by Hon. Ron Wyden
                            medicaid per-capita caps
        Question. Beginning in 2020, the Graham-Cassidy proposal would
    convert the open-ended structure of the traditional Medicaid program to
    a per-capita cap system, where Federal reimbursements for Medicaid
    expenditures are capped at a set amount per beneficiary.

        Proposals like Graham-Cassidy to cap Medicaid would dramatically
    reduce Federal funding for the program, especially over the long-term,
    forcing States to compensate for shortfalls by limiting Medicaid
    enrollment, eliminating optional benefits, and reducing payments to
    providers. Thus, Medicaid per-capita caps risk beneficiaries' access to
    needed benefits as well as the quality of Medicaid-funded services.

        During the September 25th hearing before the U.S. Senate Finance
    Committee, in an exchange concerning Medicaid in Kansas, Senator Pat
    Roberts asked Senator Cassidy whether it was ``fair to say the Kansas
    cap is in fact higher than what they currently spend?'' In response,
    Senator Cassidy said, ``Yes, you can spend, you can also supplement, if
    you will, the traditional Medicaid budget with the extra dollars that
    Kansas is receiving, and you have the flexibility to do that as well.''
    Could you please clarify whether States like Kansas will face
    reductions in Federal support under the per-capita cap proposed by
    Graham-Cassidy? Would such a cap take into account economic factors
    like a recession or local down-turn, costs of new medical treatments
    like new drugs, or demographic factors like an aging baby boomer
    population?

        Answer. All States--including Kansas--could receive a reduction in
    Federal support under the per-capita cap proposed by Graham-Cassidy.
    This is because the per-capita cap limits most Medicaid spending to
    growth rates that are below national averages projected for Medicaid
    spending. Because, on average, the rate of growth in the per-capita cap
    trend rates would not keep pace with actual expenditure growth that
    would occur under current law, as confirmed by CBO's analyses, the
    Graham-Cassidy Medicaid per-capita caps could result in reduced Federal
    support for States. Kansas's experience is instructive. Even though
    Kansas's per capita spending between 2000 and 2011 grew more slowly
    than spending in many other States, Kansas's spending for the aged,
    children, and adults grew more rapidly than CPI and also outstripped
    medical CPI for children and adults.\4\ Furthermore, while Federal
    funding under the caps would adjust for enrollment increases during a
    recession or local down-turn, the caps would not provide any allowance
    for increased costs associated with new medical treatments, health
    emergencies like the opioid crisis, or demographic factors like an
    aging baby boomer population. It is difficult to predict with certainty
    the level of added costs that will arise due to these types of
    occurrences, but there is no question that such costs will arise. This
    is the fundamental challenge of a per-capita cap that uses a one-size-
    fits all, predetermined trend rate to set future spending levels and
    does not adjust to reflect variations in spending triggered by factors
    well beyond a State's control.
    ---------------------------------------------------------------------------
        \4\ ``Medicaid Capped Funding: Findings and Implications for
    Kansas,'' Robert Wood Johnson Foundation, State Health Reform
    Assistance Network (April 5, 2017), available at: http://
    www.statenetwork.org/wp-content/uploads/2017/04/KS-Fact-Sheet_rev-
    4.4.17-1.pdf.

                                     ______

                    Questions Submitted by Hon. Bill Nelson
        Question. Eleven seniors in Florida died after being trapped in a
    nursing home in extreme temperatures after Hurricane Irma knocked out
    the facility's power. Most troubling is that there was a functioning
    hospital located directly across the street from the nursing home, and
    yet they weren't evacuated. There's an ongoing criminal investigation
    to determine what went wrong and who is to blame, but quite simply,
    this isn't acceptable.

        Nursing homes and other long-term care facilities are under
    tremendous pressure to provide quality care and take care of our loved
    ones, but they need the resources in order to do so.

        The Graham-Cassidy bill caps Medicaid, effectively cutting billions
    from the program. The cap would grow more slowly each year than the
    projected growth in State per-beneficiary costs, especially over time
    with an aging population. The cuts to Federal Medicaid funding would
    only deepen in 2025 as the annual adjustment becomes even more
    inadequate.

        This is especially problematic for Florida as the rate of Medicaid
    enrollment for disabled persons and low-income seniors has risen faster
    than the national average over the last 10 years.

        Moreover, the cap would force States to make hard choices about
    cutting eligibility, benefits, and/or provider payments. Many States
    will be faced with no choice but to cut-home and community-based
    services, and other ``optional'' benefits.

        Do you believe the Graham-Cassidy bill would allow nursing homes,
    home health agencies, and other long-term care facilities to provide
    quality care to the Nation's seniors?

        Answer. The bill would put quality care for seniors at significant
    risk. Over time, the per-capita caps would result in Federal payments
    that increasingly fall short of need, driving hard decisions for States
    about cutting benefits, eligibility, or provider rates, including for
    nursing homes and home care. Long term care services account for nearly
    30 percent of Medicaid costs;\5\ if long term care could be protected
    it could only be done at the expense of medical services for the
    elderly, for people with disabilities, children and pregnant women--or
    with significant new State funding. The fact that the trend rate for
    aged/disabled populations is less constraining than the rate applied to
    other populations under Graham-Cassidy does not protect these
    populations for two reasons. First, at least based on Florida's recent
    past, the trend rates proposed in the legislation for the elderly fall
    short of need. Between 2000 and 2011, Florida's average annual per
    enrollee spending growth was 7.3 percent for the aged, significantly
    outstripping CPI (2.5 percent) and medical CPI (4 percent) during that
    period, suggesting that a per-capita cap pegged at medical CPI or
    medical CPI plus one would fall short of need.\6\
    ---------------------------------------------------------------------------
        \5\ Steve Eiken, Kate Sredl, Brian Burwell, and Rebecca Woodward,
    ``Medicaid Expenditures for Long-Term Services and Supports (LTSS) in
    fiscal year 2015,'' Figure 7 (Truven Health Analytics, April 14, 2017),
    available at: https://www.medicaid.gov/medicaid/ltss/downloads/reports-
    and-evaluations/ltssexpendituresffy2015final.pdf.
        \6\ ``Medicaid Capped Funding: Findings and Implications for
    Florida,'' Robert Wood Johnson Foundation, State Health Reform
    Assistance Network (April 5, 2017), available at http://
    www.statenetwork.org/wp-content/uploads/2017/04/FL-Fact-Sheet-revised-
    4.4.17-1.pdf.

        Second, because the per-capita caps build up to an aggregate cap,
    the elderly will not be protected from cuts even if their per enrollee
    costs are below the caps. If there is extra ``room'' for some
    populations it will be used to finance coverage for other populations
    for whom the caps will squeeze more deeply. States will manage their
    budgets under the aggregate caps and the elderly will be as vulnerable
    under the aggregate cap as other groups. As State budgets are
    increasingly squeezed, States could reduce reimbursement for nursing
    homes and other long-term care facilities, thus jeopardizing the
    quality of care the beneficiaries receive. In addition, since most home
    care services are optional, States may end up dropping those services
    (or create new or longer waiting lists under home and community based
    services waivers). While home care services are a cost effective
    alternative to nursing home care for seniors who do not need to be
    served in a nursing home, home care for someone who needs extensive
    help with activities of daily living is still costly and may be at risk
    ---------------------------------------------------------------------------
    in a capped funding environment.

        It is also important to note that while States will generally turn
    to eligibility reductions last under a per-capita cap, the caps provide
    a perverse incentive to end optional eligibility for the most high
    need, high cost patients. The elderly and people with disabilities who
    rely on Medicaid for their long-term care are often covered under
    optional eligibility categories and their relatively high cost will no
    doubt prompt States to consider whether they can continue to afford to
    maintain this coverage.

        Question. Twenty-five percent of Florida's population or 5 million
    Floridians are 60 or older, making Florida the State with the largest
    population of seniors. Generally older adults have more health-care
    needs, chronic conditions and co-morbidities than younger people. Many
    older Americans are also forced to tighten their belts to afford things
    like health coverage.

        Please tell me with a ``yes'' or ``no'' answer, does the Graham-
    Cassidy bill repeal the ACA's premium tax credits?

        Answer. Yes.

        Question. Does the Graham-Cassidy bill eliminate cost-sharing
    reduction payments?

        Answer. The Graham-Cassidy bill repeals the Federal Cost-Sharing
    Reduction (CSR) payments after 2019. Until then, it does not explicitly
    appropriate funds for the CSR payments.

        Question. Does the Graham-Cassidy bill allow States to take us back
    to the days when insurers could charge older adults higher rates than
    under the existing law?

        Answer. Yes. Although the September 25th version of Graham-Cassidy
    puts more restrictions on States' ability to change rating laws than
    previous versions, the revised legislation still permits States to seek
    HHS permission to vary otherwise applicable rules in order to offer
    coverage that does not meet all Federal requirements. States therefore
    could seek authority to let insurers vary premiums based on factors
    such as age. States also would have discretion to allow rating rules
    that increase premiums for people with preexisting conditions, a
    provision that would impact older adults. In addition, although the
    newer version appears to facially prohibit premium rating based on
    health, it expressly allows ``multiple risk pools'' which could open
    the door to discrimination based on health status if States allow
    insurers to put people with preexisting conditions in separate risk
    pools where all premiums will be higher than standard rates. This
    change could result in a return to pre-ACA practices, where people with
    minor health issues may be required to pay higher rates than would be
    actuarially justified for their particular condition because they are
    identified as having a preexisting condition and made ineligible for
    the standard risk pool. Individuals placed in an expensive plan under
    these circumstances might also find themselves without recourse, since
    plan underwriting decisions are discretionary and generally not subject
    to as much State review as rating decisions. In addition to expressly
    allowing multiple risk pools, the September 25th version of the
    legislation also allows States to override Federal rules establishing
    out of pocket limits and actuarial value requirements, essentially
    removing many meaningful protections for the quality of coverage.

        Question. The opioid crisis is devastating families across the
    country. In Florida alone, 2,600 people died from opioids in the first
    half of 2016. Fentanyl was responsible for 704 of those deaths.

        The Affordable Care Act made great strides to increase access to
    substance abuse treatment. It ensured that newly covered individuals
    would receive mental health and substance use disorder services,
    including behavioral health treatment, under their health insurance
    plan as part of their essential health benefits.

        Is substance use disorder treatment a necessary component of
    efforts to prevent and treat opioid addiction?

        Answer. There are many strategies to combat the opioid epidemic and
    substance use disorder treatment is certainly a necessary component.
    Preventing addiction is important, of course, but so too is ensuring
    that States have the infrastructure and resources to treat individuals
    with opioid addiction.

        Question. Does the Graham-Cassidy bill allow States to waive
    essential health benefits, like coverage of mental health and substance
    use disorder services?

        Answer. As most recently revised on September 25th, Graham-Cassidy
    give States broad latitude to obtain HHS approval to implement
    ``alternative rules'' that would override the ACA's consumer protection
    and insurance regulation provisions for individual or small group
    coverage funded through the Market-Based Grant Program. Therefore, by
    implementing alternative rules, States presumably could receive
    approval to either eliminate or modify Essential Health Benefits.
    Therefore, this provision puts coverage for mental health and substance
    use disorder services in jeopardy.

        Question. By capping the Medicaid program and ending Medicaid
    expansion, the Graham-Cassidy bill cuts billions of dollars from
    Medicaid, the largest payer of substance use services in the country. A
    September 25th CBO report stated that the Graham-Cassidy bill cuts $1
    trillion out of Medicaid over 10 years. If those cuts are made, how do
    you propose States like Florida provide the necessary services to help
    individuals with substance use disorders?

        Answer. States would have several options, none of which would
    provide funding at the levels available today and all of which would
    likely force tradeoffs against funding for other key services. States
    like Florida could devote a higher share of State dollars to support
    substance use disorder services, they could pursue limited Substance
    Abuse and Mental Health Services Administration Federal grant funds, or
    they could use their Market Based Health Care block grant to finance
    treatment of substance use disorders either as a stand-alone benefit or
    as part of coverage funded by the block grant. Either approach to using
    block grant funds would mean that the State would have to make
    difficult tradeoffs in light of the limited funding available under the
    Graham-Cassidy block grant. For example, investing more in substance
    use disorder treatment and prevention would necessarily crowd out other
    services and initiatives, which would jeopardize the State's ability to
    maintain coverage at current levels. Or, even if States spent all of
    their block grant funds on coverage for people who could be eligible
    for the Medicaid expansion or who are currently enrolled in Marketplace
    coverage, nationally the funding would not be sufficient to cover both
    populations or to ensure that funding includes full scope mental health
    or SUD treatment. And, if States like Florida used funding just for SUD
    treatment, people experiencing SUD but who have other, often related,
    medical and behavioral health-care needs wouldn't receive the treatment
    they need to restore or maintain their health.

        Your question also raises a little-appreciated challenge associated
    with the
    Market-Based Health Care Grants. In addition to determining how best to
    use block grant funds to address lack of coverage, stabilize the
    market, and reduce premiums and other out-of-pocket costs, State
    policymakers could use block grant funds to supplant current State
    funding as long as it was health related. The pressure may be strong
    for a State to use some of these funds to address State budget issues,
    particularly because other components of the bill, including the per-
    capita cap on Federal Medicaid payments and the bill's restriction on
    States' use of provider taxes and assessments will create significant
    new budget pressures for States. The competing demand for the block
    grant dollars will crowd out or at least substantially limit States'
    ability to address the opioid epidemic.

        Question. Some have said that the public health emergency response
    fund could be used for the opioid epidemic; however, it is my
    understanding that this money was for disasters like Hurricane Irma.
    Does that mean flood victims and those suffering from opioid addiction
    will be pitted against each other?

        Answer. Unfortunately, the very nature of capped programs is that
    funding is limited so, yes, relying on the public health emergency
    response fund to finance a response to the opioid epidemic would very
    likely crowd out disaster response spending.

        Question. Ms. Mann, if Florida expanded its Medicaid program,
    wouldn't it be able to increase access to treatment for those with
    opioid use disorders? And wouldn't expanding Medicaid help States avoid
    the rising costs associated with the opioid crisis better than what was
    proposed in the Graham-Cassidy bill?

        Answer. Yes, under current law, if Florida expands its Medicaid
    program to adults up to 138 percent of poverty, it could vastly expand
    access to treatment for those with opioid use disorder. And it could do
    so with a 90 percent Federal match going forward, meaning that with a
    10 percent State contribution the State could draw down significant
    Federal support to help cover low-income adults in Medicaid.\7\
    ---------------------------------------------------------------------------
        \7\ ``Medicaid's Role in Addressing the Opioid Epidemic,'' Kaiser
    Family Foundation (September 2017), available at: https://www.kff.org/
    infographic/medicaids-role-in-addressing-opioid-epidemic/.

        The comprehensive Medicaid benefit available to beneficiaries
    provides coverage for substance use treatment as well as behavioral
    health and other issues that could drive addiction. By comparison,
    there is no guarantee that coverage under Graham-Cassidy would provide
    either a comprehensive benefit package or effective, targeted coverage
    for the types of services most helpful in combatting the opioid
    ---------------------------------------------------------------------------
    epidemic.

        Question. Ms. Mann, how would Florida fair under this bill as
    compared to if the State had expanded Medicaid as is currently an
    option under the existing law?

        Answer. Manatt's quantitative analysis suggests that Florida could
    fare worse under Graham-Cassidy than if the State expanded Medicaid
    under current law with the Medicaid expansion funding and Marketplace
    subsidies remaining intact. For example, Manatt's analysis projects
    that Florida residents will receive $10.2 billion in Federal
    Marketplace funds in 2020 to support coverage for individuals from 100
    percent to 400 percent of poverty.\8\ If Florida expanded Medicaid up
    to 138 percent of poverty, Manatt estimates that the State would
    receive a net increase in Federal funding of $1 billion or more in
    2020, as previously uninsured individuals gain Medicaid coverage and
    Marketplace enrollees between 100 percent and 138 percent FPL shift to
    Medicaid.\9\ Thus, Florida's combined Marketplace and Medicaid
    expansion Federal funding would exceed $11 billion in 2020 and to
    remain ``whole'' under
    Graham-Cassidy relative to current law, in 2020 the State would need a
    Market-Based Health Care allotment of at least $11 billion. (This does
    not account for any additional funding Florida might need due to
    unanticipated costs which Medicaid would cover but which would not be
    accommodated by the block grant.) According to our analysis of the
    September 13th version of the legislation, Florida's unadjusted
    allotment was expected to be only $8.9 billion in 2020; this is less
    than the State could expect to receive if current law remained intact
    and the State expanded Medicaid. In addition, if block grants were
    adjusted to reflect each State's health care prices relative to the
    national average (as allowed at the option of the Administrator of the
    Centers for Medicare and Medicaid Services in 2023 and beyond under the
    September 25th version of the proposal), our analysis finds that
    Florida could see a 5-percent reduction in its block grant amount,
    further lowering the Federal funding available under Graham-Cassidy-
    Heller relative to current law.
    ---------------------------------------------------------------------------
        \8\ See August 2017 Manatt analysis of a July 27th version of
    Graham-Cassidy at https://www.statenetwork.org/wp-content/uploads/2017/
    08/SHVS_Repeal-and-Replace_Final.pdf.
        \9\ See August 2017 Manatt analysis of a July 27th version of
    Graham-Cassidy at https://www.statenetwork.org/wp-content/uploads/2017/
    08/SHVS_Repeal-and-Replace_Final.pdf. Note that a later Manatt analysis
    of the September 13th version of Graham-Cassidy contained somewhat
    lower Marketplace spending estimates due to a downward revision of
    national projections issued by the Congressional Budget Office in
    September. See: ``Update: State Policy and Budget Impacts of the New
    Graham-Cassidy Repeal and Replace Proposal,'' prepared by Manatt Health
    for the Robert Wood Johnson Foundation, State Health and Value
    Strategies (September 2017), available at: http://www.statenetwork.org/
    wp-content/uploads/2017/09/SHVS_Graham-Cassidy-Sept-2017_Final.pdf.

        Question. The Graham-Cassidy bill repeals the Affordable Care Act's
    Medicaid expansion, premium tax credits, and cost-sharing reduction
    ---------------------------------------------------------------------------
    payments and instead creates a block grant.

        It is my understanding that the block grant funding ends after 2026
    under the Graham-Cassidy bill. What happens to the individual
    marketplace after 2026?

        Answer. It is difficult, if not impossible, to predict what will
    happen in the individual marketplace after 2026 when the block grant
    funds expire. Without Federal funding for tax credits or other
    subsidies to help make coverage affordable, even if a State continued
    to offer coverage, it is likely that most people will be priced out of
    the market. The block grant funds could be renewed but whether and at
    what level they might be renewed is highly speculative particularly
    given the cost of renewal. To take a current example of this type of
    uncertainty, as of November 15th, the CHIP block grant, which is much
    smaller, and highly popular has yet to be renewed.

        Question. Would you say that gutting the current individual
    marketplace by changing it to a block grant from 2020 to 2026, and
    creating a funding cliff after 2026 is good for the stability of the
    individual insurance market? Insurers are already having trouble
    setting their 2018 rates because the administration won't commit to
    funding the CSRs. How do you expect them to plan for 2027?

        Answer. Graham-Cassidy is not good for the long-term stability of
    the individual insurance market, and it will be impossible for insurers
    to plan for 2027. To take just one example, because Graham-Cassidy
    eliminates the individual mandate, to the extent that States continue
    to offer coverage it is likely that the risk pool will be skewed
    because more sick people will be motivated to purchase coverage than
    healthy people, making coverage difficult for insurers to price and
    prohibitively expensive for consumers. The funding cliff will add
    significantly to the uncertainty for insurers as well as States.

        Question. I'm the former Florida insurance commissioner, and I've
    seen what can help stabilize an insurance marketplace. That's why I,
    with my friend from across the aisle, Senator Collins, have introduced
    the Lower Premiums Through Reinsurance Act to help States establish
    their own reinsurance programs. Do you think this bill is a good
    solution to help stabilize the ACA's individual market?

        Answer. The legislation you introduced with Senator Collins, the
    Lower Premiums Through Reinsurance Act, is part of a good solution to
    stabilize the ACA's individual market. Reinsurance programs help
    promote marketplace stability by reducing premiums by separately
    financing the most expensive cases, increasing insurer participation by
    removing outlier costs that make it harder to set adequate premiums,
    and enhancing market stability by spreading the most volatile costs
    across a broader funding base. Coupled with your legislation, another
    key step to stabilize the market is for Congress to act to fund cost
    sharing reductions as well.

        Question. Medicaid is the largest health-care program for children,
    covering more than 30 million kids. As it is currently structured, the
    Medicaid program gives States flexibility to innovate and pursue
    delivery system reforms. How will States be able to transform care and
    pursue delivery system reforms to improve child health outcomes if the
    Medicaid program is gutted under either a cap or block grant?

        Answer. Delivery system reform efforts would be challenging in a
    per-capita cap or block grant environment. Delivery system reform
    efforts often require investments in order to drive change; in a capped
    funding environment, States will be less likely--or able--to make such
    investments as they strive to maintain eligibility, services, and
    access to providers for their enrolled population, especially over time
    as the caps tighten. In addition, actions States may have to take to
    keep spending below the caps could compromise the care children
    receive; this is likely to be particularly the case for children with
    disabilities or chronic illnesses. Reductions in provider payment rates
    could limit access to specialists and make it more difficult to support
    integrated delivery systems and a strong continuum of care for children
    with special needs. Furthermore, with the loss of the expansion,
    millions of parents will lose coverage and that too affects children's
    coverage and well-being.

                                     ______

                   Questions Submitted by Hon. Sherrod Brown
             intellectual and developmental disabilities population
        Question. The Graham-Cassidy proposal includes a provision that
    seems to try and protect children with intellectual or developmental
    disabilities who are on Medicaid by exempting those receiving
    Supplemental Security Income, or SSI, from the block grants. Through
    this provision, the authors are acknowledging that these individuals--
    children with disabilities--need protection. That is why they have
    excluded them from the block grant.

        However, in Ohio, only 24% of children with intellectual or
    developmental disabilities, or IDD, who are on Medicaid rely on SSI.
    The Graham-Cassidy proposal does not seem to protect the remaining 76%
    of children on Medicaid with IDD, who are not on SSI and who are
    therefore not exempted from block grants.

        The proposal also does not seem to protect these children when they
    grow up. A diagnosis of autism does not disappear when a child becomes
    an adult. Under this language, children could lose critical services
    and supports when they become adults.

        Do proposals that cap or block grant Medicaid funds put all
    individuals at risk, whether they are exempted from a block grant or
    not? Do you believe that Medicaid beneficiaries like children, pregnant
    women, and individuals with disabilities will be protected under this
    proposal?

        Answer. Proposals that cap or block grant Medicaid funds put all
    individuals at risk, even if particular populations are exempted from
    the block grant, because these policies eliminate the Federal
    Government's guarantee to share with States the cost of all qualifying
    Medicaid expenditures. Since Graham-Cassidy also ends the Medicaid
    expansion, the consequences of this major change in financing falls
    solely on those enrolled in the ``traditional'' Medicaid program:
    newborns and other children, very low-income parents, pregnant women,
    and low-income seniors and people with disabilities. It would affect
    preventive and acute care services as well long term care (nursing home
    care and home and community based services). Even though a few
    populations--including children eligible based on disability--are
    exempt from the per-capita cap, the aggregate cap on Federal spending
    that is computed based on those caps will affect all populations and
    the providers who serve them, too. This is because the per-capita caps
    build up to an aggregate cap and States will have to manage that cap;
    when States must cut program spending to keep within the cap, children
    with special health-care needs will not be protected from those cuts.

        The Congressional Budget Office's (CBO's) preliminary score of the
    September 25th version of Graham-Cassidy-Heller estimated that the
    legislation would reduce Federal Medicaid spending by about $1 trillion
    over the 2017-2026 period.\10\ This includes elimination of the
    Medicaid expansion funding but also the reductions in spending due to
    the per-capita caps. As noted, these cuts grow over time as the trend
    rates used to make the annual adjustments to the per-capita caps drop
    beginning in 2025. Although Graham-Cassidy-Heller provides a modestly
    less constraining trend rate than the Better Care Reconciliation Act
    (BCRA), under both proposals the deepest cuts occur just beyond the
    CBO's 10-year budget scoring window. The sheer volume of these cuts
    (which also includes the impact of eliminating the Medicaid expansion)
    makes it clear that it will be difficult to fully protect even
    populations that may appear to be exempted from per-capita caps.
    ---------------------------------------------------------------------------
        \10\ ``Preliminary Analysis of Legislation That Would Replace
    Subsidies for Health Care With Block Grants,'' Congressional Budget
    Office (September 2017), available at: https://www.cbo.gov/system/
    files/115th-congress-2017-2018/costestimate/53126-health.pdf. CBO
    projected that the rejected BCRA bill upon which Graham-Cassidy is
    based would have cut Medicaid by $756 billion over 10 years. See
    Congressional Budget Office letter to Hon. Mike Enzi re: H.R. 1628, the
    Better Care Reconciliation Act of 2017: An Amendment in the Nature of a
    Substitute [ERN17500], as posted on the website of the Senate Committee
    on the Budget on July 20, 2017, available at: https://www.cbo.gov/
    system/files/115th-congress-2017-2018/costestimate/52941-
    hr1628bcra.pdf.

        You are also correct in pointing out that the provision in Graham-
    Cassidy to not allow children receiving SSI to be included in the
    Medicaid block grant does not protect children with intellectual or
    developmental disabilities who do not receive SSI from block grant
    funding. Furthermore it leaves those children with SSI subject to the
    constrained Federal funding that will result from the per-capita cap,
    as described above.
                                 nursing homes
        Question. Three in five nursing home residents in Ohio rely on
    Medicaid to cover the cost of their nursing home care.

        What will the Medicaid cuts included in Graham-Cassidy mean to
    seniors and their families and nursing home providers in States like
    Ohio?

        Answer. Medicaid is a lifeline for seniors (and people with
    disabilities) who need nursing home care. Medicare does not pay for
    long term nursing home services; there is very little commercial long
    term care insurance; and most families do not have the resources to pay
    nursing home costs out of pocket for an extended period of time.
    Capping Medicaid funding is likely to jeopardize both access to and the
    quality of nursing home services as States seek to manage their budgets
    within Medicaid spending caps that get increasingly tight over time.
    These caps could mean that nursing home providers see reductions in
    provider payment rates, which could potentially lead some providers to
    exit the market, making care less available. And caps puts quality at
    risk for the nursing homes that remain open. Nursing home quality has
    improved significantly in recent decades thanks to reforms instituted
    by Congress, States and the nursing homes, but with significant
    reductions in funding that progress may well unravel.

                                     ______

                Questions Submitted by Hon. Robert P. Casey, Jr.
        Question. Some supporters of the Graham-Cassidy amendment have
    stated there are similarities between the program it establishes and
    the successful CHIP program. Two questions:

        Does Graham-Cassidy build upon and possibly expand CHIP?

        Answer. No. Graham-Cassidy does not address CHIP and certainly does
    not expand it. The Market-Based Health Care block grant language is
    dropped into the CHIP statute but the Graham-Cassidy proposed
    legislation in no way expands on CHIP. In fact, Graham-Cassidy could
    have a detrimental impact on CHIP because it will strain State budgets
    in ways that could force States to make hard choices about how to use
    State dollars in support of CHIP and other coverage. It also weakens
    Medicaid for all populations, including 37 million children; CHIP is
    successful in large part because of the key role Medicaid plays for low
    income children and children with significant medical needs.

        Question. Are there similarities and/or differences between the
    block grant
    Graham-Cassidy proposes and the CHIP program?

        Answer. Yes, like the block grant that Graham-Cassidy proposes,
    CHIP is also a block grant that provides capped allocations to States.
    It also must be regularly reauthorized as would the Graham-Cassidy
    block grant and of course we have seen that even with the very popular
    CHIP program, reauthorization is not certain or at least not always
    timely.

        But there the similarities end.

        First, since CHIPRA, the funding for CHIP has intentionally been
    set at levels above expected need to ensure that the funding gaps and
    waiting lists that resulted from funding shortfalls in the early years
    of CHIP no longer occurred. In addition, the CHIP funding formula
    provides for several safeguards, including a contingency fund, to
    further protect against shortfalls. By contrast, the Graham-Cassidy
    block grant is funded at levels that are below the levels of funding
    that would be available under current law and does not include the CHIP
    financing protections.

        Second, CHIP covers a relatively small number--8.9 million--of
    mostly healthy children. Graham-Cassidy's block grant would end the
    existing coverage for the more than 23 million people who are projected
    to be covered by Medicaid and the Marketplace in 2019, many of whom are
    in poor health; replacing this coverage is a much heavier lift than
    CHIP.

        Third, CHIP has been successful in part because the CHIP statute
    requires that at least 90 percent of CHIP spending be used to cover
    children and the basic standards of the coverage are spelled out in the
    law. By contrast, the Graham-Cassidy block grant does not require the
    funds be used for coverage nor does it provide minimum standards of
    coverage.

        Finally, CHIP operates within the context of the Medicaid program,
    which covers many more children including children with significant
    health-care needs. Medicaid, with its more flexible funding and strong
    benefit guarantees for children, works as an important backstop for
    children and for States. Graham-Cassidy eliminates the backstop (by
    terminating the Medicaid expansion and tax subsidies in the
    Marketplace) and weakens, through per-capita caps, the so called
    ``traditional'' Medicaid program.

        Question. I understand that you think Graham-Cassidy should not be
    adopted, but what new options and strategies do you think should be
    provided to States to address growing Medicaid expenditures and improve
    health-care outcomes?

        Answer. Health-care spending in this country is higher than
    spending in other developed countries on a per person basis and yet our
    outcomes generally are far worse. The growth in health-care costs needs
    to be constrained through system-wide changes that include some
    fundamental changes in the way care is delivered and paid for. Medicaid
    like other payers can do more to lower costs through better integration
    of care (for example between physical and behavioral health), improved
    data and technology, and by adopting reforms that reduce cost shifting
    and instead focus on total cost of care. But it is important to note
    that Medicaid expenditures have grown largely because it is covering
    more people. On a per person basis, Medicaid has generally grown more
    slowly than Medicare and commercial insurance in recent years.\11\ And
    if there is one recurring complaint about Medicaid it is that it pays
    its providers too little, not too much.
    ---------------------------------------------------------------------------
        \11\ ``Medicaid Per Person Spending: Historical and Projected
    Trends Compared to Growth Factors in Per Capita Cap Proposals,'' MACPAC
    (June 2017), available at: https://www.
    macpac.gov/wp-content/uploads/2017/07/Medicaid-per-Person-Spending-
    Historical-and-Projected-Trends-Compared-to-Growth-Factors-in-Per-
    Capita-Cap-Proposals.pdf.

        Many State Medicaid programs and health plans and health systems
    that serve Medicaid beneficiaries have been actively engaged in efforts
    to reduce costs through delivery system and payment reforms, but they
    face some considerable barriers, including homelessness and other
    nonmedical issues that affect Medicaid health-care spending and health
    outcomes, rising drug costs, an aging population, and difficulty
    managing care for Medicaid beneficiaries who are also covered by
    Medicare (almost 40 percent of Medicaid spending is on so called ``dual
    eligibles'').\12\ These are some of the important issues that must be
    tackled to improve care and lower costs, but these are not addressed
    and, in key ways, are made worse by proposals to cut and cap Federal
    Medicaid funding.
    ---------------------------------------------------------------------------
        \12\ ``Medicaid Financing: The Basics,'' Kaiser Family Foundation
    (December 22, 2016), available at: https://www.kff.org/report-section/
    medicaid-financing-the-basics-issue-brief/.

        Question. What are the implications of the per-capita cap included
    in Graham-Cassidy for seniors and people with disabilities? Advocates
    for the bill point to the trend rate provided for seniors and people
    with disabilities, which is set at medical CPI plus one, as protecting
    seniors and people with disabilities, but would this actually protect
    ---------------------------------------------------------------------------
    seniors and people with disabilities?

        Answer. No, the higher trend rate for seniors and people with
    disabilities would not protect these populations. As noted, the trend
    rate for these two groups of people is set at medical CPI plus one from
    2020 through 2024 and then drops to medical CPI beginning in 2025. Even
    though that trend rate is less constraining than the trend rate that
    will be applied to other populations (and could accommodate expenditure
    growth in some States), overall, capped funding will squeeze States'
    Medicaid budgets and force tradeoffs. Under the proposal, the per-
    capita caps build up to an aggregate cap and States will have to manage
    to that cap. When they must cut program spending to keep within the
    cap, seniors and people with disabilities will not be protected from
    those cuts. In fact, seniors and people with disabilities are likely to
    be particularly vulnerable to cuts because they account for the
    majority of spending under the program. Some of the services that
    seniors and people with disabilities receive are optional services
    (e.g., home and community-based services) and could therefore be
    particularly vulnerable to cuts as States seek to maintain mandatory
    benefits across the program.

        Caps fundamentally change the basic funding of the Medicaid
    program, replacing the financial partnership between States and the
    Federal Government with a system where all costs above the caps--
    whether they can be anticipated or not, whether they are within a
    State's control or not--are shifted to States. States that are not able
    to shoulder significant new costs will need to reduce provider payment
    rates and benefits, increase beneficiary costs, and/or reduce
    eligibility. Since
    Graham-Cassidy ends the Medicaid expansion, the consequences of this
    major change in financing falls solely on those enrolled in the
    ``traditional'' Medicaid program: newborns and other children, very
    low-income parents, pregnant women, and low-income seniors and people
    with disabilities. The somewhat higher trend rates for low-income
    seniors and people with disabilities will offer little protection as
    States seek to manage their overall Medicaid budgets in a capped
    funding environment.

                                     ______

     Prepared Statement of Teresa Miller, Acting Secretary, Department of
                  Human Services, Commonwealth of Pennsylvania
        Good morning Chairman Hatch, Ranking Member Wyden, and members of
    the U.S. Senate Committee on Finance. Thank you for the opportunity to
    be here today to speak about a proposal that would have a breathtaking
    impact on residents of the Commonwealth of Pennsylvania.

        I appreciate the invitation to share my perspective, as acting
    secretary for the Pennsylvania Department of Human Services and former
    Pennsylvania Insurance Commissioner, on how the Graham-Cassidy-Heller-
    Johnson Proposal would impact Pennsylvania. However, I must express
    disappointment that Congress is again considering rushing through a
    major reform of our health-care system, rather than pursuing a
    bipartisan, consensus-driven effort to enact targeted reforms to
    stabilize our markets and ensure the Affordable Care Act (ACA) works
    better for everyone going forward. I had the opportunity to testify a
    few weeks ago before the Senate Health, Education, Labor and Pensions
    (HELP) committee about just that topic. I was so optimistic after that
    hearing because, for the first time in this debate, it appeared
    Senators from both sides of the aisle were genuinely interested in
    focusing on the problem (the need to stabilize the individual market)
    and finding a solution to that problem, rather than using the problems
    in the individual market as an excuse to reduce Federal funding and
    consumer protections. And now I find myself here again talking about a
    proposal that would make draconian cuts to Federal health-care funding
    and force Governors across the country to make the most gut-wrenching
    decisions they could possibly face.

        Governor Wolf and I share the goal of ensuring that Pennsylvanians
    have access to affordable, high quality health-care services so that
    they can lead healthy and productive lives. And I believe that is a
    goal we all share. I'm proud to say that the Commonwealth has been
    diligently working toward that goal, and has made significant progress
    thanks in large part to the ACA.

        Before the ACA, sick people often couldn't get health insurance due
    to a pre-
    existing condition. If they were able to get coverage, they often paid
    significantly more for it than someone without a pre-existing
    condition. In some cases, these individuals would be offered a policy,
    but it would not include coverage for their pre-
    existing condition. Individuals with chronic medical issues or anyone
    who underwent a costly procedure like a transplant could face annual
    and lifetime limits that were often financially devastating. Women
    would see higher coverage costs than men and perhaps not have
    contraception or maternity care covered. Other critical services like
    mental health and substance use disorder treatment services and
    prescription drugs were often difficult if not impossible to find
    coverage for. Most importantly, more than 10 percent of Pennsylvanians
    and 16 percent of Americans nationwide went uninsured.

        Since the ACA's passage, the national uninsured rate has fallen to
    8.6 percent and Pennsylvania's uninsured rate has dropped to 5.6
    percent--the lowest it's ever been. More than 1.1 million
    Pennsylvanians have accessed coverage only available because of the
    ACA, and that coverage is much more comprehensive than what was
    previously available. There are 12.7 million Pennsylvanians, and more
    than 40% of them--5.4 million--with pre-existing conditions cannot be
    denied health insurance coverage due to the ACA. Approximately 4.5
    million Pennsylvanians no longer have to worry about large bills due to
    annual or lifetime limits on benefits, and 6.1 million Pennsylvanians
    benefit from access to free preventive care services. More than 175,000
    Pennsylvanians have also been able to access substance use disorder
    treatment services through their exchange and Medicaid expansion
    coverage. This is critical as our commonwealth and other States around
    the country strive to combat the overwhelming impact of the opioid
    crisis.

        The narrative I continue to hear from Republicans in Washington is
    that the ACA is imploding and that unless Congress takes action, it
    will in fact implode. While the ACA has not been perfect, it is
    critical that we level set and talk about the issues that exist and the
    people those issues are really impacting. The ACA has had minimal
    impact to the Medicare program and has enhanced the already very
    successful Medicaid program by expanding access to millions more around
    the country. Further, since the passage of the ACA, the employer
    markets where small and large businesses purchase insurance products
    for their employees have been stable and even seen costs grow at a
    slower pace than before the ACA. The individual market, where we see
    problems, is a very small market relative to these others, covering
    only about 5 percent of Pennsylvanians. It is also a very important
    market, because it is where individuals and families who do not have
    access to coverage through their employer or public programs go to
    purchase insurance. But, this is also the market that is heavily
    subsidized through the ACA. About 80 percent of Pennsylvanians who
    receive their coverage through the exchange receive tax credits to help
    pay their premiums. In fact, the U.S. Department of Health and Human
    Services estimated that 3 in 4 returning marketplace consumers could
    find a plan for less than $100 per month in 2017. And, because of the
    way the tax credits are structured based on income, these lower-income
    consumers do not feel the full impact of premium increases. Further,
    more than half of consumers who enroll in the exchanges are eligible
    for cost-sharing reductions, additional financial assistance to low-
    income consumers that helps them pay for their out-of-pocket costs like
    deductibles and co-pays. However, the people who this market may not be
    serving well are those that are not eligible for financial assistance,
    which is about 1-2 percent of Pennsylvanians. In a perfect world, I
    would like to see the income level for subsidies increased to help this
    1-2 percent, but if that is not possible I think there are still ways
    to improve affordability and their experience moving forward.

        I also want to be clear that we are seeing the individual market
    stabilize in Pennsylvania. Assuming that the current Federal regulatory
    structure continues, our insurers requested an average increase of 8.8
    percent statewide for 2018 plans. When they filed their rate requests,
    we asked insurers to provide information on what they would need to
    request if cost-sharing reductions payments were not made or if the
    individual mandate was not enforced. The differences are stark. If
    cost-sharing reductions are not paid, they reported they would need to
    request a statewide average increase of 20.3 percent. If the individual
    mandate is not enforced, they say they would seek a 23.3 percent
    increase. If both changes occur, our insurers estimate that they would
    seek an increase of 36.3 percent. While Pennsylvania has not released
    final rates, it is critical to recognize that if the increases are
    higher than that 8.8 percent it is not because the ACA is failing--it
    is because of the uncertainty and inaction here in Washington, DC.

        Instead of furthering that uncertainty, I believe we need to build
    upon the foundation of the health-care system we have and make
    targeted, common sense changes that will improve the ACA and make it
    work better for the people it is not working perfectly for today.
    Starting over, or even moving backwards as I believe the
    Graham-Cassidy-Heller-Johnson proposal will do, will not better serve
    Pennsylvanians or Americans throughout the Nation. With that context, I
    would like to offer my department's thoughts on the Graham-Cassidy-
    Heller-Johnson proposal and contrast that proposal with ideas on what a
    real bipartisan solution that would improve our health-care system
    could look like.
                 the graham-cassidy-heller-johnson proposal's
                        potential impact on pennsylvania
        As someone with experience as an insurance regulator in two
    different States and as a Federal regulator, I truly believe States are
    in a better position to make decisions impacting our residents. We know
    our markets better and we are more nimble and able to respond to issues
    impacting our consumers. So, when we hear that you want to give us more
    flexibility as States, we are interested in hearing more.

        However, as it stands, I don't believe that this flexibility
    exists. The proposal's sponsors say that they want to turn power over
    to States to create their own health-care system, and claim to do so by
    creating a block grant that levels the playing field between expansion
    and non-expansion States. As I will detail, this creates an
    insurmountable burden on States that want to maintain their current
    coverage levels, let alone expand them. For some States, this may be an
    opportunity to craft a health-care system as they see fit, but given
    how Federal funding is projected to decrease over time compared to
    funding levels if the proposal weren't enacted and the fiscal cliff if
    the block grant funding ends after 2026, this flexibility is illusory.
    At some point, all States will be left to fill sizable gaps in their
    State budgets, and we will likely see legislative crises to make up the
    funding loss. States may then be forced to either impose significant
    tax increases, further coverage losses, or both. Is that really the
    flexibility we need?

        Both our internal analysis and independent external analyses
    conclude that the Graham-Cassidy-Heller-Johnson proposal would result
    in the loss of billions of dollars in Federal funding. In our internal
    estimate, assuming average cost growth, Pennsylvania would lose $30
    billion in Federal funding over the next decade. Other independent
    external analyses estimate losses ranging from $15 billion to $22.5
    billion over that period. Whether the ultimate amount is at the low or
    high end of that range, we're looking at losses that the State has no
    way to make up. Pennsylvania is facing a $2 billion structural deficit
    in our budget. We don't even have a balanced budget for this current
    fiscal year, 3 months into it. And we certainly don't have the ability
    to cover the loss of billions of dollars in Federal funding. This
    extreme shift in funding will result in a fiscal crisis beyond what
    Pennsylvania has experienced to date.

        These losses are due to a major restructuring of the Federal health
    care financing structure. As the National Association of Medicaid
    Directors put it, this would be the largest intergovernmental transfer
    of financial responsibility from the Federal Government to States in
    our country's history. This proposal would dismantle the Medicaid
    expansion of the ACA, which has resulted in the coverage of more than
    715,000 newly eligible Pennsylvanians, and the individual market
    subsidies, which reduce health insurance costs for hundreds of
    thousands of Pennsylvanians who purchase commercial coverage on their
    own, typically because they are self-
    employed or do not get health insurance through their employer.
    Medicaid expansion and individual market subsidy funding would be
    replaced with a block grant using a formula that appears to
    disadvantage States like Pennsylvania that have acted responsibly to
    expand Medicaid and increase health-care coverage. Based upon an
    analysis from the Kaiser Family Foundation, we estimate Pennsylvania
    would receive 20 percent less in Federal dollars under the proposed
    block grant for the Medicaid expansion population, compared to the
    amount projected under the ACA for the Medicaid expansion population
    over the next decade.

        Not only does the Graham-Cassidy-Heller-Johnson proposal
    drastically and dangerously restructure Federal financing for the
    Medicaid expansion and individual market populations, it also
    fundamentally changes the Federal financing structure for what are
    known as ``traditional'' Medicaid-eligible populations: low-income
    adults and elderly, children, pregnant women, and individuals with
    disabilities. Currently, the Federal and State government share the
    cost of providing coverage for these populations, with the Federal
    Government covering a set percentage of their cost of care. These are
    our most vulnerable populations, yet this proposal would set a per-
    capita cap on Federal funding for these individuals, and that Federal
    funding would increase at a rate below actual cost growth, resulting in
    plummeting Federal funding over the years as actual costs outpace the
    Federal cap. Children are especially hard hit by this proposal--Avalere
    Health projects that, nationally, Federal Medicaid funding for kids
    would be slashed by more than 10 percent in the next decade and more
    than 30 percent by 2036. I struggle to see how a proposal that cuts
    coverage for kids, who are our future, could ever be in the best
    interest of Pennsylvanians.

        I want to make sure you understand just how critical Medicaid is to
    Pennsylvanians. Medicaid serves 2.8 million Pennsylvanians, or 22
    percent of the commonwealth's population. This includes 1.2 million
    children, nearly 250,000 seniors, 565,000 individuals who receive
    outpatient mental health services, and 215,000 individuals relying on
    substance use disorder treatment. In 2015, Medicaid paid for over
    58,000 births in the commonwealth--nearly 40 percent of Pennsylvania's
    total births.

        These statistics show how important Medicaid is to our population,
    but let me share with you a personal story of Medicaid's impact. Debra
    S., age 60, and her husband, Wayne S., age 61, have four grown children
    and six more they have adopted or care for through foster arrangements.
    All but two of the adopted children have significant developmental
    disabilities. Four of the six adopted children's birth mothers suffered
    from a substance use disorder, reflecting the growing national opioid
    epidemic. Medicaid makes it possible for most of Debra and Wayne's
    children to live at home rather than in an institution--covering
    everything from prescription drugs to home nursing visits to the
    nutritional drink for their adopted son's tube feedings.

        These Federal funding cuts would force Governors across the country
    to make impossible decisions. We would be tasked with replacing these
    Federal funds or be forced to cut services, reduce provider payments,
    or eliminate coverage for some of our most vulnerable citizens. Who
    should receive health care--Debra and Wayne's children? A young adult
    struggling with an opioid addiction who needs our help to receive
    recovery services? A mom fighting breast cancer? A senior who has
    worked hard all his life and needs access to quality health care to age
    with dignity? These are decisions that no Governor should have to make,
    and Pennsylvania is not interested in the ``State flexibility'' to make
    decisions about who deserves health care and who must go without.

        This proposal also chips away at a number of the ACA's protections
    for people in the individual market, by resurrecting several proposals
    in legislation floated over the summer, including a repeal of the
    individual mandate, which would do nothing but exacerbate the stability
    issues we currently face. The bill also does not include funding for
    cost-sharing reduction payments. The ACA's ``three-legged stool'' in
    the individual market--the individual mandate, non-discrimination
    requirements for people with pre-existing conditions, and subsidies and
    cost-sharing reductions--was designed to help insurers balance the
    added risk of individuals with pre-existing conditions while avoiding
    the risk of adverse selection where people only enter the market when
    they are sick and need care. The proposal's proponents may point to
    proposed funding to stabilize the individual market as a sweetener to
    keep insurers from raising rates or exiting the market due to the
    mandate repeal, but I fear that will not be enough to prevent rate
    increases and additional insurer market exits.

        As I mentioned previously, due to the implementation of the ACA and
    Medicaid expansion Pennsylvania's uninsured rate is at a historic low
    of 5.6 percent. If the Graham-Cassidy-Heller-Johnson proposal is
    adopted, we are confident this positive trend will be reversed and the
    commonwealth's uninsured rate will skyrocket. While the Congressional
    Budget Office (CBO) will not have an opportunity to provide a full
    picture of how this plan will impact insurance rates, many of the
    provisions in the Graham-Cassidy-Heller-Johnson proposal were
    previously considered in the bills that failed in the House and Senate.
    Those bills would have, according to CBO estimates, resulted in
    anywhere between 23 million and 32 million Americans losing health-care
    coverage by 2026 and take us back to the days when too many residents
    had to seek treatment in emergency rooms.

        I've been thinking a lot over the past few days about what we would
    do in Pennsylvania if this bill passes and becomes law. And honestly, I
    struggle to figure out how we would respond. We would have 2 years to
    completely revamp our health-care system, work with stakeholders to
    figure out what this new system could look like, develop whatever
    infrastructure would be needed, make system changes required, pass
    legislation, get any necessary Federal waivers, and a host of other
    activities. All of this would need to happen apparently without Federal
    funding to support these essential planning activities. The ACA gave
    States almost 4 years and a lot of funding to support their work.

        And after 7 years, the proposed block grant funding disappears and
    it is unclear from the proposal what if any funding would continue to
    be available or if the State would be left holding the bag to fund
    whatever system we put in place. That alone would make it very
    difficult to put a plan in place in Pennsylvania by 2020. In my
    experience, State legislatures don't want to develop a major system
    that relies upon Federal dollars without a guarantee of sustainable
    Federal funding support. But let me be clear--providing implementation
    funding or extending this funding scheme indefinitely into the future
    would not fix the insurmountable flaw in this bill: the staggering cut
    in Federal funding.
            opportunities for bipartisan solutions to stabilize the
                       individual health insurance market
        As I've mentioned, the real problem we face is the need to
    stabilize the individual health insurance market. I urge you to resume
    the work of Senators Alexander and Murray to enact targeted, bipartisan
    reforms to stabilize the individual market, using as a model the
    reforms that Governor Wolf and a group of bipartisan governors have
    proposed. Their proposal would stabilize the market in the short-term
    and, through bipartisan compromises, would ensure the long-term health
    of individual markets around the country. These proposals include
    guaranteeing Federal payment of cost-sharing reductions to compensate
    insurers for reducing out-of-
    pocket costs for low- and middle-income Americans; adequately funding a
    reinsurance program to help insurers cover the costs of the sickest
    enrollees, which would reduce premiums for everyone; and addressing the
    underlying costs of health care through opportunities like increased
    cost and quality transparency and a continued drive away from a fee-
    for-service payment system that incentives the increased utilization of
    health-care services and towards a value-based payment system that
    rewards prevention and high-quality care.
               making changes on a realistic and careful timeline
        If any changes are going to come to the ACA, they must be done in a
    way that does not disrupt care, coverage, and protections for consumers
    in the interim. Given the conversations taking place in the Senate, I
    am extremely concerned that this is not the path you are taking.

        We have had less than 2 weeks to analyze this proposal, a bill that
    would have a dramatic effect on the approximately 3.2 million
    Pennsylvanians with coverage through Medicaid and the Federal exchange.
    I understand that the Senate is supposed to vote on this bill this
    week, before receiving a complete CBO analysis of the bill's impacts on
    coverage rates and premiums.

        By rushing through a plan that we do not fully understand and have
    not fully evaluated, and throwing States into a brief, unfunded,
    chaotic implementation period to restructure our health-care system, I
    fear that you will be jeopardizing the health and financial well-being
    of the individuals we serve. Washington must keep the needs of
    consumers at the forefront of their minds as conversations continue,
    and I truly hope that Congress and the Trump administration will slow
    down and take a more deliberative approach than they have thus far.
    Significant and swift changes to our health-care system could have a
    devastating impact on the people that rely on it every day. This is
    about Americans accessing and affording care that is vital to their
    health and well-being. We cannot return to a time when people are
    forced to accept less coverage at an increased cost, and make tough
    choices between their finances or their health.

        Please do not paper over spending cuts and diminishment of consumer
    protections using the guise of State flexibility. On behalf of
    Pennsylvanians, on behalf of our children, seniors, and individual with
    disabilities--our most vulnerable populations--I implore you to return
    to the bipartisan process that the Senate was engaging in earlier this
    month, and craft a compromise bill to stabilize the individual market
    and improve our current system.

        Again, thank you for allowing me to speak with you today. I would
    be happy to take any questions that you might have.

                                     ______

              Questions Submitted for the Record to Teresa Miller
                  Questions Submitted by Hon. Claire McCaskill
        Question. Under current law, could States elect to pursue auto-
    enrollment through a section 1332 waiver?

        Answer. I do not believe there is anything that would prohibit a
    state from pursuing auto-enrollment through a 1332 waiver today.

        Question. Does the Graham-Cassidy-Heller-Johnson proposal require
    States to establish an auto-enrollment mechanism?

        Answer. No.

        Question. Does the Graham-Cassidy-Heller-Johnson proposal eliminate
    the individual mandate?

        Answer. Yes. The proposal eliminates the individual mandate
    effective retroactively (January 2016).

        Question. Do you anticipate that the number of individuals with
    insurance coverage will decrease under the Graham-Cassidy-Heller-
    Johnson proposal and that uncompensated care costs may rise?

        Answer. Yes. The proposal would certainly result in fewer
    individuals with insurance coverage, which would increase the amount of
    uncompensated care. Although we do not have the benefit of a full
    Congressional Budget Office (CBO) score, the CBO did project this
    proposal would result in ``millions'' of people with comprehensive
    health insurance losing their coverage.

        A literature review by the Kaiser Family Foundation found that
    Medicaid expansion has positive effects on multiple economic outcomes.
    National, multi-state, and single state studies show that States
    expanding Medicaid under the Affordable Care Act (ACA) have realized
    budget savings, revenue gains, overall economic growth, and reductions
    in uncompensated care costs for hospitals and clinics. Last year alone,
    thanks to the ACA, hospitals in Pennsylvania experienced a $129 million
    decline in uncompensated care.

                                     ______

                  Questions Submitted by Hon. Robert Menendez
        Question. The United States is facing a rapidly aging population.
    Medicaid pays for the long-term care needs of millions of seniors, a
    number that is expected to grow rapidly in the near future. How will
    funding caps for Medicaid funding impact the ability of States to meet
    the needs of the elderly? In particular, can the needs of the growing
    number of individuals afflicted by Alzheimer's disease be met under the
    Graham-Cassidy-Heller-Johnson proposal?

        Answer. According to the Pennsylvania Department of Aging's 2016-
    2020 State Plan on Aging, out of Pennsylvania's more than 12.8 million
    residents, approximately 2.9 million are adults age 60 and older, and
    more than 300,000 are aged 85 and older. By 2020, the population of
    older Pennsylvanians is projected to increase by 25%.

        In Pennsylvania, we are in the process of implementing a program
    called Community HealthChoices, which aims to allow older
    Pennsylvanians and individuals with a physical disability to receive
    services in their community and in their homes, rather than a nursing
    home. We all know it is much more cost effective to allow people to
    receive services in the community and, this is where most of us want to
    age if possible. Under current Medicaid rules, nursing homes are the
    default in terms of what Medicaid covers, even though it is the most
    expensive setting for long term care services. If we must absorb
    Medicaid cuts of anywhere from $15-30 billion over the next decade, I
    worry about our ability to continue to move to community based services
    for older Pennsylvanians. Yet, if we do not move in this direction,
    both the State and Federal Government will be on the hook for the most
    expensive type of long term care services. Cuts of the magnitude
    required by this legislation to Medicaid will certainly have an impact
    on our ability to meet the needs of older Pennsylvanians. Our Governor
    will be forced to make unconscionable decisions about which services we
    will no longer be able to provide or who will no longer be able to
    receive services if this legislation were to pass.

        Question. Families who have children with special needs often face
    an uphill battle in accessing services. What protections does the
    Graham-Cassidy-Heller-Johnson bill offer them to ensure their children
    are not cut off from care for their conditions? That a young child
    isn't forced to go without care because they have hit an annual cap? A
    lifetime cap?

        Answer. Under this proposal, whether children with special needs or
    pre-existing conditions are protected will depend largely on where they
    live. The bill allows States, through their block grant program, to
    waive certain important requirements that protect people with pre-
    existing conditions today. States could allow insurers to charge people
    with pre-existing conditions more based on their health status. While
    individuals cannot technically be denied coverage, they could be forced
    to pay more for that coverage, which may leave some priced out of
    coverage they need. Additionally, States can waive essential health
    benefit requirements, so people with pre-existing conditions may not
    have the benefits they need available to them if they live in a State
    that decides to waive some of those benefits. While the ACA's
    prohibition on annual and lifetime dollar limits remains, the
    prohibition only applies to limits on essential health benefits, which
    can be waived by States.

        Having said that, I think the larger issue that will impact
    children with special needs, like it will impact everyone else, is the
    significant loss of Federal funding that will force Governors across
    the country to figure out how they are going to revamp their health-
    care systems with less money. In States like Pennsylvania that would
    not otherwise choose to waive essential health benefits, we are not
    going to be able to make up for this loss of Federal funding and will
    be forced to make impossible decisions about who will no longer have
    access to health care and/or what services will no longer be covered.

                                     ______

                    Questions Submitted by Hon. Bill Nelson
        Question. The Graham-Cassidy bill repeals the Affordable Care Act's
    Medicaid expansion, premium tax credits, and cost-sharing reduction
    payments and instead creates a block grant.

        It is my understanding that the block grant funding ends after 2026
    under the Graham-Cassidy bill. What happens to the individual
    marketplace after 2026?

        Answer. I am concerned if this proposal passes, the individual
    market in Pennsylvania would collapse long before 2026. By
    retroactively repealing the individual mandate and creating significant
    uncertainty about the future, I think it is likely insurers would exit
    the market in the next few years. If for some reason our individual
    market had not collapsed before then, it is hard to imagine how it
    could withstand the changes in 2027. At that point, not only would we
    not have the individual mandate, but the block grant funding allowing
    States to implement cost-sharing reductions, premium tax credits or
    other methods of providing financial assistance to help people pay for
    coverage, would be gone but, the guaranteed issue requirement for
    companies would still be in place.

        The ACA was predicated on three interrelated principles--the
    individual mandate, the requirement insurers cover anyone who signs up
    for coverage, and the availability of financial assistance to help
    people pay for coverage. If you remove any of these three provisions,
    or two of them as this proposal would do, it sets the market up to
    fail. In this scenario, only the sickest individuals are going to sign
    up for coverage, which ultimately leads to a death spiral. I do not
    know how our individual market would survive such a scenario.

        Question. Would you say that gutting the current individual
    marketplace by changing it to a block grant from 2020 to 2026, and
    creating a funding cliff after 2026 is good for the stability of the
    individual insurance market? Insurers are already having trouble
    setting their 2018 rates because the administration won't commit to
    funding the CSRs. How do you expect them to plan for 2027?

        Answer. This proposal is not going to be good for the stability of
    the individual market, either in the short term or the long term. This
    bill retroactively repeals the individual mandate and does not replace
    it with any continuous coverage requirements or anything that might
    assist with adverse selection concerns. Consequently, I am very
    concerned about the impact this bill would have on the individual
    market in the next few years, before the State block grant kicks in. In
    Pennsylvania, our individual market is stabilizing. Our proposed
    increases of 8.8 percent in this market are evidence of this
    stabilization.

        However, when we asked insurers to file their rates, we asked them
    to estimate their increases if the individual mandate were to go away
    and/or if the CSR payments were not made. If both of those things
    happened, as proposed in this bill, in Pennsylvania, we will be looking
    at a statewide average increase in the individual market of 36 percent.
    So, if this bill passes, we will certainly see significant increases as
    a result. But, my bigger fear is that we will see insurers exit the
    market because of the instability created by the combination of no
    mandate and no CSR payments and a very uncertain future. And, those are
    the problems we have in the immediate future. I do not know that we
    would have any insurance companies still participating in the market in
    2026. If we did, it is hard to imagine how they would plan for 2027
    when the State block grant funds end.

        Question. I'm the former Florida insurance commissioner, and I've
    seen what can help stabilize an insurance marketplace. That's why I,
    with my friend from across the aisle, Senator Collins, have introduced
    the Lower Premiums Through Reinsurance Act to help States establish
    their own reinsurance programs. Do you think this bill is a good
    solution to help stabilize the ACA's individual market?

        Answer. The Graham-Cassidy proposal, even though it does include a
    short-term reinsurance program, would destabilize the individual
    market. While a reinsurance program could be a key component of a bi-
    partisan solution to help stabilize the individual market, such a
    program, on its own, is not enough. That is the problem with the
    reinsurance program in the Graham-Cassidy proposal. It won't be nearly
    enough to make up for the fact that the proposal retroactively repeals
    the individual mandate and eliminates CSR payments.

        As we discussed during the hearing, if we are serious about
    stabilizing the individual market, we should let Senator Alexander and
    Senator Murray continue the work the HELP Committee began in early
    September.

        Question. Medicaid is the largest health-care program for children,
    covering more than 30 million kids. As it is currently structured, the
    Medicaid program gives States flexibility to innovate and pursue
    delivery system reforms. How will States be able to transform care and
    pursue delivery system reforms to improve child health outcomes if the
    Medicaid program is gutted under either a cap or block grant?

        Answer. If we are forced to make the draconian cuts required by
    this bill, all of our efforts would be focused on how we cut $15-30
    billion from our Medicaid program. Instead of using our time and
    resources to continue down the path of pursuing delivery system reforms
    and focusing on improving outcomes, we will be left making very
    difficult decisions about what services we will no longer provide or
    who will no longer be able to receive services.

                                     ______

                   Questions Submitted by Hon. Sherrod Brown
             intellectual and developmental disabilities population
        Question. The Graham-Cassidy proposal includes a provision that
    seems to try and protect children with intellectual or developmental
    disabilities who are on Medicaid by exempting those receiving
    Supplemental Security Income, or SSI, from the block grants. Through
    this provision, the authors are acknowledging that these individuals--
    children with disabilities--need protection. That is why they have
    excluded them from the block grant.

        However, in Ohio, only 24% of children with intellectual or
    developmental disabilities, or IDD, who are on Medicaid rely on SSI.
    The Graham-Cassidy proposal does not seem to protect the remaining 76%
    of children on Medicaid with IDD, who are not on SSI and who are
    therefore not exempted from block grants.

        The proposal also does not seem to protect these children when they
    grow up. A diagnosis of autism does not disappear when a child becomes
    an adult. Under this language, children could lose critical services
    and supports when they become adults.

        What is the likely impact of Graham-Cassidy on services for the
    vulnerable populations of seniors and people with disabilities who wish
    to receive services in their home and communities?

        Answer. In Pennsylvania, we are in the process of implementing a
    program called Community HealthChoices, which aims to allow older
    Pennsylvanians and individuals with a physical disability to receive
    services in their homes and communities, rather than a nursing home. We
    are also planning to expand our home and community based services for
    individuals with intellectual disabilities and autism through a new
    Community Living Waiver program. We all know it is much more cost
    effective to allow people to receive services in the community and this
    is where most of us want to receive services if at all possible. Under
    current Medicaid rules, nursing homes are the default in terms of what
    Medicaid covers, even though it's the most expensive setting for long
    term care services. But, if we have to absorb Medicaid cuts of anywhere
    from $15-30 billion over the next decade, I worry about our ability to
    continue to move to community based services for individuals with
    disabilities and older Pennsylvanians who are truly the most
    vulnerable. And, yet if we don't move in this direction, both the State
    and Federal Government will be on the hook for the most expensive type
    of long term care services.
                                 nursing homes
        Question. Three in five nursing home residents in Ohio rely on
    Medicaid to cover the cost of their nursing home care.

        What will the Medicaid cuts included in Graham-Cassidy mean to
    seniors and their families and nursing home providers in States like
    Ohio?

        Answer. When States are faced with cuts of this magnitude, for
    Pennsylvania our losses are expected to be somewhere between $15-30
    billion over the next decade, there are only three levers available. We
    will have to decide what services we may no longer be able to provide,
    who may no longer be able to receive services and/or where we can make
    reductions in provider payment rates. More than 55,000 individuals per
    month rely on Medicaid to pay for their services in a nursing home. I
    am afraid seniors and their families will see a reduction in services
    as we are left making impossible decisions and forced to make deep cuts
    to the program. It's entirely possible nursing home providers would see
    their Medicaid payment rates impacted as States make significant cuts
    to their Medicaid programs.
                                      jobs
        Question. The Graham-Cassidy proposal could cost people their jobs
    when area hospitals are forced to cut services to patients and lay off
    workers.

        Earlier this year, I met with hospitals across the State of Ohio
    who shared their concerns over proposals like Graham-Cassidy, and what
    they would mean for communities across Ohio.

        In Toledo, a representative from ProMedica hospital said that
    proposals that include massive cuts to Medicaid ``could potentially
    result in massive job losses and even hospital closures across our
    industry.''

        In Cleveland, the CEO of MetroHealth Hospital, said: ``a
    replacement plan must not create gaps in coverage. This is about
    people, millions of them, who will suffer needlessly if they go without
    health care. Losing health care affects more than their health. It
    affects their ability to work, support for their children's education,
    and the overall economy of the community. Significant increases in the
    number of uninsured and under-insured patients will strain the finances
    of health systems and will negatively impact both medical services and
    employment.''

        Do you agree with the concerns above? What would this proposal mean
    for health-care jobs in States like Pennsylvania and Ohio?

        Answer. I share these concerns about what this proposal would mean
    for jobs in Pennsylvania and around the country. For Pennsylvania, the
    Medicaid expansion generated an infusion of over $1.8 billion in direct
    care health spending into the commonwealth in calendar year 2015 and
    the addition of 15,500 jobs in Pennsylvania in year one. Although I
    can't speak to the effect of the Graham-Cassidy bill specifically on
    Pennsylvania, given how little time we've had to review it, I can point
    to a study by the Commonwealth Fund and George Washington University's
    Milken Institute on the effects of the AHCA, the House bill proposed
    this summer, which also would've cut Medicaid expansion. The study of
    that bill concluded that, nationally, nearly 1 million jobs would be
    lost due to the AHCA due to a sicker workforce, a loss of health-care
    jobs, and economic downturn. They estimated that Pennsylvania would
    lose 85,000 jobs by 2026--second only to New York.

                                     ______

                Questions Submitted by Hon. Robert P. Casey, Jr.
        Question. Ms. Miller, the sponsors of the Graham-Cassidy proposal
    have said that States with budget challenges would see relief under the
    Graham-Cassidy proposal. Is this accurate? Would Pennsylvania's budget
    be helped by the funding proposal in Graham-Cassidy? What would the
    impact of this proposal be on the State's ability to pay for the
    necessary health care for its residents?

        Answer. Let me start by talking about who Medicaid serves in
    Pennsylvania. We serve 1.2 million children, nearly 250,000 seniors,
    565,000 individuals who receive outpatient mental health services, and
    215,000 individuals relying on substance use disorder treatment.
    Medicaid pays for nearly 40% of Pennsylvania's total births.

        Both our internal analysis and independent external analyses
    conclude that this proposal would result in the loss of billions of
    dollars in Federal funding for Pennsylvania, anywhere from $15 billion
    to $30 billion over the next decade. Whether the ultimate amount is at
    the low or high end of that range, we're looking at losses that the
    State has no way to make up. Pennsylvania is facing a $2 billion
    structural deficit in our budget now. We don't even have a balanced
    budget for this current fiscal year, three months into it. We certainly
    don't have the ability to cover the loss of billions of dollars in
    Federal funding. This extreme shift in funding will result in a fiscal
    crisis beyond what Pennsylvania has experienced to date.

        These funding cuts would force Governor Wolf to make truly
    impossible decisions. We would be left with the only three levers that
    exist when we are forced to cut Medicaid. We would have to cut
    services, reduce provider payments, or eliminate coverage for some of
    our most vulnerable citizens. I worry about not only the 1.1 million
    Pennsylvanians in the expansion population and on the marketplace, but
    also the 2.1 million Pennsylvanians served through traditional
    Medicaid. This level of funding cut would have far-reaching impacts on
    people served by Medicaid in Pennsylvania, which is almost a quarter of
    our population.

                                     ______

                   Prepared Statement of Hon. Rick Santorum,
                    a Former U.S. Senator From Pennsylvania
        In July of 1996, after two vetoes by President Clinton, the Senate
    passed The Welfare Reform Act of 1996. That reform ended a New Deal Era
    Federal entitlement know as Aid to Families with Dependent Children and
    replaced it with a block grant to the States called Transitional
    Assistance to Needy Families. I was the floor manager of that bill and
    worked closely with Representative Clay Shaw in the House and numerous
    governors to craft this reform.

        President Clinton, from his experience as Governor of Arkansas,
    realized the faults in this federally controlled open-ended entitlement
    that was both inefficient and ineffective in addressing poverty. To his
    great credit, he accepted that this broken program was in need of a
    major overhaul. He boldly campaigned on ``ending welfare as we know
    it.''

        What passed the Congress was more than a major overhaul. It
    repealed the old system and replaced it with a federalist solution that
    gave power and a block grant to the each State. The objective then, as
    with the bill before this committee, was to entrust sufficient
    resources and decisions into hands closer to the people in need so they
    can devise innovative solutions better suited for the unique needs of
    the people in their community. This was to be funded by a clearly
    defined amount of money that would be limited over time so State and
    local authorities could set their priorities.

        Many progressive voices in and outside of the administration
    claimed that cruel assault on the poor would lead to rampant poverty,
    the deaths of thousands if not millions over time. Cries that States
    couldn't be trusted with caring for their poor, lack of resources, even
    though there was no reduction in spending in the near term, mean
    spirited requirements like insisting that the able-bodied work as a
    condition to receiving cash assistance, were all used to paint
    supporters of this approach as cruel and uncaring.

        Fifty-one Republicans voted for passage along with 23 Democrats,
    including then Senators Joe Biden and John Kerry, as well as, I should
    note, the ranking member of this committee, Ron Wyden. Most of the
    States took on the challenge and transformed welfare. Within a few
    years welfare rolls were cut in half nationwide and by more than 90% in
    some States. The much feared reduction in the rolls did not however
    result in the much predicted increase in poverty. In fact, poverty
    among the most chronically poor went down, in some cases to record
    lows, and employment, particularly among the hardest to employ went up.
    This novel idea worked for those on welfare and for the taxpayer who
    has not seen an increase in the block grant in 20 years!

        It was this experience in bipartisanship and the frustration of
    seeing the process bog down in Washington that lead me to reach out to
    a small group of Governors, Senators, and House members to discuss
    designing a similar approach to addressing both Medicaid and ACA.
    Contrary to reports that this is a hastily patched together last minute
    Hail Mary, Senator Graham, Congressman Meadow and their staffs have
    been working with a group of Governors lead by Scott Walker and Doug
    Ducey for several months.

        Before I go into the details of the repeal and replacement of the
    ACA, let me briefly address a proposal that has been debated in the
    Congress for several months that I had nothing to do with. This is a
    proposal that puts Medicaid on a sustainable funding path while giving
    States both the resources and predictability necessary to craft a
    program to care for those in most need. The most significant criticism
    we hear about GCHJ is the Medicaid per-capita cap will strangle this
    program to the disadvantage of the poor. I understand the per-capita
    cap is something that President Bill Clinton proposed and in 1995, 46
    Democratic Senators including the current ranking member of the HELP
    committee signed a letter in support of it. The claim is the per capita
    annual growth rate which starts as CPI Medical plus one and which
    settles at CPI Medical for the blind, elderly and disabled and CPI U
    for the younger and healthier population is insufficient.

        I find this criticism particularly perplexing coming from those who
    supported Medicaid expansion and are now proposing Medicare for all.
    One of the principle selling points advanced by their advocates is that
    these government programs are the most efficient provider of health
    services. If that is true then pegging that program to an inflation
    rate that includes these so-called inefficient and profitable private
    sector plans should be a bonanza for Medicaid. How can you argue on one
    hand that everyone should be in a government program because it will
    increase quality and lower cost and then turn around and say that this
    government program will fail unless it gets more money than the private
    sector plans?

        In spite of the intellectual inconsistencies of the advocates of
    Medicaid, GCHJ attempts to mollify these concerns by permitting States
    to use up to 20% of the GCHJ block grant to support the State's
    Medicaid program. In most States that will eliminate or at a minimum
    greatly reduce any funding shortfall.

        That provision of GCHJ was one of the reasons that I suggested a
    ``second'' block grant to Senator Graham earlier this spring. The key
    to designing an effective solution to a rapidly changing and innovative
    sector of our economy like health care is a combination of equally
    distributed, sufficient but limited resources, the flexibility to adapt
    to its dynamic nature and multiple competitors to allow for innovation.
    The ACA provides none of those keys, GCHJ does.

        Let me address each one of those keys. Unlike the ACA which
    distributes funds based upon how States align with ACA requirements,
    GCHJ is designed to create funding parity among the States and let the
    States decide how to best spend that money. The allocation is made by
    distributing the resources on a per capita allocation based upon the
    number of people between 50%-138% of poverty. That amount is multiplied
    by the number of people at that level of poverty in each State. In
    order to minimize the impact of the transition to parity for the
    expansion States, GCHJ establishes a base year in 2020 based upon
    current levels of total funds received by the States under the ACA. The
    formula is phased in over 10 years to achieve parity among the States.
    There are three other provisions to further limit the impact on
    expansion States, non-expansion States are limited to 25% growth per
    year for the first 6 years of the formula. The 10% State funding match
    required by the ACA in 2020 is eliminated. Finally, States whose year
    over year increases fall below the rate of medical inflation (CPI-M)
    can buy back the reductions in Disproportionate Share payments
    eliminated under the ACA. As a result, only a handful of high cost
    Medicaid States see a reduction in projected spending.

        In addition to putting Medicaid under some spending restraint, GCHJ
    takes another open ended unsustainable entitlement, the ACA, and puts
    it on a budget. As was the case in 1996 with welfare, this bill
    restrains spending on an inefficient and failing program. Contrary to
    the explosive rhetoric the bill does not slash spending. In fact, there
    are voices on the right and left who oppose this proposal because of
    the amount of taxes and spending. That usually means you are somewhere
    at or near appropriate levels of spending. This bill allocates $1.2
    billion, all the ACA revenues projected to be collected over the budget
    window minus a few unpopular taxes like the medical device tax and the
    individual and employer mandate. Those States that wish to continue an
    ACA insurance and funding regime could simply adopt the identical
    mandates in their State implementing legislation.

        Unlike the Federal Government, States, like families and
    businesses, are used to living within a budget. They can't just borrow
    seemingly unlimited amounts of money. Medicaid, and particularly
    Medicaid Expansion, encourage spending and create no incentive to be
    efficient or effective. The program that welfare reform repealed had a
    similar track record. They took responsibility to craft a superior
    system to care for those falling through the cracks in our country,
    welfare reform demonstrated they will and can.

        This leads me to the last reason to support this bill. Allowing the
    States the flexibility to innovate, compete and imitate were the keys
    to welfare reform's success. Just look at what Rhode Island, Arkansas
    and Indiana have done with waivers in Medicaid and Medicaid Expansion.
    Some have suggested that States prior to the ACA didn't create
    insurance markets that were affordable and accessible to the individual
    market. That is true, but they didn't have $1.2 trillion either.

        The ACA is failing, and it is clear that the Democrats have no
    interest in structural changes to make it work and Republicans have no
    interest in propping up a doomed plan. This allows those areas of the
    country that want to continue with the ACA to do so and those that
    believe there is a better way to give it a try all within a sustainable
    budget.

                                     ______

            Question Submitted for the Record to Hon. Rick Santorum
                    Question Submitted by Hon. Sherrod Brown
                  drafting process and advocacy organizations
        Question. Creating thoughtful, responsible, and effective
    legislation requires the input of diverse subject matter experts,
    representing different stakeholder communities. The Graham-Cassidy
    proposal is a remake of the entire U.S. health-care system, which
    necessitates input from groups like advocacy organizations,
    professional societies, or other reputable associations.

        Have any organizations from the categories listed above endorsed
    the Graham-Cassidy bill that you helped create?

        Answer. The Catholic Medical Association supported the Graham-
    Cassidy development effort.

                                     ______

    Prepared Statement of Dennis G. Smith, Senior Advisor for Medicaid and
           Health Care Reform, Arkansas Department of Human Services
        I am Dennis G. Smith, Senior Advisor for Medicaid and Health Care
    Reform for the Arkansas Department of Human Services (DHS). It is a
    privilege to be with you today to convey Governor Asa Hutchinson's
    support for the Graham-Cassidy-Heller-Johnson proposed amendment to
    H.R. 1628, the Better Care Reconciliation Act of 2017 (BCRA) under
    consideration by the U.S. Senate. My remarks will focus on Federal
    funding for private insurance subsidies, the use of the Children's
    Health Insurance Program (CHIP) as the model for re-establishing the
    relationship between States and the Federal Government, Medicaid per-
    capita caps, and work requirements.
                         federal funding for subsidies
        The Graham-Cassidy-Heller-Johnson proposed amendment would provide
    States with nearly $1.2 trillion in Federal funding between 2020 and
    2026 to provide health insurance coverage and pay for direct medical
    care for our citizens who are in poverty or who are at lower income
    levels and cannot afford the full cost of their health insurance
    coverage. Earlier this month, the Congressional Budget Office (CBO)
    released its most comprehensive look at health insurance coverage and
    spending since its March 2016 baseline.\1\ This report is useful in
    understanding the context of the Graham-Cassidy-Heller-Johnson proposal
    and the populations it would impact most significantly.
    ---------------------------------------------------------------------------
        \1\ The Congressional Budget Office (CBO). ``Federal Subsidies for
    Health Insurance Coverage for People Under Age 65: 2017 to 2027''
    (September 2017). Available at: https://www.cbo.gov/system/files/115th-
    congress-2017-2018/reports/53091-fshic.pdf.

        Graham-Cassidy-Heller-Johnson would replace the private insurance
    subsidies and Medicaid expansion funding provided under the Affordable
    Care Act (ACA) with State block grants. CBO reports that 9 million
    individuals are receiving subsidies to purchase individual coverage
    through the marketplaces and coverage through the Basic Health Program
    (BHP) in 2017. By comparison, that is about the same number of people
    the CHIP program has covered in the past several years and is less than
    3 percent of the total population in the United States under age 65.
    The second population group included in the block grant proposal is the
    13 million adults who are now covered through Medicaid at a State
    option. Thus, coverage for this population is already administered by
    ---------------------------------------------------------------------------
    States.

        In scoring H.R. 3590, the Patient Protection and Affordable Care
    Act (PPACA) \2\ CBO estimated that under ``current law'' there would be
    35 million nonelderly people enrolled in Medicaid and CHIP in 2017, 5
    million fewer than the number of people enrolled in 2010 (CBO Director
    Douglas Elmendorf letter to Majority Leader Harry Reid, March 11,
    2010).\3\ Conversely, CBO projected that under PPACA (which would have
    required all States to expand Medicaid), there would be 15 million more
    people covered by Medicaid and CHIP in 2017 than under its current law
    baseline. Today, there are 69 million nonelderly people enrolled in
    Medicaid and CHIP, 13 million of whom are ``newly eligible'' adults.
    Excluding the Medicaid expansion population, CBO projected there would
    be 35 million people enrolled in Medicaid and CHIP in 2017. Instead,
    there are 56 million people enrolled in Medicaid and CHIP (excluding
    the Medicaid expansion)--21 million more people than CBO expected if
    all States had expanded the program. That difference alone is twice the
    size of the population receiving premium subsidies this year.
    ---------------------------------------------------------------------------
        \2\ PPACA was passed by the Senate on December 24, 2009. The Health
    Care and Education Reconciliation Act of 2010 made additional changes
    to PPACA. Together, the two Acts are commonly referred to as the
    Affordable Care Act (ACA).
        \3\ https://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/113xx/
    doc11307/reid_letter_hr359
    0.pdf, Table 3.

        Experience now tells us what CBO could not accurately model back in
    2010, that there is very different distribution in the sources of
    coverage for individuals with income at lower income levels than
    expected. As Congress searches for answers for how to stabilize
    premiums for those in the individual market, it should consider where
    people actually went for coverage. Millions of people CBO expected to
    enroll in the individual market are in Medicaid instead. Combining
    funding for these two groups into State block grants is consistent with
    the basic concepts of insurance pools. Adding younger, healthier lives
    and spreading the risk among a larger pool of people will help
    stabilize premiums for everyone in the individual market, both those
    ---------------------------------------------------------------------------
    who are subsidized and those who are not.

        Creating a new program to cover 22 million people beginning in 2020
    will be a challenge for States, but is not unrealistic. States are
    already serving more than half of these individuals through Medicaid;
    and there are 50 million more people under age 65 covered through
    traditional Medicaid. States administer the Supplemental Nutrition
    Assistance Program (SNAP) on behalf of the Federal Government.
    Enrollment in SNAP has ranged from 47.4 million people in October 2013
    to 41.3 million people in June 2017.\4\ So as you consider this new
    grant program to be administered by the States, it would be a program
    of relatively modest size. Additionally, using the Modified Adjusted
    Gross Income (MAGI) methodology to determine eligibility is much easier
    to administer than the old Medicaid income standards and methodologies.
    There should be no question as to whether States have the ability to
    administer such a program.
    ---------------------------------------------------------------------------
        \4\ https://fns-prod.azureedge.net/sites/default/files/pd/
    34SNAPmonthly.pdf.

        CBO estimates that, in 2020 under current law, the Federal
    Government will spend a total of $147 billion to subsidize the cost of
    ---------------------------------------------------------------------------
    coverage:

          $82 billion for the newly eligible Medicaid population;

          $49 billion for premium tax credits;

          $10 billion for cost sharing reduction outlays; and

          $6 billion for the Basic Health Program (which provides coverage
    to 1 million people).

        Graham-Cassidy-Heller-Johnson appropriates an amount nearly equal
    to the CBO projections ($146 billion in 2020) for the States and gives
    States 3 years to spend their annual allotments. It also allows States
    to use 15 percent of their funds (20 percent with a waiver) to provide
    services to Medicaid populations. There is an additional appropriation
    of $15 billion in 2020 that the Administrator of the Centers for
    Medicare and Medicaid Services (CMS) can use to provide short-term
    assistance to carriers or States to help stabilize the markets.

        In 2017, the Federal Government will spend about $111 billion on
    the Medicaid expansion population and private insurance subsidies,
    according to the September 2017 CBO report. Under the Graham-Cassidy-
    Heller-Johnson proposal, Federal spending for these populations will
    increase to $190 billion in 2026, an increase of more than 70 percent.
    Slowing the rate of growth should not be considered a ``loss'' to the
    States or to individuals. For example, in its March 2015 Medicaid
    baseline, CBO projected that the average Federal spending on benefit
    payments per elderly enrollee would be $10,620 in 2017. In January
    2017, CBO revised its estimate that the average Federal spending on
    benefit payments per elderly enrollee would be $8,000 in 2017. CBO also
    reduced its average per enrollee spending estimate for the Medicaid
    blind and disabled population for 2017 from $14,310 to $12,150. I am
    not aware of an argument among policymakers that the elderly Medicaid
    population ``lost'' $2,620 in benefits or that people with disabilities
    ``lost'' more than $2,000 in benefits. Growth in average spending has
    simply been slower than previously projected.
                         chip as the model and platform
        Twenty years ago, Chairman Hatch provided the leadership necessary
    to create the State Children's Health Insurance Program under title XXI
    of the Social Security Act. Senator Grassley was also a member of the
    Senate Finance Committee at that time and helped shape this new
    program, which serves about 8 million children today at a cost of
    approximately $16 billion this year. The original features of the CHIP
    program included:

          Capped allotments to States;

          Great flexibility given to States to determine eligibility,
    benefits, and cost sharing;

          A mandatory appropriation for a limited number of years; and

          No individual entitlement.

        One of the stated goals of the ACA was to lower the cost of health
    care, but the law has fallen far short in achieving this aim. The
    Graham-Cassidy-Heller-Johnson proposal provides a mechanism for the
    Federal Government to incentivize the States to succeed where current
    law has not. States will react to the new budget caps in the same
    manner as they did to CHIP--by designing the program in a manner that
    spreads the dollars in the most effective and economical manner
    possible while staying within the constraints of a fixed budget.

        Adopting CHIP as the model and platform should be viewed as a very
    positive advantage for the Graham-Cassidy-Heller-Johnson proposal.
    There are already policies and procedures in place to handle financial
    transactions between the Federal Government and States. States have an
    existing accountability system to modify rather than build from the
    bottom up. Over the 20-year history of CHIP, Congress has consistently
    reauthorized the program, and periodically increased funding for it.
    Indeed, Chairman Hatch and Ranking Member Wyden have recently announced
    their agreement to reauthorize CHIP for another 5 years.
             allotment formula under graham-cassidy-heller-johnson
        When CHIP was created, nothing like it existed on a national level.
    Only three States had started their own programs to serve low-income
    children. Congress constructed a funding formula out of necessity based
    on several variables, including the number of low-income children
    without health insurance. Congress also tried to create greater equity
    among the States through the enhanced match rates it would pay them.

        Today's situation is quite different. The Graham-Cassidy-Heller-
    Johnson formula starts with the current distribution of funding among
    the States. Because not all States expanded Medicaid eligibility under
    PPACA, the distribution of funds varies greatly. Over time, this
    proposal seeks to distribute funds on a more equitable basis so that,
    by 2026, per capita Federal funding is spread evenly among the States.

        There is no perfect funding formula that can accommodate all the
    variations among States and that includes the match rate formula for
    determining the Federal Medical Assistance Percentage (FMAP) used in
    the Medicaid program. Every State can give a multitude of reasons as to
    how it is disadvantaged. The goal of achieving financial parity is
    laudable. The proposal makes those adjustments gradually, over a period
    of 8 years from now.
                            medicaid per-capita caps
        While the Graham-Cassidy-Heller-Johnson proposal offers an entirely
    new approach to providing coverage for the newly eligible Medicaid
    adults and subsidized private insurance enrollees, the proposed per-
    capita cap concept for the traditional Medicaid population is familiar.
    The discussion on per-capita caps is even older than CHIP.

        The legislative language on per-capita caps is complex, as there
    are exclusions from the caps, a formula for setting the base rates by
    population group, and different growth rates among the population
    groups. The caps apply only to per-capita Federal funding of benefits,
    not to enrollment growth.

        Per-capita caps are not new to Medicaid. States, including
    Arkansas, have accepted per-capita spending caps in their various
    section 1115 Demonstration Projects. States are at full risk for any
    cost greater than these caps. These caps typically have some inflation
    protection, which Graham-Cassidy-Heller-Johnson also includes.

        The success of per-capita caps in controlling growth rates through
    section 1115 demonstration projects is ample evidence to apply them to
    the traditional Medicaid program. However, per-capita caps have been an
    option for States. And few States have accepted per-capita caps for
    their most expensive populations--the elderly and people with
    disabilities. This is the area in which CMS must be willing to give
    States ample authority to use new approaches to service delivery
    reform. Risk is only acceptable when States have the authority to
    control how services are delivered.

        States learn and borrow from each other. No doubt there will be an
    accelerated learning curve for some. The good news is many States,
    including Arkansas, are ahead of the curve with new models of organized
    care.

        Per-capita caps, without a doubt, are a means of imposing fiscal
    discipline, and there is no escaping that fact. We also know that
    Medicaid is unsustainable for both the States and the Federal
    Government, and the hard work needs to be done.
                               work requirements
        Graham-Cassidy-Heller-Johnson includes an option for the States to
    adopt a work requirement for able-bodied adults on Medicaid. Work
    requirements are consistent with the original purpose of Medicaid
    expressed in section 1901, which includes, ``. . . to help such
    families and individuals attain or retain capability for independence.
    . . .'' Medicaid can help working aged adults, on a temporary basis, to
    improve their health and get back on their feet. But the safety net
    should not be a restraint that deters someone from fully participating
    in the labor force and improving their economic standing.

        Last month, Arkansas Works paid $524.32 in premiums, cost sharing,
    and additional services for each of the 257,579 enrollees in a
    qualified health plan (QHP), which equals nearly $6,300 per year per
    individual. Approximately 60,000 of these adults had income above the
    poverty level ($12,060 for a single adult) and were required to pay
    about $13 a month for their health insurance premiums, plus up to $3
    for each drug prescription. The able-bodied adults with income below
    100 percent of poverty paid nothing for their coverage.

        We have asked CMS for approval to impose mandatory work
    requirements on certain able-bodied adults that would be enforced by
    loss of coverage if the adult does not comply for more than 3 months in
    a calendar year. On a bipartisan basis, our State legislators agreed
    that expecting able-bodied adults to work in exchange for $6,300 in
    health insurance coverage benefits is fair. Legislators across the
    political spectrum supported the Governor in a special legislative
    session earlier this year to reinforce the message that the pathway to
    independence is through work.

        If our waiver request is approved, beginning January 1, 2018, those
    with income below 100 percent of poverty will be required to either
    work or engage in one of several activities, such as going to school,
    participating in job training, or volunteering. Achieving that
    objective will help lift people in our State out of poverty. Our design
    also exempts about half of the Arkansas Works population for a variety
    of reasons, including those who already work at least part time or are
    caring for a child or disabled family member. Additionally, the
    requirement will apply only to individuals less than 50 years of age.

        Work requirements present opportunities to learn new skills,
    broaden horizons, overcome new challenges, experience the intrinsic
    dignity of work, build for the future, and give back to the community.
    The benefits of work are far greater than earning a paycheck. Work
    leads to independence, which is among the core objectives of the
    Medicaid program. Thus, our focus on promoting work goes beyond the
    Arkansas Works program. For instance, we recently redesigned our home
    and community-based services waiver for people with developmental and
    intellectual disabilities to emphasize community-supported employment
    because of this population's ardent aspirations for the experience of
    work.

        Work requirements are a fair bargain in the social contract between
    individuals on public assistance and the taxpayers who foot the bill.
    It is important to examine the relationship in a new light in which the
    cost of coverage to the taxpayer is recognized as a true value by the
    person covered. The able-bodied adults have an obligation to their
    neighbors meet the requirements of the program. Rights cannot be
    separated from responsibilities. The Department of Human Services
    (DHS), the Department of Workforce Services (DWS), health insurance
    carriers, State and local educational agencies, and private sector
    partners will assist individuals in meeting their work requirement. The
    message to these individuals is that there are people willing to help,
    but you must also be willing to help yourself.

        Creating the expectation of work has already demonstrated some
    success. Since January 1, 2017, Arkansas Works recipients have been
    referred to DWS. More than 15,000 Arkansas Work recipients started new
    jobs without accessing any DWS services. Over 8,600 individuals
    accessed at least one DWS service and, of these, 1,361 have started new
    jobs. With the new waiver, Medicaid coverage for adults will become
    more than just access to medical services. It will present new hope as
    a pathway out of poverty and to greater prosperity for individuals,
    their families, their communities, and our State. The new work
    requirements are not only about today, they are about the future.
                                   conclusion
        Governor Hutchinson has joined more than a dozen other Governors in
    lending their strong support to the Graham-Cassidy-Heller-Johnson
    solution. Working with the Arkansas Delegation, other Governors,
    administration officials, and Senators Graham, Cassidy, and Santorum,
    changes have been made to improve this approach over the past several
    weeks. It is my pleasure to convey his strong support to the committee.

                                     ______

     Prepared Statement of Dick Woodruff, Senior Vice President of Federal
            Advocacy, American Cancer Society Cancer Action Network
        Good afternoon, Chairman Hatch, Ranking Member Wyden, and members
    of the committee. My name is Dick Woodruff, Senior Vice President for
    Federal Advocacy of the American Cancer Society Cancer Action Network
    (ACS CAN). I appreciate the opportunity to testify today on behalf of
    cancer patients and other patients living with chronic diseases on the
    proposal introduced by Senators Lindsey Graham (R-SC) and Bill Cassidy
    (R-LA) to repeal and replace the current health-care law. ACS CAN, the
    nonprofit, nonpartisan advocacy affiliate of the American Cancer
    Society, supports evidence-based policy and legislative solutions
    designed to eliminate cancer as a major health problem. As the Nation's
    leading advocate for public policies that are helping to defeat cancer,
    ACS CAN ensures that cancer patients, survivors, and their families
    have a voice in public policy matters at all levels of government.

        We recognize that the current health care law requires bi-partisan
    fixes. But we oppose the Graham-Cassidy bill because of the potential
    negative impact it would have on the 1.6 million Americans who will be
    diagnosed with cancer this year \1\ and the additional 15.5 million
    Americans living today with a history of cancer.\2\ For these
    Americans--many of your own constituents--access to affordable health
    insurance is a matter of life or death. Research from the American
    Cancer Society has shown that uninsured Americans are less likely to
    get screened for cancer and thus are more likely to have their cancer
    diagnosed at an advanced stage when survival is less likely and the
    cost of care more expensive.\3\
    ---------------------------------------------------------------------------
        \1\ American Cancer Society, ``Cancer Facts and Figures 2017,''
    available at https://www.
    cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/
    annual-cancer-facts-and-figures/2017/cancer-facts-and-figures-2017.pdf.
        \2\ Id.
        \3\ E. Ward et al., ``Association of Insurance With Cancer Care
    Utilization and Outcomes,'' CA: A Cancer Journal for Clinicians 58:1
    (Jan./Feb. 2008), http://www.cancer.org/cancer/news/report-links-
    health-insurance-status-with-cancer-care.
    ---------------------------------------------------------------------------
      the graham-cassidy bill could gut pre-existing condition protections
        For many years, a cancer diagnosis made it nearly impossible to get
    or keep insurance for Americans who relied on private health insurance
    sold in the individual and smaller group markets. Prior to enactment of
    the current law, health insurers in most States that sold in those
    markets could refuse to cover an individual with a pre-existing
    condition like cancer; could limit and/or refuse to cover care
    associated with a pre-existing condition; or could charge a higher
    premium based on pre-existing conditions--making insurance
    unaffordable. A survey conducted before passage of the current law
    found that 36 percent of those who tried to purchase health insurance
    directly from an insurance company in the individual insurance market
    were turned down, charged more, or had a specific health problem
    excluded from their coverage.\4\ Some people even found their insurance
    policies rescinded after being diagnosed with cancer. The current law
    prohibits these discriminatory practices and has helped to ensure that
    millions of people with serious illnesses like cancer can get and keep
    their coverage.
    ---------------------------------------------------------------------------
        \4\ M.M. Doty, S.R. Collins, J.L. Nicholson, et al., ``Failure to
    Protect: Why the Individual Insurance Market is not a Viable Option for
    Most U.S. Families.'' The Commonwealth Fund, July 2009.

        Unfortunately, the Graham-Cassidy proposal essentially rolls back
    the non-discrimination protections in the individual and small group
    market. Although the bill would technically prohibit plans from denying
    individuals coverage due to pre-
    existing conditions, it would allow States to waive the requirement
    that prohibits health plans from considering an individual's health
    history when determining premiums. For an individual in active cancer
    treatment or a cancer survivor, the health plan could have no limit on
    the amount of the monthly premium. Products would be unaffordable to
    individuals who required--or were anticipated to require--high-cost
    ---------------------------------------------------------------------------
    treatments.

        The bill would also allow States to waive some or all of the
    essential health benefits (EHBs) requirements. Insurance should cover
    the major health needs of cancer patients and survivors, including
    hospitalization, specialty cancer care, physician services,
    prescription drugs, rehabilitative care, screenings, and mental health
    services. Eliminating EHB requirements would encourage insurers to
    streamline ``basic'' policies that do not include explicitly defined
    comprehensive benefits, thus putting cancer patients and survivors at
    risk of inadequate treatment, and could jeopardize access to necessary
    preventive care, treatment, and follow-up care.

        Moreover, since the current law ties the prohibition on lifetime
    and annual benefit limits to the EHB requirements, by eliminating the
    EHB requirements, the
    Graham-Cassidy proposal could also eliminate these other important
    protections. Health plans could once again impose lifetime or annual
    limits on benefits provided to enrollees, increasing the chances that a
    diagnosis of cancer or other serious condition could lead to severe
    financial hardships for many Americans.

        Finally, the legislation would allow States to waive the current
    three-to-one age rating requirements that limit what insurers can
    charge in premium on the basis of the age of the enrollee. While cancer
    can be diagnosed at any age, the incidence of cancer increases with
    age. According to the American Cancer Society, 85 percent of all
    cancers in the United States are diagnosed in people 50 years of age
    and older.\5\ Thus, increasing the age rating bands would mean that
    older individuals (those more at risk of developing cancer) would face
    significantly higher health-care premiums or be priced out of the
    market completely. Prior to the enactment of the current laws age
    rating band restrictions, older adults faced significant problems
    accessing health insurance coverage, in large part because insurers in
    many States were permitted to charge older enrollees many times what
    they charged younger ones, (compounded by the ability of issuers to use
    health status when setting premiums).\6\
    ---------------------------------------------------------------------------
        \5\ American Cancer Society, ``Cancer Facts and Figures 2017.''
        \6\ Gerry Smolka, Leigh Purvis, and Carols Figueiredo, ``Health
    Care Reform: What's at Stake for 50- to 64-Year-Olds,'' AARP Public
    Policy Institute, Insight on the Issues #124, March 2009.

            the graham-cassidy bill could make coverage unaffordable
        The legislation provides that, beginning in 2020, individuals would
    no longer qualify for Federal tax credits or subsidies. Instead, States
    would receive a block grant of Federal funds intended to cover the
    State's portion of Advance Premium Tax Credits (APTCs), Cost-Sharing
    Reduction subsidies (CSRs), Medicaid expansion funds, and funds from
    the Basic Health Insurance program.

        States could use these funds to implement their own insurance
    programs and the coverage could vary significantly by State.
    Unfortunately, compared to CBO projections of current law spending,
    funds available under the block grants would be substantially below the
    amounts that would be available for Medicaid and health insurance
    subsidies under current law, shortchanging States and almost
    guaranteeing that the level of subsidies will not be maintained.

        Further, the legislation is silent regarding any consumer
    protections that a State should implement in designing their individual
    State insurance program. There are no requirements that a State
    maintain the same level of subsidies for individuals, thus leaving
    individuals vulnerable to higher out-of-pocket costs under the Graham-
    Cassidy bill than would be incurred under current law. Compared to
    Congressional Budget Office projections of current law spending, the
    funds that would be made available under the block grants are
    substantially below the amounts that would be available for Medicaid
    and health insurance subsidies under current law, shortchanging States
    and almost guaranteeing that the level of subsidies will not be
    maintained.

        In addition, the block grant is only available to States until the
    end of 2026, after which the block grant is eliminated leaving the
    States to shoulder 100 percent of the cost of administering their
    health insurance program. With Federal funds eliminated, it is likely
    that any State program enacted under Graham-Cassidy would be either
    severely curtailed or eliminated entirely, depending on the State
    budget.
            the graham-cassidy bill would significantly cut medicaid
        Medicaid is the health insurance safety-net for lower income
    Americans, offering quality, affordable, and comprehensive health care
    coverage to over 74 million people \7\--including those with cancer,
    those who will be diagnosed with cancer, and cancer survivors. Medicaid
    provides important preventive screenings and treatment services for
    cancer patients and survivors. It is projected that in 2017,
    approximately 2.3 million patients (infants to age 64) with cancer or a
    history of cancer will rely on Medicaid and the Children's Health
    Insurance Program (CHIP) for their insurance--a 31 percent increase
    from 2013.\8\ Out of the 2.3 million enrollees, 540,000 are estimated
    to be receiving Medicaid coverage under the current law's Medicaid
    expansion. Additionally, Medicaid provides coverage for children--with
    approximately one-third of pediatric cancer patients enrolled in
    Medicaid at the point of diagnosis.\9\
    ---------------------------------------------------------------------------
        \7\ Medicaid.gov. June 2017 Medicaid and CHIP enrollment data
    highlights. Accessed September 18, 2017. https://www.medicaid.gov/
    medicaid/program-information/medicaid-and-chip-enrollment-data/report-
    highlights/index.html. Note: Numbers include both Medicaid and
    Children's Health Insurance Program (CHIP) enrollment.
        \8\ Analysis provided to ACS CAN by Avalere Health. Funding for
    Medicaid patients with cancer under BCRA Discussion Draft. Analysis
    performed June 2017.
        \9\ Id.

        The Graham-Cassidy bill would significantly cut funding for
    Medicaid. The bill would end the expansion of Medicaid by 2020 and
    reduce Medicaid funding for the traditional Medicaid population--
    including seniors, people with disabilities, and low-income families
    with children--by imposing a per-capita cap. The cap could potentially
    ---------------------------------------------------------------------------
    limit enrollment and services.

        The proposed repeal of Medicaid expansion along with significant
    Federal funding changes could leave the Nation's lowest income cancer
    patients and survivors without access to preventive, curative, and
    follow-up health care, as States struggle to decide how to manage their
    Medicaid populations with less Federal dollars. For low-income
    Americans, the changes proposed by Graham-Cassidy could be the
    difference between an early diagnosis when outcomes are better and
    costs are less or a late diagnosis where costs are higher and survival
    less likely.
                  the graham-cassidy time frame is unworkable
        Under the legislation States would be required to create a new
    program for their individual health insurance market within 2 years.
    The creation and implementation of new mechanisms for providing
    coverage and revising State insurance rules will require a significant
    investment in terms of time and resources from State governments and,
    in many cases, may require enactment of State laws and/or regulations.
    Many State legislatures are already out of session and are not slated
    to return until the beginning of next year, which would leave little
    time for a State to have a meaningful opportunity for input before
    enacting its new marketplace.

        Moreover, the changes to the health insurance individual market
    called for under the Graham-Cassidy proposal would require significant
    education and outreach to consumers. Because these programs would be
    administered at the State level, the same State agencies that are
    responsible for creating and implementing their marketplace would also
    be tasked with consumer education and outreach, putting additional
    strain on these already overly burdened entities.
                                 moving forward
        For the reasons previously stated, ACS CAN is opposed to the
    Graham-Cassidy legislation and urges the committee to reject the
    legislation. At the same time, we recognize that the current law will
    require additional fixes.

        We commend the bipartisan efforts of Senators Alexander and Murray
    as they work through regular order to find bipartisan solutions that
    benefit patients. Such a process must ensure that individuals with pre-
    existing conditions are protected, that essential health benefits are
    maintained, and that coverage is made affordable for individuals. We
    urge this committee to build upon their work and focus on practical,
    bipartisan efforts to strengthen health-care coverage.

        ACS CAN stands ready to work with the committee and all members of
    Congress to develop and implement policies that will improve the
    health-care system for the millions of individuals who are in active
    cancer treatment and cancer survivors.

                                     ______

              Questions Submitted for the Record to Dick Woodruff
                     Questions Submitted by Hon. Ron Wyden
                            pre-existing conditions
        Question. During the hearing on September 25th, Senator Cassidy
    stated the following regarding the protection of those with pre-
    existing conditions: ``The statute specifically says that the Governor
    must establish that those with pre-existing conditions have access to
    `adequate and affordable' coverage.'' He also stated on September 20th
    on CNN: ``We protect those with pre-existing conditions. . . . The
    protection is absolutely the same. There's a specific provision that
    says that if a State applies for a waiver, it must ensure that those
    with pre-existing conditions have affordable and adequate coverage.''
    He has made this claim that those with pre-
    existing conditions would be protected under his law to the same extent
    that they are under current law several times.

        Do you agree with Senator Cassidy that those with cancer or other
    conditions would have the same protections as under current law?

        Answer. Cancer patients would not have the same protections that
    they have under current law. The Graham-Cassidy proposal rolls back the
    non-discrimination protections in the individual and small group
    market. It would allow States to waive the current-law requirement that
    prohibits health plans from considering an individual's health history
    when determining premiums. For an individual in active cancer treatment
    or a cancer survivor, the health plan could have no limit on the amount
    of the monthly premium. Products would be unaffordable to cancer
    patients and other individuals who required--or were anticipated to
    require--high-cost treatments.

        The Graham-Cassidy bill would also allow States to waive some or
    all of the essential health benefits (EHBs) requirements. Insurance
    should cover the major health needs of cancer patients and survivors,
    including hospitalization, specialty cancer care, physician services,
    prescription drugs, rehabilitative care, screenings, and mental health
    services. Eliminating EHB requirements would encourage insurers to
    create ``basic'' policies that do not include explicitly defined
    comprehensive benefits, thus putting cancer patients and survivors at
    risk of inadequate treatment, and could jeopardize access to necessary
    preventive care, treatment, and follow-up care.

        In addition, current law ties the prohibition on lifetime and
    annual benefit limits to the EHB requirements, by eliminating the EHB
    requirements, the Graham-
    Cassidy proposal could also eliminate these other important
    protections. Health plans could once again impose lifetime or annual
    limits on benefits provided to enrollees, increasing the chances that a
    diagnosis of cancer or other serious condition could lead to severe
    financial hardships for many Americans.

        Finally, the legislation would allow States to waive the current
    three-to-one age rating requirements that limit what insurers can
    charge in premiums on the basis of the enrollee's age. While cancer can
    be diagnosed at any age, the incidence of cancer increases with age.
    According to the American Cancer Society, 85 percent of all cancers in
    the United States are diagnosed in people 50 years of age and older.
    Thus, increasing the age rating bands would mean that older individuals
    (those more at risk of developing cancer) would face significantly
    higher health-care premiums or be priced out of the market completely.
    Prior to the enactment of the current law's age rating band
    restrictions, older adults faced significant problems accessing health
    insurance coverage, in large part because insurers in many States were
    permitted to charge older enrollees many times what they charged
    younger ones, (compounded by the ability of issuers to use health
    status when setting premiums).

        Question. What do you believe would be the impact of this law on
    cancer patients' and survivors' ability to access and afford needed
    care?

        Answer. Graham-Cassidy could negatively impact the 1.6 million
    Americans who will be diagnosed with cancer this year and the
    additional 15.5 million Americans living today with a history of
    cancer. For these Americans access to affordable health insurance is a
    matter of life or death. Research from the American Cancer Society has
    shown that uninsured Americans are less likely to get screened for
    cancer and thus are more likely to have their cancer diagnosed at an
    advanced stage when survival is less likely and the cost of care more
    expensive.

        We are deeply concerned that cancer patients and other patients
    would lose their insurance if the Graham-Cassidy legislation is
    enacted. If States elect to make available policies without EHB
    requirements, protection against annual and lifetime caps could be
    eliminated because the caps are tied to those benefits. Insurers could
    be allowed to segment the risk pool by pricing high-risk patients out
    of the market. Insurers could be allowed to offer plans that don't
    cover the treatment or all the services that seriously ill patients or
    survivors of cancer need. The plan they need may not even be offered,
    or it may be too expensive for any of them to afford.

        Again, we know that patients without coverage have their cancers
    discovered later, they are more expensive to treat, and they have lower
    chance of survival. They forego preventive care, they choose between
    doctor-recommended treatments because they can't afford everything
    they're supposed to have. Their medical costs force them into debt and
    sometimes into bankruptcy. If enacted, the Graham-
    Cassidy legislation would be a disaster for patients with cancer,
    survivors of cancer, and other Americans with serious illness.

        Question. Prior to the ACA, what was the impact of annual and
    lifetime caps on cancer patients?

        Answer. Prior to the enactment of the ACA cancer patients and
    survivors were often affected by annual and/or lifetime benefit caps
    which limited their benefits and thus their ability to access needed
    and recommended treatment and other health-care benefits. These caps
    were the norm in the individual and small group markets, but also
    existed is some employer based plans as well affecting millions of
    Americans. The ACA, by requiring qualified plans to cover 10 specific
    Essential Health Benefits and abolishing caps on those benefits,
    effectively made sure that insurance actually covers Americans when
    they get sick without an arbitrary monetary cap on their care.

        Among the many patient stories reported to the American Cancer
    Society in 2010 about the inequity of benefit caps, was the experience
    of the 10 year-old leukemia patient from Ohio who had reached the $1
    million lifetime benefit cap imposed on her father's employer-based
    health-care plan. This family was forced to delay their daughter's hip
    surgery, which was necessitated by the side effects of her cancer
    treatment. At the time ACS learned of her condition, she was confined
    to a wheelchair while her family searched for alternative ways to
    finance her surgery.

        No family in America expects their child to be diagnosed with a
    serious disease like cancer. But the experience of this young girl was
    not unique. Americans with serious and chronic illnesses routinely
    exhausted their limited benefits which severely impacted their ability
    to access needed health care. Elimination of the caps by the ACA ended
    that terrible situation.

                                     ______

                   Questions Submitted by Hon. Sherrod Brown
        Question. Creating thoughtful, responsible, and effective
    legislation requires the input of diverse subject matter experts,
    representing different stakeholder communities. The Graham-Cassidy
    proposal is a remake of the entire U.S. health-care system, which
    necessitates input from groups like advocacy organizations,
    professional societies, or other reputable associations.

        Were you or representatives of the American Cancer Society Cancer
    Action Network or other advocacy organizations you work with, consulted
    on this legislation?

        Answer. The American Cancer Society Cancer Action Network (ACS CAN)
    was pleased to be invited to testify about the legislation before the
    Finance Committee on September 25th. Prior to that event, however,
    neither I nor anyone employed by ACS CAN, received any communication or
    consultation, or request for such, from the authors of the legislation
    or their staffs. I can't speak with complete knowledge about the extent
    of consultation by the authors with other advocacy organizations we
    work with, but my understanding is that there was none.

        Question. Are you convinced that individuals with preexisting
    conditions will be protected under this bill?

        Answer. No, individuals with preexisting conditions will not be
    protected under the Graham-Cassidy legislation. I'll take the liberty
    of repeating my response to a similar question asked by Senator Wyden.

        Cancer patients would not have the same protections that they have
    under current law. The Graham-Cassidy proposal rolls back the non-
    discrimination protections in the individual and small group market. It
    would allow States to waive the current-law requirement that prohibits
    health plans from considering an individual's health history when
    determining premiums. For an individual in active cancer treatment or a
    cancer survivor, the health plan could have no limit on the amount of
    the monthly premium. Products would be unaffordable to cancer patients
    and other individuals who required--or were anticipated to require--
    high-cost treatments.

        The Graham-Cassidy bill would also allow States to waive some or
    all of the essential health benefits (EHBs) requirements. Insurance
    should cover the major health needs of cancer patients and survivors,
    including hospitalization, specialty cancer care, physician services,
    prescription drugs, rehabilitative care, screenings, and mental health
    services. Eliminating EHB requirements would encourage insurers to
    streamline ``basic'' policies that do not include explicitly defined
    comprehensive benefits, thus putting cancer patients and survivors at
    risk of inadequate treatment, and could jeopardize access to necessary
    preventive care, treatment, and
    follow-up care.

        In addition, current law ties the prohibition on lifetime and
    annual benefit limits to the EHB requirements, by eliminating the EHB
    requirements, the Graham-
    Cassidy proposal could also eliminate these other important
    protections. Health plans could once again impose lifetime or annual
    limits on benefits provided to enrollees, increasing the chances that a
    diagnosis of cancer or other serious condition could lead to severe
    financial hardships for many Americans.

        Finally, the legislation would allow States to waive the current
    three-to-one age rating requirements that limit what insurers can
    charge in premium on the basis of the age of the enrollee. While cancer
    can be diagnosed at any age, the incidence of cancer increases with
    age. According to the American Cancer Society, 85 percent of all
    cancers in the United States are diagnosed in people 50 years of age
    and older. Thus, increasing the age rating bands would mean that older
    individuals (those more at risk of developing cancer) would face
    significantly higher health-care premiums or be priced out of the
    market completely. Prior to the enactment of the current laws age
    rating band restrictions, older adults faced significant problems
    accessing health insurance coverage, in large part because insurers in
    many States were permitted to charge older enrollees many times what
    they charged younger ones, (compounded by the ability of issuers to use
    health status when setting premiums).

                                     ______

                     Prepared Statement of Hon. Ron Wyden,
                           a U.S. Senator From Oregon
        Nobody has to buy a lemon just because it's the last car on the
    lot. The Graham-Cassidy bill is a health-care lemon; a disaster in the
    making. The fact that it's the last Republican repeal plan standing
    doesn't make it acceptable. It'll be a nightmare for tens of millions
    of Americans. It makes a mockery of the Trump promises of better
    insurance for everybody at much lower costs.

        This bill's sponsors aren't even waiting for the official facts and
    figures from the independent scorekeepers. Version after version after
    version of the bill is floating around, and the pork parade is up and
    running. The process that has brought
    Graham-Cassidy to the brink of passage would be laughable if the well-
    being of tens of millions of Americans wasn't hanging in the balance.

        I want to blow the whistle on a few key points right at the outset
    of today's hearing. First off, the American people do not want this
    bill. In the last few days, the committee has received more than 25,000
    comments from people who want it stopped. As with every other version
    of Trumpcare, this proposal is about as popular as prolonged root canal
    work.

        There's just one group cheering this bill on--the right-wing
    Republican donor class. The big donors wanted the entire ACA thrown in
    the trash can from the beginning. But that didn't work, since it turns
    out it's bad policy to take health coverage away from tens of millions
    of Americans and raise costs for virtually everybody else.

        So the new strategy you see in Graham-Cassidy is repeal by a
    thousand cuts. It'll be national repeal and state-by-state repeal. The
    heart of this bill is a scheme that punishes States that have worked
    hard to build strong private markets and make health care more
    affordable. It rewards the States where lawmakers have sat on their
    hands--where they've spent years loudly rejecting the opportunity to
    improve the lives of millions of the people they serve.

        But that's obviously not a proposition that will garner much
    support. So instead, what the committee will hear today is a lot of
    hocus-pocus talk about ``flexibility.'' The story goes, it's
    flexibility for the States, more control at the local level, and
    everybody will somehow be better off. But let's be up-front about what
    that'll mean in practice.

        The real flexibility created by this bill is the option for States
    to do worse--so that Americans are forced to pay more money for less
    care.

        Right off the top, Graham-Cassidy guts funding for health care in
    its new block grants. Then, Governors and State legislators building
    new health insurance systems will have to make Hunger Games choices,
    deciding which vulnerable groups will get the care they need and which
    will not.

        The ironclad, loophole-free, guaranteed protection for those with
    pre-existing conditions under the Affordable Care Act will be gone. The
    bill's sponsors will tell you otherwise, but the facts are the facts.

        The guaranteed protection that nobody will be gouged due to a
    catastrophic illness like cancer will be gone. That's because this bill
    reopens the door to annual and lifetime limits on care.

        The guarantee of essential health benefits will be gone. That means
    prescription drug coverage will be on the chopping block. Maternity
    care will be on the chopping block. Mental health and substance abuse
    treatment will be on the chopping block, along with much more. The
    guarantee that nobody can be charged higher premiums because of their
    health status or their job will be gone under this bill.

        So bottom line, this bill is an attack on vital consumer
    protections. It revives some of the worst insurance company abuses that
    were banned under the ACA. And it will make the health care that many
    people need unaffordable. So no, it does not protect people with pre-
    existing conditions.

        What this bill does include are a few toothless lines about
    affordability and access. That's supposed to be enough to protect those
    with pre-existing conditions. But there's no enforcement mechanism--no
    tough standards or strict definitions. And the watered-down protections
    that States put together for new insurance systems will get a rubber
    stamp from Team Trump.

        Once again in Graham-Cassidy, the attack on women's health
    continues. Hundreds of thousands of women will lose the right to see
    the doctors of their choosing--that's what happens when you defund
    Planned Parenthood.

        The traditional Medicaid program--which is a lifeline for people
    with disabilities, seniors, kids and pregnant women--suffers draconian
    cuts. An aging baby boomer who's suffered a stroke might be told they
    can't get the help they need--nursing home care might no longer an
    option for them. The community-based program that offers care to people
    at home where they're most comfortable might disappear. Special
    education programs funded by Medicaid for vulnerable kids could be put
    in jeopardy.

        A few final points. The process that's led to this moment has been
    an abomination. What's happening this afternoon isn't a serious
    hearing--it's a talking point. This is a scheme to allow Senators to go
    home to fearful constituents and offer false reassurances that the
    Graham-Cassidy bill got a fair examination and went through regular
    order. But it won't be true.

        Senate Republicans haven't gotten answers to the most basic
    questions about the real-world effects of their bill. How many people
    will lose coverage? By how much will premiums increase? Will health-
    care markets survive next year? The independent scorekeepers at the
    budget office have told us that it'll be several weeks before they can
    put forward estimates of coverage and costs. And their job keeps
    getting tougher. The bill is changing by the hour as the majority
    throws around in the scramble for votes.

        And why the rush job, you might ask. It's because the coach turns
    back into a pumpkin at the end of the month. That's when the
    reconciliation fast-track to pass this partisan bill expires.

        Finally, this committee right now ought to be working on bipartisan
    priorities, such as getting our CHIP bill over the finish line. There's
    work to be done on stabilizing the private insurance markets, that
    ought to be happening with our sister committee. Instead, what's on
    offer with Graham-Cassidy would trigger a health-care disaster--a death
    spiral in the insurance markets as tax credits and cost sharing
    payments go away, as healthy people flee and costs go into the
    stratosphere.

        My Democratic colleagues and I have done and will continue to do
    everything we can to stop this dreadful proposal in its tracks.

                                     ______

                              United States Senate

                              COMMITTEE ON FINANCE

                           Washington, DC 20510-6200

                               September 22, 2017

    The Honorable Orrin Hatch
    Chairman
    Committee on Finance
    U.S. Senate
    Washington, DC 20510

    Dear Chairman Hatch:

    We respectfully request that the Finance Committee's September 25th
    hearing on the Graham-Cassidy bill be held in one of the Senate's
    larger hearing rooms rather than in our regular hearing room, Dirksen
    215. This would be in keeping with the extraordinary importance of the
    hearing and with the committee's usual practice with respect to matters
    of such intense public interest.

    The Graham-Cassidy bill would radically reshape the American health-
    care system, and the Senate Finance Committee's hearing will be the
    first and only opportunity for this bill to be debated in public before
    it is due to be considered on the Senate floor. There is enormous
    interest in the hearing, from the general public, groups representing
    affected interests, and the press. We should do everything we can to
    accommodate as many members of the public and the press as possible.

    When considering the Affordable Care Act, the Senate Finance Committee
    engaged in a bipartisan, collaborative process which included more than
    50 hearings and roundtables and full 8 days marking up the legislation.
    We engaged in this process because we believed our work should be
    accountable to the American people. We also wanted the Affordable Care
    Act to reflect a serious, carefully considered effort involving
    stakeholder input and expert opinions, independent of ideology, because
    we knew others had important contributions that would make the bill
    stronger. While one hearing is better than none, this process reflects
    none of the rigor that resulted in the passage of the Affordable Care
    Act.

    During consideration of the Affordable Care Act, the Senate Finance
    Committee held multiple hearings in large meeting rooms, including Hart
    216 and Dirksen 108. The committee held its 8-day markup, the longest
    in committee history, in Hart 216. Additionally, the Health, Education,
    Labor, and Pensions Committee recently held four hearings in Hart 216
    that attracted significant attention from the media and press to
    discuss a much narrower legislative objective.

    Given that Monday's hearing will be the only venue for public debate on
    the
    Graham-Cassidy proposal, we feel it is appropriate that hearing be
    moved to a larger Senate meeting room. We hope that you can accommodate
    this modest request.

    Sincerely,

    Ron Wyden
    Ranking Member
    Committee on Finance

    Debbie Stabenow                     Maria Cantwell
    U.S. Senator                        U.S. Senator

    Bill Nelson                         Robert Menendez
    U.S. Senator                        U.S. Senator

    Thomas R. Carper                    Benjamin L. Cardin
    U.S. Senator                        U.S. Senator

    Sherrod Brown                       Michael F. Bennet
    U.S. Senator                        U.S. Senator

    Robert P. Casey, Jr.                Mark R. Warner
    U.S. Senator                        U.S. Senator

                                     ______

                              United States Senate

                              COMMITTEE ON FINANCE

                           Washington, DC 20510-6200

                               September 25, 2017

    The Honorable Orrin Hatch
    Chairman
    Committee on Finance
    U.S. Senate
    Washington, DC 20510

    Dear Chairman Hatch:

    We respectfully invoke our right, under Senate Rule XXVI, for a
    majority of the minority members of the Finance Committee to call for
    an additional day of hearings with respect to the Graham-Cassidy
    proposal.

    Today's hearing is the first hearing any Senate committee has held on
    the
    Graham-Cassidy bill or, for that matter, any previous version of bills
    to ``repeal and replace'' the Affordable Care Act. A single hearing
    does not give the committee, much less the public, sufficient time to
    consider a major bill affecting one-sixth of the economy and the lives
    of hundreds of millions of Americans. This is particularly the case
    given that three different version of the bill have been released over
    the past 24 hours.

    This process contrasts sharply with the Finance Committee's process
    during the consideration of the Affordable Care Act, when we held 11
    days of hearings, followed by 8 days of markup during which 133
    amendments were considered and 44 adopted, followed by 23 days of
    debate on the Senate floor.

    This call for additional witnesses is not intended to delay. We believe
    that one or two panels of witnesses can be convened to testify
    tomorrow, drawn from among groups representing patients, physicians,
    nurses, hospitals, insurance companies, state program administrators,
    the Congressional Budget Office, and health-care economists.

    Thank you for attention to this matter.

    Sincerely,

    Ron Wyden
    Ranking Member
    Committee on Finance

    Debbie Stabenow                     Claire McCaskill
    Michael F. Bennet                   Sherrod Brown
    Benjamin L. Cardin                  Robert P. Casey, Jr.
    Maria Cantwell                      Mark R. Warner
    Robert Menendez                     Thomas R. Carper
    Bill Nelson
                                     ______

                                 Communications

                                  ----------

                       Letter Submitted by Marilyn Adams

                               September 24, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Building
    Washington, DC 20510-6200

    Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
    Monday, September 25, 2017

    Dear Senator Hatch and members of the Senate Finance Committee:

    I am writing to give my perspective on the Graham-Cassidy-Heller-
    Johnson bill. I have been frankly amazed as I have watched Congress
    repeatedly trying to slap together a bill and ram it through with
    clearly little or no regard for discussion, review of the facts, a full
    report from the CBO, etc. It seems obvious that your only goal is to
    ``repeal the ACA'' with zero regard for the actual impact your actions
    will have on health care for the American people you have been elected
    to represent.

    I urge you to stop playing these games with our health and our lives,
    slow down, and actually do the job you were elected to do. Please work
    to find a solution that balances fiscal responsibility with the good of
    the American people (your constituents) and take the time to get it
    right. We will respect you for it and may even vote you back into
    office.

    I had hope when I heard there was a bipartisan group trying to develop
    a plan together, and then all of a sudden here we are trying to shove
    through yet another health-care bill at the last minute. I am guessing
    most members of Congress don't even understand what is in the bill or
    what impact it will have on their constituents. How could they possibly
    understand it when we don't even have a full report yet from the CBO?

    Please stop this nonsense and do the right thing! You were elected to
    represent us, so please show some integrity and do the job you were
    elected to do. I realize many of you do not know or understand this,
    but people's lives are in your hands. Please don't blow it!

    Respectfully,

    Marilyn Adams

                                     ______

                   Alliance of Community Health Plans (ACHP)

                         1825 Eye Street, NW, Suite 401

                              Washington, DC 20006

                                p: 202-785-2247

                                f: 202-785-4060

                             https://www.achp.org/

    September 22, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Building
    Washington, DC 20510-6200

    On behalf of the 19 million Americans and the communities we serve, I
    write to express our profound disappointment that bipartisan efforts to
    stabilize our health-care system have been halted. The Graham Cassidy-
    Heller-Johnson legislation being considered by the Senate would
    jeopardize the health of millions of working Americans, and we cannot
    support the bill.

    Over the course of 2017, ACHP and its member plans have worked with
    both houses of Congress and both sides of the aisle to put forward
    measured and proven ways to expand coverage, stabilize the market and
    make our nation's health-care system more affordable. ACHP members
    believe in the importance of preventive and comprehensive care and have
    consistently offered robust coverage, regardless of geographic location
    or health status of their members.

    This proposal would significantly impact the health of our communities,
    hurting our neighbors, friends, and employees. It puts in jeopardy the
    coverage gains won over the past few years and the critical consumer
    safeguards provided by essential health benefits and protections
    afforded by a ban on pre-existing conditions.

    Millions of working Americans, many making an average of just $18,000
    per year, would suffer under this bill from the loss of critical cost-
    sharing reduction payments. While this debate is going on in
    Washington, millions of Americans across the country are living month
    to month wondering if they will have access to coverage this year or
    next.

    We are deeply troubled by the proposed changes to Medicaid. Graham-
    Cassidy-
    Heller-Johnson fundamentally erodes the Medicaid safety net and
    significantly alters the gains in eligibility, coverage and benefits
    achieved in almost every community nationwide, and does little to
    mitigate the impact on local hospitals and economies.

    While we support greater state flexibility, it is imperative that
    capitation rates be actuarially sound and sufficient to ensure
    beneficiary access to the full range of health-care services and a
    stable Medicaid market. Further, it is critical that any health reform
    effort harness the innovative and competitive market solutions driven
    by the private sector. We fully support preserving the public-private
    partnership unique to the American system.

    We have supported the Senate HELP Committee as it worked to develop a
    limited bipartisan bill that would stabilize the individual insurance
    market. The health-care needs of Americans were well served by the
    collaborative and inclusive way the hearings were held and the diverse
    viewpoints aired during witness testimony. Health care should provide
    Americans peace of mind. Rather than creating certainty in the lives of
    the American people, Graham-Cassidy-Heller-Johnson takes us in the
    opposite direction.

    As always, ACHP member plans stand ready to work with you and members
    of both parties to develop market-tested solutions based on our many
    years of real-world experience to improve the health of communities
    across the nation. If you or your staff have any questions or would
    like to discuss these issues further, please do not hesitate to contact
    me at cconnolly@achp.org or 202-785-2247.

    Sincerely,

    Ceci Connolly
    President and CEO

                                     ______

                              The ALS Association

                          1275 K Street, NW, Suite 250

                              Washington, DC 20005

                                  www.alsa.org

    On behalf of people living with ALS and their caregivers, The ALS
    Association submits this statement for the record to oppose the
    amendment to the American Health Care Act (ARCA) proposed by Senators
    Lindsey Graham, Bill Cassidy, Dean Heller, and Ron Johnson.

    The ALS Association, along with leading patient and provider groups,
    opposes the Graham-Cassidy proposal because it does not meet our core
    set of principles that health care must be accessible, affordable, and
    adequate.

    Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative
    disease that affects nerve cells in the brain and the spinal cord. The
    progressive degeneration of the motor neurons in ALS patients leads to
    disability and death of patients living with ALS--with an average life
    span of 2 to 5 years after diagnosis. The prevalence of ALS in the
    military is twice that of civilians.

    The mission of The ALS Association is to discover treatments and a cure
    for ALS, and to serve, advocate for, and empower people affected by ALS
    to live their lives to the fullest. Affordable, adequate care is vital
    to the patients we represent. Our Chapters work closely with Certified
    Centers of Excellence that offer multidisciplinary ALS clinics as well
    as provide a range of free services for people living with ALS and
    their families including: support groups, care services coordinators,
    equipment loan programs, assistive technology support, and respite care
    grants. The ALS Association is a non-partisan organization that leads
    the fight to treat and cure ALS through global research and nationwide
    advocacy.

    Unfortunately, the Graham-Cassidy proposal would negatively impact the
    access of people living with ALS and many Americans to adequate and
    affordable health coverage and care.

          Patient Protections: First, it would undermine nationwide
    protections for patients by offering states the ability to allow
    insurance companies to charge higher prices and place limitations on
    coverage (such as annual or lifetime caps) for those with preexisting
    conditions.

          Premium Assistance: Second, it would remove current premium
    assistance to help lower-income and moderate income families to afford
    to purchase the insurance that they need. This is especially important
    for people living with ALS who lose their job and insurance coverage
    after an ALS diagnosis but need to purchase health insurance for
    themselves and their families. Without premium assistance, many of
    these families could face serious financial stress or bankruptcy.

          Medicaid: Third, it would dramatically cut access to Medicaid
    health care by cutting and capping funds through block grants. Under
    Graham-Cassidy, states would be forced to change eligibility to fit
    their block grant funding or close enrollment in Medicaid when funds
    run out. This impacts not only people living with ALS who depend solely
    on Medicaid for coverage but also those patients who receive both
    Medicare and Medicaid.

          Veterans: Medicaid cuts would also harm veterans, as reported by
    2017 research from the RAND Corporation, entitled ``Veterans' Health
    Insurance Coverage under the Affordable Care Act and Implications of
    Repeal for the Department of Veterans Affairs.'' Although many veterans
    do receive health care through the Department of Veterans Affairs (VA),
    a good number do not qualify or are unable to access VA care for a
    number of reasons. The RAND report notes that Medicaid expansion and
    marketplaces helped address gaps in health insurance coverage and
    contributed to lower rates of un-insurance among veterans. This is
    particularly important because the incidence of ALS in individuals is
    much higher for those who have served in the military.

    While we urge the Senate to reject Graham-Cassidy, we understand that
    improvements to the current system are needed. We greatly appreciate
    the bipartisan effort being spearheaded by Senators Alexander and
    Murray. In hearings in the Senate Committee on Health, Education,
    Labor, and Pensions, state regulators and governors of both parties
    offered solutions to help stabilize the insurance market. We urge the
    Finance Committee to join in these efforts to address issues within its
    jurisdiction to develop bipartisan solutions to these complex issues.

    In closing, we encourage Congress to reject the Graham-Cassidy proposal
    because it will negatively impact people living with ALS who are part
    of the 133 million Americans with chronic diseases and disabilities and
    their family caregivers.

    For More Information Contact:

    Kathleen Sheehan, Vice President Public Policy
    ksheehan@alsa-national.org (202) 591-5319
    Stephen Goewey, Vice President Communications
    sgoewey@alsa-national.org (202) 246-1619

                                     ______

                             ALS Association et al.

    Contact: Katie.berge@heart.org
    1150 Connecticut Avenue, NW
    Washington, DC 20036
    202-785-7900

    Our organizations stand together in unified opposition to the
    legislation being considered by the Senate Finance Committee today.
    This proposal to overhaul our nation's health care system fails to
    serve the needs of the millions of patients and consumers we represent.

    A group of patient, provider, and consumer groups came together earlier
    this year to engage with Congress in order to ensure that Members
    understand how any legislation to repeal and replace the Affordable
    Care Act would impact the individuals and families we represent. We
    agreed that to gain our support, any proposal put forward must meet a
    core set of criteria by providing care that is accessible, affordable,
    and adequate. It is clear that the legislation before the Senate
    Finance Committee today falls far short of meeting these standards and
    would in fact do more harm than good. We stand united in opposition to
    the proposal put forward by Senators Lindsey Graham (R-SC), Bill
    Cassidy (R-LA), Dean Heller (R-NV), and Ron Johnson (R-WI) because of
    the negative consequences it will have for patients' access to adequate
    and affordable health care coverage.

    This bill would drastically cut funding for the Medicaid program, roll
    back important essential health benefit protections, reverse current
    protections that ensure coverage for people with preexisting
    conditions, open the door to lifetime caps on coverage, and endanger
    access to critical care for millions of Americans. Much of the proposal
    is just a repackaging of the most problematic provisions of the Better
    Care Reconciliation Act (BCRA), which we also opposed.

    On Friday, the Brookings Institution, a trusted independent and non-
    partisan organization, released a report estimating that 21 million
    fewer people will be covered from 2020-2026. This unprecedented loss of
    coverage is completely unacceptable.

    Affordable, adequate care is vital to the patients we represent and can
    mean the difference between life and death. It is clear to our
    organizations that this legislation fails to provide Americans with
    what they need to maintain their health. Our organizations, instead,
    strongly support improving our system of care through a rigorous and
    transparent bipartisan legislative process. It is time for Congress to
    put the interest of patients and consumers before politics. The Graham-
    Cassidy proposal will have devastating impacts on those we represent
    and we urge every member of the Senate to oppose this legislation.

    ALS Association                     American Diabetes Association
    American Heart Association          American Lung Association
    Arthritis Foundation                Consumers Union
    Crohns and Colitis                  Cystic Fibrosis Foundation
    Epilepsy Foundation                 Family Voices
    Lutheran Services in America        March of Dimes
    Muscular Dystrophy Association      National Health Council
    National Multiple Sclerosis Society National Organization for Rare
                                        Disorders (NORD)
    WomenHeart: The National Coalition
    for Women With Heart Disease

                                     ______

                  American Academy of Family Physicians (AAFP)

                    1133 Connecticut Avenue, NW, Suite 1100

                           Washington, DC 20036-4305

                                 (800) 794-7481

                                 (202) 232-9033

    September 25, 2017

    The Honorable Orrin Hatch           The Honorable Ron Wyden
    Chairman                            Ranking Member
    U.S. Senate                         U.S. Senate
    Committee on Finance                Committee on Finance
    Washington, DC 20510                Washington, DC 20510

    Dear Chairman Hatch and Ranking Member Wyden:

    On behalf of the American Academy of Family Physicians (AAFP) and the
    129,000 members we represent, I respectfully submit this letter to the
    Senate Finance Committee to assist you and members of the Committee in
    your evaluation and consideration of the Graham-Cassidy-Heller-Johnson
    (GCHJ) proposal.

    Thank you for holding this hearing and providing an opportunity for
    organizations, such as the AAFP, to share with the Committee our views,
    opinions, and recommendations on the GCHJ proposal and our current
    health-care system.

    The AAFP has significant concerns with the Graham-Cassidy-Heller-
    Johnson bill and the negative impact it would have on individuals,
    families, and our health-care system overall. The changes proposed by
    GCHJ, according to numerous independent and non-partisan organizations,
    would result in millions of currently insured individuals losing their
    health-care coverage. Furthermore, it would destabilize insurance
    markets, allow for discrimination against people based on their health
    conditions, rollback vital insurance and consumer reforms, cause
    increased premiums and deductibles for individuals and families, and do
    nothing to reduce the costs of health care. For these reasons, we
    oppose the Graham-Cassidy-Heller-Johnson proposal.

    We urge the Senate to set aside efforts to repeal the ACA and focus on
    improving current law in ways that expand access to affordable
    coverage, reconnect patients back to primary care, stabilize insurance
    markets, and begin to lower health-care costs.

    Sincerely,

    John Meigs, Jr., M.D., FAAFP
    Board Chair

    Background

    The AAFP first adopted a policy on health-care coverage for all in
    1989. Research shows that the two most telling factors indicative of
    individual health is health-care coverage and a continuous relationship
    with a primary care physician. Individuals who have a long-term,
    continuous relationship with a physician, tend to be healthier and have
    lower health-care costs per capita than those who lack such a
    relationship. A key to establishing and maintaining a long-term
    relationship with a physician is continuous health-care coverage.

    The GCHJ proposal, in its current form, is not consistent with AAFP
    policies on health-care coverage and, in our opinion, falls well short
    of achieving our goal of ensuring that every American has health-care
    coverage and improved and affordable access to a family physician.

    The AAFP recognizes that current law and our current health-care system
    has flaws and is failing to achieve some of our shared goals,
    especially those aimed at slowing the escalating costs of health care.
    However, we also recognize that tremendous improvements have been made
    to our health-care system as a result of the enactment of the
    Affordable Care Act in 2010. In fact, just this month, the U.S. Census
    Bureau released a report that showed the U.S. uninsured rate fell to a
    historic low of 8.8 percent in 2016. Since enactment of the ACA, we
    have seen significant decreases in our national uninsured rate,
    especially among vulnerable populations. We should be celebrating this
    accomplishment and seeking ways to extend health-care coverage to those
    who still lack it--not pursuing legislation that would drive up the
    number of uninsured.

    The GCHJ proposal, if enacted, would end the Medicaid expansion and its
    financing and fundamentally alter the Medicaid program through
    significant changes to that programs financing. In addition, the
    proposal seeks to eliminate the tax subsidies currently available for
    low to moderate income individuals purchasing their coverage on the
    individual market. The bill attempts to replace these two coverage
    opportunities through the establishment of an overly complex
    methodology that would redistribute current federal financial support
    through a state-by-state block grant system.

    We are troubled by the fact that the GCHJ proposal appears to punish,
    financially, those states that have taken the most meaningful steps to
    expand coverage over the past few years and rewards those that chose to
    forgo federal dollars that would have assisted their citizens in
    securing health-care coverage. Our goal as a country should be to
    increase coverage and provide continuing support to those who are doing
    this well and additional support to those that need it. We should not
    punish states for extending health-care coverage to individuals and
    families.

    We also are deeply concerned about the impact the proposal would have
    on individuals with pre-existing conditions. The proposed legislation,
    while retaining guaranteed issue provisions in current law, fails to
    maintain other protections that protect patients with pre-existing
    conditions. Yes, the proposal preserves access to health-care coverage
    for everyone, but it exposes individuals with pre-existing conditions
    to discriminatory pricing based on their health condition. In fact, the
    proposal explicitly allows insurers to charge individuals with pre-
    existing health conditions more, solely based on their health status.

    Furthermore, the proposal, establishes a waiver process, which
    currently lacks definition or criteria; that would allow states to no
    longer comply with requirements that insurance products sold cover a
    minimal set of benefits. Since the prohibitions on annual and lifetime
    caps are tied to the essential health benefits under current law, the
    proposal would allow insurance companies to once again impose annual
    and lifetime caps on individuals and families.

    The AAFP is increasingly concerned with the escalation in deductibles
    that has occurred in the employer-sponsored, small group, and
    individual insurance markets. Higher deductibles create a financial
    disconnect between individuals, their primary care physician, and the
    broader health-care system. The ACA has been successful in reducing the
    number of uninsured individuals and families through expanded access to
    health-care coverage, but the law has fallen short in reducing costs
    and most specifically the out-of-pocket cost for individuals. In fact,
    for some Americans, the law has provided increased access to health-
    care coverage but has done so by increasing out-of-pocket cost through
    higher deductibles.

    In an effort to maximize the proven benefits of health-care coverage
    and a continuous relationship with a primary care physician, the AAFP
    proposes the establishment of a standard primary care benefit for
    individuals and families with any high-deductible health plans (HDHP).
    Our proposal would establish a standard primary care benefit for all
    individuals with a high-deductible health plan. Individuals with a
    HDHP, as defined by the Internal Revenue Service (IRS)*,
    would have access to their primary care physician, or their primary
    care team, without the cost-sharing requirements (deductibles and co-
    pays) stipulated by their policy.

    The AAFP agrees that innovation in care delivery are essential to
    reducing costs. The AAFP has been a national leader in efforts to
    better align our delivery and payment systems to produce higher-quality
    care at lower cost. The GCHJ proposal points to one innovation we see
    as a high-impact innovation in primary care. The proposal would support
    the expansion of a delivery model commonly known as ``direct primary
    care (DPC).'' The AAFP strongly supports DPC, but we do not see this
    delivery model as an alternative to comprehensive health-care coverage.

    There are bipartisan solutions, such as those mentioned above, to
    challenges we face and the AAFP is standing ready to partner with you
    and your colleagues to identify, develop, and implement those
    solutions. On July 27, 2017, the AAFP sent a letter to Senate Leaders
    outlining a set of bipartisan policies that we believe would be
    appropriate steps towards improving our health-care system.

    Health care is an immensely personal issue. Each of us, at some point
    in our lives, will interact with the health-care system either as a
    result of our own health issue(s) or the health issues of a family
    member or loved one. Our individual views and opinions regarding our
    health-care system are shaped by our experiences and observations, but
    we all agree that health care and health-care coverage should be
    accessible and affordable for every person and family.

    Changes to current law must be patient-centered, be focused on
    enhancing and improving our health-care system for all Americans, and
    acknowledge the important role of family physicians and primary care in
    our health-care system. Family physicians are on the frontline each day
    providing care to millions of men, women, and children in communities
    large and small, rural and urban, wealthy and poor across the country.
    Today, one in five physician office visits takes place with a family
    physician.

    They are not only physicians, they also are patient advocates. They are
    the physicians that individuals and their families turn to when they
    are sick and when they are in need of guidance on life's most
    complicated and challenging decisions. They are, without question, the
    foundation of our health-care system.

    Our members witness each day the importance of individuals and families
    having health insurance coverage. They see the value of those patient-
    centered protections that ensure each individual is able to obtain
    health-care coverage regardless of their gender, health history, or
    socioeconomic status. Our health-care system is not perfect and there
    clearly are areas of our insurance and health-care system that require
    additional reforms. The AAFP is committed to engaging in a dialogue and
    process that identifies policies that strengthen our health-care system
    and make health care more affordable for individuals and families at
    all income levels.

    The AAFP's policies and advocacy on these issues are guided by a
    standard that has been proven the world over--the two primary factors
    that are most indicative of better health and more efficient spending
    on health care are continuous health-care coverage and having a usual
    source of care, normally through a primary care physician.
    Unfortunately, the GCHJ proposal is not consistent with this standard.

                                     ______

            American Cancer Society Cancer Action Network (ACS CAN)

                         555 11th Street, NW, Suite 300

                              Washington, DC 20004

                                (t) 202-585-3241

                                (f) 202-661-5750

                                 www.acscan.org

    Washington, DC, September 25, 2017--Changes to the nation's health-care
    system as proposed in the pending Graham-Cassidy health legislation
    could leave millions of cancer patients and survivors without access to
    adequate, affordable health insurance coverage, according to Dick
    Woodruff, senior vice president of federal advocacy for the American
    Cancer Society Cancer Action Network (ACS CAN).

    During a Senate Finance Committee hearing, Woodruff told committee
    members the bill essentially rolls back the patient protections
    implemented under current law, including those for people with pre-
    existing conditions. While plans would still be prohibited from denying
    someone coverage based on their health history, in states that applied
    for waivers, insurers could instead be free to charge people more for
    their coverage based on their health status.

    ``For an individual in active cancer treatment or a cancer survivor,
    the health plan could have no limit on the amount of the monthly
    premium,'' said Woodruff. ``Products could be unaffordable for
    individuals who required--or were anticipated to require--high cost
    treatments.''

    States could also apply to change what services plans are required to
    cover, putting current guaranteed essential health benefits (EHB),
    including coverage for hospitalization, physician services, specialty
    cancer care and prescription drugs at risk.

    ``Insurance should cover the major health needs of cancer patients and
    survivors,'' said Woodruff. ``Eliminating EHB requirements would
    encourage insurers to streamline `basic' policies that do not include
    explicitly defined comprehensive benefits, thus putting cancer patients
    and survivors at risk of inadequate treatment, and could jeopardize
    access to necessary preventive care, treatment and follow-up care.''

    Woodruff added that because current law ties a prohibition on lifetime
    or annual benefit limits to the EHB requirements, the Graham-Cassidy
    proposal could once again bring back coverage caps, increasing the
    chances that a cancer diagnosis or other serious condition could leave
    patients financially devastated.

    The bill would also make coverage much less affordable for many by
    ending guaranteed premium subsidies and cost-sharing payments that help
    low and moderate income Americans afford private coverage, and by
    slashing Medicaid funding.

    Medicaid serves as a vital safety-net and provides coverage to more
    than 2.3 million Americans with a history of cancer, including one-
    third of all pediatric cancer patients at the point of diagnosis.

    ``For low-income Americans, the changes proposed by Graham-Cassidy
    could be the difference between an early diagnosis when outcomes are
    better and costs are less or a late-stage diagnosis where costs are
    higher and survival less likely,'' said Woodruff.

    Woodruff urged senators to reject the Graham-Cassidy legislation and
    instead resume bipartisan work to improve the health-care law that was
    being done by Senators Lamar Alexander and Patty Murray.

    ``ACS CAN stands ready to work with the Committee and all Members of
    Congress to develop and implement policies that will improve the
    health-care system for the millions of individuals who are in active
    cancer treatment and cancer survivors,'' said Woodruff.

    To read the full written testimony: http://bit.ly/2fpEMNF.

                                     ______

                     American Civil Liberties Union (ACLU)

                                915 15th St., NW

                              Washington, DC 20005

    On behalf of the American Civil Liberties Union (ACLU) and our more
    than two million members and supporters, we submit this statement for
    the record of the Senate Finance Committee's September 25, 2017 hearing
    on the Graham-Cassidy-Heller-Johnson proposal (hereinafter ``Graham-
    Cassidy''). We write in opposition to this legislation, which repeals
    key provisions of the Affordable Care Act (ACA), harms people with
    disabilities and women by cutting and capping Medicaid, denies patients
    access to Planned Parenthood, and restricts abortion coverage. Though
    the Congressional Budget Office has not had the opportunity to provide
    a full analysis of the bill, there is no doubt that it would deprive
    millions of people of the health-care coverage they need and without
    which they cannot fully participate in the life of our nation.

    Graham-Cassidy, like the various Senate health care repeal proposals
    considered this summer, would decimate the Medicaid program. It would
    both replace the Medicaid expansion with temporary and inadequate block
    grants, and fundamentally restructure the over 50-year-old Medicaid
    program by limiting federal financing through a per capita cap and
    cutting billions from the program.

    Medicaid cuts directly implicate basic freedoms for the disability
    community. Medicaid is the vehicle that allows people to stay out of a
    nursing home or other institution and to be able to live at home, with
    family, in the community. Consider Curtis Wolff; who spoke at an ACLU
    congressional briefing on the Medicaid program this June. In August
    2012, Curtis was paralyzed due to a bite from a mosquito carrying the
    West Nile Virus.\1\ Despite being a successful small business owner
    with excellent private insurance, Curtis had to turn to Medicaid in
    order to access home and community based services, in-home care that
    enables people with disabilities to live their lives on their own terms
    and get access to the support necessary to stay in the community.
    ---------------------------------------------------------------------------
        \1\ Curtis Wolff, Opinion, ``I was paralyzed by a mosquito bite.
    The GOP health care plan would be devastating for me,'' Denver Post,
    June 29, 2017, available at https://www.denverpost.com/2017/06/29/i-
    was-paralyzed-by-a-mosquito-bite-the-gop-health-care-plan-would-be-
    devastating-for-me/.

    We might wonder about what would have happened to Curtis in a nursing
    home or similar institutional facility but Elizabeth Grigsby can speak
    directly to that.\2\ She was born with cerebral palsy. Her disability
    limits her control of her limbs, and slows her speech. As a young
    woman, she was put in a Board and Care home run much like a nursing
    home. She told us that ``someone else decided when I would get up in
    the morning; someone else decided when and what I would eat for
    breakfast; someone else decided who I would see and what I would do
    that day. It was like being in prison--but I hadn't committed a
    crime.''
    ---------------------------------------------------------------------------
        \2\ Vania Leveille and Susan Mizner, ``Don't Underestimate the
    Catastrophic Impact That the Trump Administration's Policies Will Have
    on People With Disabilities,'' ACLU, January 23, 2017, available at
    https://www.aclu.org/blog/disability-rights/integration-and-autonomy-
    people-disabilities/dont-underestimate-catastrophic.

    Like Curtis, Elizabeth was able to regain her freedom through in-home
    service and support aids funded primarily by Medicaid. She now lives in
    her own apartment, holds down a part-time job, and volunteers her time
    helping medical professionals better understand how to work with people
    with disabilities. And she can choose when, what, and with whom she
    ---------------------------------------------------------------------------
    will eat breakfast.

    Institutionalization severely limits the opportunities for people with
    disabilities to make basic decisions about their own lives or to
    interact with the broader community. Institutionalization is
    segregation, locking Americans with disabilities away from the most
    basic of freedoms. Over the last several decades, people with
    disabilities have fought for--and increasingly won--greater access to
    care and supports in the community. This is thanks to Medicaid.
    Medicaid not only provides adults with mobility impairments with
    support for daily activities, it also provides job coaching to adults
    with intellectual and developmental disabilities so that they can enter
    the workforce, and pays for in-home care for seniors to stay safely in
    their homes.

    To the disability community, there is no question that Medicaid needs
    more funding, not less. Even with all this progress, hundreds of
    thousands of people with disabilities are on waiting lists to receive
    home and community services. There is not enough money to serve
    everyone.

    Slashing resources, through a per capita cap, will only exacerbate this
    problem Researchers at the University of California, San Francisco
    recently analyzed the impact per capita caps would likely have on the
    disability community.\3\ This analysis found that, had such a system
    been imposed in the last decade of Medicaid spending, funding for home
    and community based services for seniors and people with physical
    disabilities would have, on average, been cut by 30 percent, while
    people with developmental disabilities would have seen a cut of as much
    as 14 percent.
    ---------------------------------------------------------------------------
        \3\ H. Stephen Kaye, Ph.D., ``The Potential Impact of the Better
    Care Reconciliation Act on Home and Community-Based Services Spending
    1'' (2017), http://clpc.ucsf.edu/sites/clpc.ucsf.edu/files/reports/
    Impact%20of%20BCRA%20on%20HCBS%20spending%20updated%
    207-14-17_0.pdf.

    In short, Medicaid home and community based services funding has been
    and continues to be the vehicle that advances the liberty of people
    with disabilities. Without the current Medicaid program, countless
    people with disabilities now living life on their own terms would be
    forced into the regimentation and isolation of institutional life. This
    result is unacceptable and should be rejected by every member of the
    ---------------------------------------------------------------------------
    United States Senate.

    Women, too, would be disproportionately impacted by per capita caps and
    cuts to the program because they make up the majority of those enrolled
    in Medicaid. Nearly 40 million women rely on Medicaid for care,
    including 20 percent of women of reproductive age.\4\ For these women,
    Medicaid coverage is essential to their ability to decide when,
    whether, and how to start families. It covers 75 percent of publicly
    funded family planning services and approximately half of all births in
    the U.S.\5\ Graham-Cassidy's cuts to Medicaid would especially harm
    women of color, who are enrolled in Medicaid at higher rates.
    ---------------------------------------------------------------------------
        \4\ Adam Sonfield, ``Why Protecting Medicaid Means Protecting
    Sexual and Reproductive Health,'' Guttmacher Policy Review 20 (2017),
    https://www.guttmacher.org/sites/default/files/article_files/
    gpr2003917.pdf.
        \5\ Hanna Katch, et al., ``Medicaid Works for Women--But Proposed
    Cuts Would Have Harsh, Disproportionate Impact,'' Center on Budget and
    Policy Priorities, May 11, 2017, https://www.cbpp.org/sites/default/
    files/atoms/files/5-11-17health.pdf.

    Graham-Cassidy would hurt women's access to reproductive health care in
    a variety of other ways. It would prevent patients enrolled in Medicaid
    from seeking care at Planned Parenthood, which more than 2 million
    people rely on annually for preventive care including cancer
    screenings, birth control and testing and treatment for sexually
    transmitted infections. This bill would force some Planned Parenthood
    health centers to close their doors, leaving a void that could not be
    filled by community health centers or other providers.\6\ In addition,
    the bill would expand already harmful abortion coverage restrictions.
    It would ban the use of tax credits for insurance policies that cover
    abortion beyond cases of rape, incest, or life endangerment,
    effectively eliminating coverage from the private insurance market
    altogether, and restrict women's use of health savings accounts to
    access abortion care.
    ---------------------------------------------------------------------------
        \6\ Kinsey Hasstedt, ``Federally Qualified Health Centers: Vital
    Sources of Care, No Substitute for the Family Planning Safety Net,''
    Guttmacher Institute, May 17, 2017, https://www.
    guttmacher.org/gpr/2017/05/federally-qualified-health-centers-vital-
    sources-care-no-substitute-family-planning.

    Finally, the bill allows states to waive key patient protections,
    including the requirement that insurance cover maternity care, newborn
    care, mental health and substance use treatment, prescription drugs,
    and other Essential Heath Benefits. Maternity coverage was often
    excluded from individual plans prior to the ACA, and may be again if
    this bill becomes law. The bill also allows states to waive the ACA's
    prohibition against charging higher premiums based on health status.
    Before the ACA, insurers could discriminate against a person with a
    disability or chronic condition, or a woman who was pregnant or had a
    cesarean section, breast cancer, or who sought care to treat injuries
    associated with domestic violence or other forms of gender-based
    violence. Under Graham-Cassidy, insurance companies in some states
    could charge significantly more for an insurance policy if an
    individual has such a pre-existing condition, driving the cost of
    coverage out of reach. Eliminating these protections will doubtless
    have a negative and disproportionate impact on people with
    disabilities, women, and other vulnerable populations who, prior to the
    ---------------------------------------------------------------------------
    ACA, had difficulty obtaining insurance and care.

    We strongly urge you to oppose and abandon this harmful and ill-
    conceived legislation. Should you have any questions, please contact
    Georgeanne Usova at (202) 675-2338 or gusova@acluorg, or Vania Leveille
    at (202) 715-0806 or vleveille@acluorg.

                                     ______

                American College of Emergency Physicians (ACEP)

                           2121 K St., NW, Suite 325

                              Washington, DC 20037

    The American College of Emergency Physicians (ACEP) and our 37,000
    members write to share our deep concerns with the recently released
    proposal from Senators Cassidy, Graham, Heller, and Johnson to repeal
    and replace the Affordable Care Act. We urge you not to bring this
    amendment to the Senate floor for consideration, as its passage would
    have devastating impacts on millions of Americans.

    ACEP cannot support any legislation that does not include emergency
    medical care as a covered benefit in health insurance. The Affordable
    Care Act included emergency services as an essential health benefit,
    and any replacement legislation must do the same. Yet the Cassidy-
    Graham-Heller-Johnson Amendment to H.R. 1628, the American Health Care
    Act, allows states to easily forego requiring insurers to adhere to
    important consumer protections, including the requirement to cover the
    10 essential health benefits, and protections for those with pre-
    existing conditions.

    We are very alarmed by reports that the Senate might proceed to a vote
    on this proposal without a full score by the Congressional Budget
    Office (CBO) on both coverage and financial impacts of the Cassidy-
    Graham-Heller-Johnson amendment. It is clear that the proposal would
    result in tens of millions of Americans losing health insurance
    coverage through its drastic cuts to the Medicaid program,
    destabilization of health insurance markets, and decreased access to
    affordable coverage and care. The proposal directly challenges many of
    ACEP's health care reform principles that we shared with you at the
    start of the 115th Congress' health care reform debate, and would
    result in devastating consequences for emergency medicine patients.

    Americans overwhelmingly (95 percent) say health insurance companies
    should cover emergency medical care \1\ and emergency physicians agree
    with them. Patients can't choose when and where they will need
    emergency care, and they shouldn't be punished financially for having
    emergencies.
    ---------------------------------------------------------------------------
        \1\ Morning Consult poll, February 9-10, 2017 (http://
    newsroom.acep.org/2017-03-16-Public-Overwhelmingly-Wants-Insurance-
    Companies-To-Cover-Emergency-Care-and-To-Be-Transparent).

    We urge you to halt consideration of the Cassidy-Graham-Heller-Johnson
    amendment, and instead work together in a bipartisan, bicameral, multi-
    stakeholder effort to cultivate a health-care system that expands
    access for patients, protects consumers, encourages innovation, and
    ---------------------------------------------------------------------------
    ensures the continued availability of health-care providers.

                                     ______

                      American College of Physicians (ACP)

                     25 Massachusetts Avenue, NW, Suite 700

                           Washington, DC 20001-7401

                                  202-261-4500

                                  800-338-2746

                           https://www.acponline.org/

    As the Senate Finance Committee considers the merits of the Graham-
    Cassidy-
    Heller-Johnson (GCHJ) proposal to repeal and replace the Affordable
    Care Act (ACA), the American College of Physicians (ACP) would like to
    take this opportunity to provide our view that the Senate should not
    move forward with this bill. We outlined our opposition to the initial
    version of this legislation in our September 13th letter that detailed
    many of the reasons why it would undermine or eliminate health-care
    coverage, benefits, and consumer protections for millions of people.
    Based on the most recent version of this legislation that was released
    on September 25th, we reaffirm our strongest possible opposition to the
    new draft of the bill as it would make it even more harmful to our
    patients by creating new and perhaps insurmountable coverage barriers
    for Medicaid enrollees, and patients with pre-existing conditions and
    for the many millions of Americans who will be priced out of coverage,
    or will pay more for less coverage.

    We are dismayed that the revised bill is an even more blatant violation
    of regular order because it was released just hours ago, with a vote
    possible in the Senate by Friday. As a result, the Congressional Budget
    Office (CBO) will have no time to do a complete cost and coverage
    estimate of GCHJ's impact by the time a vote is taken, there will be no
    committee mark ups, no time for other independent analyses and
    stakeholder input, and just a single, cursory hearing today that does
    not even allow time for the public to offer testimony that reflects a
    thorough review of the latest revised bill.

    ACP urges the Finance Committee to move forward with the development of
    bipartisan legislation to stabilize the health insurance marketplace,
    create competition among insurers, and lower the cost of health care
    for all Americans. We believe that the bipartisan hearings that
    occurred earlier this month in the Senate Finance Committee on health-
    care issues impacting cost and coverage and in the Senate HELP
    Committee on ways to stabilize and lower premiums in the individual
    insurance market offer a good starting point for the consideration of
    such health reform proposals.

    ACP is the largest medical specialty organization and the second
    largest physician group in the United States, representing 152,000
    internal medicine physicians (internists), related subspecialists, and
    medical students. Internal medicine physicians are specialists who
    apply scientific knowledge and clinical expertise to the diagnosis,
    treatment, and compassionate care of adults across the spectrum from
    health to complex illness.

    ACP has developed criteria, 10 key questions that should be asked to
    ensure that any legislation that would alter the coverage and consumer
    protections under current law ``first, do no harm'' to patients and
    ultimately result in better coverage and access to care for essential
    medical services. We remain concerned the GCHJ legislation falls well
    short of meeting the criteria that we have established to ensure that
    the health of patients is improved rather than harmed by changes to
    current law.

    Medicaid

    The GCHJ legislation would eliminate or weaken coverage for individuals
    insured through Medicaid by eliminating the enhanced federal match
    provided under the ACA for states that opt to expand the Medicaid
    program starting on January 1, 2020. It would allow states to
    redetermine Medicaid eligibility for individual's eligible every 6
    months or more frequently for individuals eligible for Medicaid through
    the ACA expansion or the state option for coverage for individuals with
    income that exceeds 133 percent of the federal poverty level. This
    change would result in a substantial number of citizens who reside in
    states that expanded their Medicaid population that would lose coverage
    under this legislation, with no assurance that they would be covered
    under a state plan or in the marketplace. It would put at risk the
    gains that we have made under the ACA in ensuring that low income
    individuals would have coverage and a regular source of care to
    maintain their well-being or treat illness when they are sick.

    It would also significantly decrease federal funding for the Medicaid
    program by converting the current federal financing formula to a per
    capita cap model. The proposed per capita cap on federal funding would
    be devastating to coverage and access to care for many of the 72
    million people currently enrolled in Medicaid. Because most states are
    required by law to balance their budgets, a reduction in and/or a cap
    on federal matching funds will necessarily require them to greatly
    reduce benefits and eligibility and/or impose higher cost-sharing for
    Medicaid enrollees, most of whom cannot afford to pay more out of
    pocket--or alternatively and concurrently, reduce payments to
    physicians and hospitals (including rural hospitals that may be forced
    to close), enact harmful cuts to other state programs or raise taxes.

    The GCHJ proposal would also allow states the option to participate in
    a Medicaid Flexibility block grant program beginning in Fiscal Year
    2020. Under the Medicaid Flexibility Program, states would receive
    block grant funding instead of per-capita cap funding for non-elderly,
    non disabled, and non-expansion adults. We remain opposed to this block
    grant funding structure as we believe it would be devastating to
    coverage and access to care especially under this legislation as
    overall federal funding for Medicaid would be reduced from current law.
    Under block grants, because states do not get any additional payment
    per enrollee, strong incentives would be created for states to cut back
    on eligibility, resulting in millions of vulnerable patients
    potentially losing coverage. Block grants will not allow for increases
    in the federal contribution should states encounter new costs, such as
    devastating hurricanes, flooding or tornadoes that may injure their
    residents or destroy health-care facilities. Under either block grants
    or per capita spending limits, states would be forced to cut off
    enrollment, slash benefits, or curb provider reimbursement rates.

    The GCHJ legislation would also permit states, effective October 1,
    2017, to require non-disabled, non-elderly, non-pregnant individuals to
    satisfy a work requirement as a condition for the receipt of Medicaid
    medical assistance. We oppose work requirements because Medicaid is not
    a cash assistance or job training program; it is a health insurance
    program and eligibility should not be contingent on whether or not an
    individual is employed or looking for work. While an estimated 80
    percent of Medicaid enrollees are working, or are in working families,
    there are some who are unable to be employed, because they have
    behavioral and mental health conditions, suffer from substance use
    disorders, are caregivers for family members, do not have the skills
    required to fill available positions, or there simply are no suitable
    jobs available to them. Skills--or interview-training initiatives, if
    implemented for the Medicaid population--should be voluntary, not
    mandatory. Our Ethics, Professionalism and Human Rights Committee has
    stated that it is contrary to the medical profession's commitment to
    patient advocacy to accept punitive measures, such as work
    requirements, that would deny access to coverage for people who need
    it.

    The bill requires all states to establish their own system for
    financing health care by 2020, or risk losing all federal block grant
    funding. This would be highly disruptive and nearly impossible task for
    most states to accomplish in that time frame. It would also authorize
    massive redistribution of funding from states that expanded Medicaid
    coverage to the most vulnerable to those that did not, resulting in
    billions of dollars in cuts to Medicaid expansion states. In addition,
    all federal Medicaid funding to the states will sunset in 2027, when
    all states would lose federal block grant funding unless funding is
    reauthorized.

    Medicaid is an essential part of the health care safety net. Studies
    show that reductions in Medicaid eligibility and benefits will result
    in many patients having to forgo needed care, or seek care in costly
    emergency settings and potentially have more serious and advanced
    illnesses resulting in poorer outcomes and even preventable deaths. As
    an organization representing physicians, ACP cannot support any
    proposals that would put the health of the patients our members treat
    at risk. We believe though that improvements can and should be made in
    Medicaid, including more options for state innovation, without putting
    the health of millions of patients at risk.

    Premium Tax Credits

    This proposal would repeal the ACA premium tax credits as of January 1,
    2020 and allocate some of the funds that were used for that purpose to
    a new Market Based Health Care Grant Program. States would be able to
    use payments allocated from the program for one or more of the
    following activities:

          To establish or maintain a program or mechanism to help high-
    risk individuals purchase health benefits coverage, including by
    reducing premiums for such individuals, who have or are projected to
    have high health care utilization (as measured by cost) and who do not
    have access to employer-sponsored insurance;

          To establish or maintain a program to enter into arrangements
    with health insurance issuers to assist in the purchase of health
    benefits coverage by stabilizing premiums and promoting market
    participation and plan choice in the individual market;

          To provide payments for health care providers for the provision
    of services specified by the CMS Administrator;

          To provide health insurance coverage by funding assistance to
    reduce out-of-pocket costs (such as copayments, coinsurance, and
    deductibles) for individuals with individual health insurance coverage.

    We remain concerned that this formula provides less funding than
    currently in place for individuals to purchase health insurance in the
    individual market and that states could use these funds for a broad
    range of health-care purposes, not just coverage, with essentially no
    guardrails or standards to ensure affordable meaningful coverage.

    The estimates from the bill's sponsors and/or administration showing
    that many states will receive more federal dollars under the GCHJ
    Market Based Health Care Grant Program does not appear to take into
    consideration the impact of the Medicaid per-capita limits and
    reduction in the federal contribution to Medicaid. Even in the select
    states that the sponsors (questionably) assert will experience short-
    term gains in funding, all states are expected to experience reductions
    when the impact of Medicaid caps and cuts, and the expiration of
    funding in 2027, are taken into account. Any temporary increase in
    funding to a few states does not make up for the damage that will be
    done to their residents, and those of other states, resulting from
    eliminating essential patient protections and capping and cutting
    Medicaid. GCHJ would plunge the country back to the pre-ACA days when
    people with pre-existing ``declinable'' medical conditions in most
    states were priced out of the market and the insurance products
    available in the individual market did not cover medically necessary
    services.

    Rather than grant states large sums of funding to use on the options
    listed in this legislation that offer no assurance of increased access
    to coverage, we wish to work with you to enact meaningful reforms to
    strengthen the individual market and build on the gains in health-care
    coverage ensured by the ACA. ACP has offered a forward looking document
    that provides our prescription for meaningful reforms to accomplish
    these goals.

    Elimination of Essential Health Benefits and Other Consumer Protections

    We are alarmed that the most recent changes to the GCHJ legislation
    would do even more harm to individuals with pre-existing conditions by
    making it even easier for states to opt out of essential health
    benefits (EHBs) and could also allow annual and lifetime limits on
    patient coverage, resulting in bare-bones coverage. States will only
    have to submit to the Department of Health and Human Services a broad,
    undefined statement that they ``shall'' provide access to affordable
    coverage with insufficient or non-existent guardrails of what that is
    or requirements to ensure that such coverage is truly affordable.
    States could offer plans with lower or no ``actuarial equivalent''
    standards, meaning higher deductibles and out-of-pocket costs for
    patients.

    We believe that Congress should consider additional policies to
    encourage state innovation and bring more choice and competition into
    insurance markets without rolling back current coverage, benefits and
    other consumer protections guaranteed by the ACA and other federal laws
    and regulations. Provided that coverage and benefits available in a
    particular state would be no less than under current law, Congress
    should encourage the use of existing section 1332 waiver authority to
    allow states to adopt their own innovative programs to ensure coverage
    and access. Section 1332 waivers offer states the opportunity to test
    innovative ways to expand insurance coverage while ensuring that
    patients have access to comprehensive insurance options. However, ACP
    believes that Congress should not weaken or eliminate the current-law
    guardrails that ensure patients have access to comprehensive essential
    health benefits and are protected from excessive co-payments and
    deductibles. The waiving of essential benefits would undermine the
    assurance that insurance policies would cover essential health-care
    services such as physician and hospital benefits, maternity care and
    contraception, mental health and substance use disorder treatments,
    preventive services, and prescription drugs.

    Unfortunately, if existing requirements were removed (e.g., that
    waivers provide comprehensive, affordable coverage that covers a
    comparable number of people as would be covered under current law), a
    backdoor would emerge for insurers to offer less generous coverage to
    fewer people and to make coverage unaffordable for patients with
    preexisting conditions. As long as a state's waiver program meets the
    ACA's standard of comprehensiveness at the same cost and level of
    enrollment, it can test a more market-based approach, or make other,
    more targeted revisions to continue existing state initiatives.

    Elimination of the Individual and Employer Mandates

    The GCHJ legislation eliminates the mandate that requires individuals
    to pay a penalty if they do not acquire health insurance or employers
    with 50 or more full time workers to pay a fine if they do not provide
    health insurance for their employees. We are concerned that the
    elimination of this mandate would allow individuals to wait until they
    are ill to purchase insurance and that insurers would need to increase
    premiums to compensate for the resulting sicker risk pool and the
    destabilization of the insurance market. Maintaining effective
    adherence to the mandate helps balance the market's risk pool, attract
    healthier employees, and avoid dramatic premium rate increases. In
    addition, Congress should not enact any legislation to weaken or repeal
    the individual insurance requirement absent an alternative that will be
    equally or more effective.

    Conclusion

    In July of this year, the Senate failed to garner the necessary votes
    in the process of moving forward with legislation to repeal and replace
    the Affordable Care Act in a budget reconciliation bill. Rather than
    continue with an effort to repeal and replace the Affordable Care Act,
    we urge you to set aside this legislation and instead, focus on
    bipartisan efforts to improve coverage and lower costs based on the
    hearings that were held in the Senate Finance and HELP Committee
    earlier this month. We also urge that any legislation to amend current
    law should be developed through regular order, with hearings, debate,
    and committee mark-ups, and with sufficient time for comprehensive
    independent analysis by the Congressional Budget Office (CBO),
    independent experts, and the clinicians and patients directly affected
    by the proposed changes. We stand ready to work with you should our
    expertise be of help.

                                     ______

                         American Diabetes Association

                         2451 Crystal Drive, Suite 900

                              Arlington, VA 22202

                                 1-800-DIABETES

                              http://diabetes.org/

    American Diabetes Association Urges Senators to Oppose Graham-Cassidy
    Repeal Bill and Continue Working on Bipartisan Health Care Legislation

    Proposal would be devastating for the more than 30 million Americans
    living with diabetes.

    The American Diabetes Association is extremely concerned with the
    Graham-
    Cassidy health care bill and the impact it will have on people with
    diabetes. Individuals with diabetes need ongoing access to health care
    to effectively manage their disease and to prevent dangerous and costly
    complications. Access to affordable, adequate health coverage is
    critical to people with diabetes. The proposed legislation does not
    guarantee this access and would instead increase costs and jeopardize
    care for those with pre-existing conditions such as diabetes. The
    Association urges Senators to vote against this misguided and harmful
    legislation should it be brought to a vote in the Senate.

    The Association is deeply troubled by many aspects of the Graham-
    Cassidy bill. It allows states to opt out of key insurance protections
    for patients, including the ban on charging people with preexisting
    conditions higher premiums and requirements that ensure adequacy of
    coverage. This would put people with diabetes at risk of being unable
    to get the care necessary to manage their disease. In addition, the
    bill is estimated to slash more than $4 trillion in vital health-care
    funding to states by 2036, and lumps all funding for health programs
    designed or administered by states into a single block grant. States
    will have a limited amount of funds available for multiple critical
    health-care programs, such as offering low- and moderate-income people
    coverage or financial assistance and covering adults under Medicaid,
    and will be forced to make difficult trade-offs in determining how the
    funds are used. Even worse, the funding is cut off completely after
    2026.

    The bill also makes drastic changes to the financing structure of the
    Medicaid program. In addition to repealing funding for the Medicaid
    expansion program, the bill converts the traditional Medicaid program
    to a fixed per-capita cap, severely limiting the funding provided to
    states. It is estimated that this bill would cut federal Medicaid
    funding to states by $489 billion by 2027. These cuts would have a
    devastating impact on low-income Americans, who are disproportionately
    affected by diabetes. In states that expanded their Medicaid programs,
    more individuals are being screened for diabetes than non-expansion
    states. Cuts to Medicaid would leave the most vulnerable individuals
    with, or at risk for, diabetes without the health coverage they need to
    be diagnosed and treated for the disease as early as possible.

    The Association is also alarmed that the Senate would vote on this
    legislation without understanding its full impact on insurance coverage
    for millions of Americans. The Congressional Budget Office (CBO), which
    provides nonpartisan estimates on the impact of proposed legislation,
    recently announced that they would take several weeks to provide an
    estimate on the number of Americans who might lose their coverage under
    this bill. We ask the Senate leadership to not hold a vote on this bill
    until they have a full understanding of the impact it will have on all
    Americans. The well-being of millions of Americans with diabetes is at
    risk.

    The Association opposes the Graham-Cassidy legislation because it falls
    short of the minimum standards for replacing the important safeguards
    and coverage provided by the Affordable Care Act (ACA), which the
    Association has outlined. We urge the Senate to reject this bill and
    continue negotiations on a bipartisan health care bill that will
    protect access to affordable and adequate health coverage for people
    with diabetes.

    If you have any questions, please contact Rob Goldsmith, Director,
    Federal Government Affairs at rgoldsmith@diabetes.org or 703-253-4837.

                                     ______

                           American Heart Association

                            1150 Connecticut Ave, NW

                              Washington, DC 20036

                                  202-785-7900

               Statement of Nancy Brown, Chief Executive Officer

    The American Heart Association is the nation's oldest and largest
    voluntary organization dedicated to building healthier lives free from
    heart disease and stroke--two of the leading causes of death in the
    United States. Our non-profit, non-partisan organization works with
    more than 30 million volunteers and supporters across the country and
    in your state. Today, one out of three Americans suffer from one or
    more forms of cardiovascular disease (CVD).

    We welcome the opportunity to share our concerns about the Graham-
    Cassidy-
    Heller-Johnson health-care proposal on behalf of our volunteers,
    clinicians, supporters, and the millions of other constituents with, or
    at risk of developing CVD. We believe this legislation would cause
    millions to lose coverage, eliminate or weaken access to care for
    people with preexisting health conditions, increase out-of-
    pocket costs for individual market consumers, and allow insurers to
    reduce or eliminate essential health benefits that are critical for
    individuals with CVD and stroke. We believe this proposal will do
    irreparable harm to the patients that we represent. We urge the
    Committee to reject this plan and resume bipartisan discussions aimed
    at strengthening--rather than weakening--access to the care Americans
    need and deserve.

    Why We Care

    The connection between health insurance and health outcomes is clear
    and well documented. For instance, Americans with CVD risk factors who
    lack health insurance, or are underinsured, have higher mortality rates
    and poorer blood pressure control than those who are insured; uninsured
    stroke patients suffer from greater neurological impairments, longer
    hospital stays and higher risk of death than similar patients covered
    by health insurance; and uninsured and underinsured patients are more
    likely to delay seeking medical care during an acute heart attack.

    Lack of comprehensive coverage also impacts the financial stability of
    those individuals. More than 60 percent of all bankruptcies in 2007
    were a result of illness and medical bills, and more than a quarter of
    these bankruptcies were the result of CVD. Nearly 80 percent of those
    who filed for medical bankruptcy were insured. In a survey commissioned
    by the American Heart Association, one in five (21 percent) of
    respondents said they ``frequently'' put off care because of the costs
    involved. Among those with heart disease, 51 percent said they
    occasionally put off care because of costs, with 20 percent saying they
    ``frequently'' delay care. In addition, heart transplants and surgeries
    for the approximately 40,000 babies born with heart defects each year
    are clear examples where caps on coverage can be quickly reached.

    Low-income populations are disproportionately affected by CVD--with
    low-income adults reporting higher rates of heart disease,
    hypertension, diabetes, and stroke. Americans with a history of CVD
    make up 28 percent of the Medicaid population. Medicaid provides
    critical access to prevention, treatment, disease management, and care
    coordination services for low income people with CVD.

    In addition, older Americans, like many of the patients we represent,
    are more likely to have a preexisting health condition.

    AHA's Health Care Reform Priorities

    Our association, in collaboration with 20 other non-partisan patient
    and provider organizations, developed a set of core principles that are
    fundamental to ensuring Americans continue to have access to affordable
    and adequate health care. In addition to preserving the coverage gains
    we have achieved in recent years, we believe that three key elements--
    affordability, accessibility and adequacy of health care coverage--must
    be incorporated into any proposal to alter existing law. Our groups
    agreed to evaluate any proposed changes based on these key
    considerations.

    It is important to note that this legislation is being rushed through
    Congress to meet an arbitrary budget deadline, so a complete analysis
    of this bill from the Congressional Budget Office (CBO) is not
    available. Therefore, our evaluation of the impact on our patient
    population is based largely on other independent sources. While these
    sources may differ in some respect, they all demonstrate that this
    legislation does not come close to meeting the principles patients
    groups have endorsed and represent a major step backward in health-care
    coverage for our nation.

    Health Care Coverage

    The AHA believes that any changes to existing law must not jeopardize
    the health-care coverage Americans currently have through employers,
    the private marketplace, Medicare or Medicaid. The Graham-Cassidy
    legislation fails that test.

    The coverage losses estimated by the CBO for the previous health-care
    bills ranged from 22 million in the Senate-reported American Health
    Care Act to 24 million in the House-passed Better Care Reconciliation
    Act. The Commonwealth Fund has estimated that 32 million people could
    lose coverage under the Graham-Cassidy proposal after 2026--and that
    15-18 million people could become uninsured in the first full plan year
    after enactment. An analysis by The Brookings Institution found that
    the legislation would reduce the number of people with insurance
    coverage by 15 million between 2018 and 2019; 21 million between 2020
    and 2026 and 32 million in 2027 and later.

    It's not surprising that these estimates are higher than the previous
    bills because the legislation would effectively repeal the Affordable
    Care Act's (ACA) major coverage expansions after 2026, and make
    increasingly severe federal funding cuts to the rest of the Medicaid
    program (outside of the expansion) under its per capita cap proposal.
    But even without a CBO estimate of coverage losses the math is
    straightforward. According to several sources, the proposal being
    considered by the Finance Committee would reduce the federal commitment
    to health care by as much as $215 billion through 2026 and more than $4
    trillion over a 20-year period. Any ``flexibility'' given to the states
    could not possibly replace cuts of this magnitude--a point made
    strongly by the National Association of Medicaid Directors, who
    expressed their concern that ``this legislation would undermine efforts
    in many states and fail to deliver on our collective goal of an
    improved health care system.'' In speaking about the block grant
    structure proposed in the Graham-Cassidy legislation, Avalere Health
    writes, ``funding cuts of this magnitude will force states to re-
    evaluate their Medicaid programs, including the number of individuals
    covered and the generosity of the provided benefits.'' This is
    unacceptable.

    The ACA brought about significant coverage gains across the U.S.
    population and for CVD patients, specifically. A study released in 2016
    by the American Heart Association revealed that more than 6 million
    adults at risk of CVD and 1.3 million with heart disease, hypertension
    or stroke gained health insurance between 2013 and 2014. The numbers
    are likely much higher today. This coverage expansion brought about
    both health and financial status improvements. In Oregon, full
    implementation led to a 17 percent reduction in deaths from sudden
    cardiac arrest for those aged 45-64. In Massachusetts, health-care
    expansion led to a nearly 3 percent decline in all-cause mortality, a
    nearly 7 percent reduction in the number of uninsured and a 3 percent
    decline in all-cause mortality. Additionally, over the period since
    ACA's passage, personal financial bankruptcies have dropped by 50
    percent.

    Medicaid expansion has been particularly beneficial for individuals
    with or at risk of developing CVD. A 2016 study conducted by the George
    Washington University found that adults who live in non-expansion
    states are at higher risk of CVD, or are more likely to have
    experienced acute CVD, while also having lower insurance coverage
    rates. Patients in non-expansion states may also have greater
    difficulties getting preventive, primary or acute care. It is harder
    for the physicians treating these patients to collect insurance
    payments for their services as well. This translates into significantly
    worse health outcomes for patients and a lost opportunity to
    incentivize cost-efficient care.

    This legislation could largely reverse the coverage gains achieved
    since the Affordable Care Act was enacted in 2010. These losses would
    likely be more concentrated among people with pre-existing conditions
    and serious health needs--the very people who need health insurance the
    most. Our association finds these coverage losses and the impact it
    would have on the lives and health of Americans with CVD unacceptable.

    Access to Care and Preexisting Conditions

    Our association believes that access to care must be maintained by
    preserving patient protections currently in place, which include
    prohibitions on preexisting condition exclusions, annual and lifetime
    limits, insurance policy rescissions, gender pricing and excessive
    premiums for older adults. The Graham-Cassidy legislation fails that
    test.

    Many of our patients were uninsurable prior to passage of the ACA, or
    they were simply priced out of the insurance market. An analysis of
    some of the largest for-profit health insurance companies in the
    country revealed that between 2007 and 2009, one out of every seven
    applicants was denied coverage based on a health condition. This
    highlights the widespread discrimination that has impacted CVD patients
    for decades.

    In addition, preexisting conditions are clearly linked to age: 75
    percent of those aged 45 to 54 and 84 percent of those ages 55 to 64
    have one or more preexisting condition. Hypertension tops the list and
    high cholesterol ranks fourth. This is of particular concern because
    individuals with CVD tend to be older.

    Although the sponsors of this legislation claim that these patients are
    protected, several independent sources disagree. This legislation
    allows states to waive both the ACA's prohibition against charging
    higher premiums based on health status and the requirement that
    insurers cover essential health benefits (or cover them adequately). In
    addition, caps on lifetime limits are tied to the existence of
    essential health benefits, so those too could be re-imposed. Unlike the
    ACA's Section 1332, there are no coverage ``guardrails'' limiting the
    waivers. Instead, states must describe in their waiver applications how
    individuals with pre-existing conditions will have ``adequate'' and
    ``affordable'' coverage. There is no definition in the law of what
    adequate and affordable coverage actually means.

    Based on a detailed analysis for the CBO, 50 percent of the U.S.
    population lives in states that are likely to enact waivers eliminating
    consumer protections or reducing required benefits. Therefore,
    protections that our patients have relied are no longer guaranteed. CBO
    estimates of a similar model found that less healthy individuals, such
    as those with preexisting conditions, would be unable to purchase
    comprehensive coverage with premiums close to those under the current
    law and might not be able to purchase coverage at all. For those who
    can acquire coverage, their premiums will likely rise despite
    additional funding.

    The ACA offered coverage to CVD patients who had previously been
    without, either because they were denied coverage in the individual
    market due to their preexisting condition, or because of expensive
    premiums that were out of their financial reach. For the first time,
    they were offered a genuine pathway to real and meaningful health
    insurance coverage. This legislation removes the guarantee of coverage
    for individuals with preexisting health conditions, which is
    unacceptable to the association and the individuals we represent.

    Affordability

    Affordable plans ensure that patients are able to access needed care in
    a timely manner from an experienced provider without undue financial
    burden. Affordable coverage includes reasonable premiums and cost
    sharing (such as deductibles, copays and coinsurance) and limits out-
    of-pocket expenses. Adequate financial assistance must be available for
    low-income Americans and individuals with preexisting conditions. They
    should not be subject to increased premium costs based on their disease
    or health status. The Graham-Cassidy legislation fails that test.

    Older and sicker people make up a significant portion of our patient
    population. The bill eliminates two sources of financial assistance for
    that population--premium tax credits and cost sharing reductions. This
    assistance is critical to ensuring low- to moderate-income older adults
    are able to afford the coverage they need. The bill also allows states
    to charge older adults aged 50-64 significantly higher premiums on the
    basis of their age than what states charge under the current law by
    waiving federal protections that limit the practice known as age
    rating. For example, under current law, a 60-year-old earning $25,000 a
    year would pay an average of $1,608 per year in health insurance
    premiums in 2020. Under the proposed legislation, however, he or she
    could see their premiums increase by as much as $10,572 in 2020 at the
    national level--amounting to a total $12,180--due to the elimination of
    tax credits. In Alaska, for instance, a 60-year old earning $25,000
    buying insurance in the Marketplace could see their premiums increase
    as much as $26,986.

    Cardiovascular disease is the costliest condition in America. An
    unaffordable plan is no different than a coverage denial for our
    patients. This legislation would reduce the affordability of plans on
    the exchange, particularly for older people, and cuts in Medicaid could
    terminate coverage to individuals based on each state's decision about
    which individuals they choose to cover. This is a dramatic step
    backward from the current law. It is unacceptable to us and our
    patients.

    Adequacy

    In addition to maintaining access to insurance coverage, all plans
    should be required to cover a full range of needed health benefits,
    with a comprehensive and stable network of providers and plan features.
    The provision in current law that requires all individual and small-
    group plans, whether in or out of the marketplaces, to cover 10
    categories of required services is critically important to individuals
    with heart disease--particularly, rehabilitation and habilitation
    services, as well as preventive health care. The Graham-Cassidy
    legislation fails that test.

    Previously, many plans in the individual and small-group markets lacked
    coverage in one or more of the 10 essential benefit categories. For
    people living with or at risk of CVD the benefit requirements in the
    ACA protected insured individuals from overwhelming financial burden in
    the event of a CVD-related illness. It also enabled them to receive
    health-care services that help prevent a recurrence or disease
    progression.

    According to the CBO, about half of the population resides in states
    that would make changes to essential health benefits given the chance.
    People who rely on these services could face drastic increases in out-
    of-pocket costs or forgo needed services, including maternity care,
    mental health and substance abuse treatment, and rehabilitative and
    habilitative services.

    Preventive care is critically important for patients if we are going to
    make notable progress towards controlling CVD, which is the deadliest
    and costliest disease in our nation. Currently, the preventive
    screenings required under current law apply to nearly all individual
    and small-group plans, most large group plans and all Medicaid
    expansion plans. Enrollees have access to a broad set of evidence-based
    preventive services without cost-sharing requirements, and these
    services include many that are relevant to preventing, identifying, and
    managing CVD: blood pressure screening, diabetes (type 2) screening,
    diet counseling, statin preventive medication for those with CVD risk,
    and obesity screening and counseling. These are all core components to
    preventing, diagnosing or treating CVD. Evidence demonstrates that when
    preventive services come with out-of-pocket costs, utilization rates
    fall, particularly for the working, low-income population. An
    investment in preventive services prevents significant loss of work-
    days and improves quality of life for millions of heart and stroke
    patients. Once again, the continuation of these benefits would be left
    up to the states, putting them in jeopardy for the millions of patients
    who could benefit from them.

    Conclusion

    On behalf of the millions of individuals struggling with heart disease
    and stroke, we urge the Committee to oppose this legislation that fails
    every test of adequate and affordable health-care coverage. We press
    the committee to instead consider bipartisan approaches to stabilizing
    the insurance markets, like those considered by the Health Education
    Labor and Pensions (HELP) Committee. The AHA stands ready to work with
    Congress to draft meaningful legislation to improve access to
    affordable, adequate health coverage for all.

                                     ______

                      American Hospital Association (AHA)

                              800 10th Street, NW

                           Two CityCenter, Suite 400

                           Washington, DC 20001-4956

                              Phone (202) 638-1100

                           https://www.aha.org/front

    On behalf of our nearly 5,000 member hospitals, health systems and
    other health-care organizations, as well as our clinician partners--
    including more than 270,000 affiliated physicians, 2 million nurses and
    other caregivers--and the 43,000 health-care leaders who belong to our
    professional membership groups, the American Hospital Association (AHA)
    appreciates the opportunity to submit for the record our comments on
    the importance of maintaining coverage and access to care as the Senate
    considers a proposal that would radically transform the health-care
    system.

    The AHA opposes the Graham-Cassidy-Heller-Johnson proposal. This
    proposal cuts or repeals major health care coverage programs without
    putting an adequate alternative in place, placing coverage for tens of
    millions of Americans at risk. The exact impact of this proposal is
    uncertain as the Congressional Budget Office (CBO) has been unable,
    thus far, to fully analyze the proposal. However, an analysis conducted
    by KNG Health Consulting for the AHA found that more than 20 million
    individuals would lose coverage by 2026, and the proposal would result
    in $275 billion less in federal funding to states. This is similar to
    CBO projections for an earlier proposal, which found that 22 million
    individuals or more would lose coverage, and hundreds of billions of
    dollars would be cut from the health care system. Moreover, while some
    states may receive additional federal funds under the proposal, our
    analysis found that the rate of uninsured would increase in every
    state. We urge the Senate to go back to the drawing board and work in a
    bipartisan manner to address the challenges facing our nation's health-
    care system.

    Among the AHA's key concerns with the Graham-Cassidy-Heller-Johnson
    proposal:

      The Proposal Would Result in Millions Losing Health Coverage. The
    proposal would repeal the Affordable Care Act's (ACA) individual and
    employer mandate penalties, and it would slash funding for traditional
    Medicaid by transitioning financing for the program to a per capita cap
    model with trend factors that are generally below historic spending
    growth, jeopardizing coverage for our most vulnerable. Finally, the
    proposal would repeal Medicaid expansion, the Basic Health Program, and
    the Health Insurance Marketplace subsidies--through which more than 20
    million people receive coverage--and direct a portion of the funds for
    those programs to establish a state grant program. The proposal would
    provide approximately $200 billion less than the federal government
    would spend under current law.\1\ The proposal, as updated on September
    24, 2017, would also direct approximately $4.5 billion to several
    states based on whether the state expanded Medicaid after December 31,
    2015 \2\ or has an approved 1332 waiver that provides federal ``pass-
    through'' funding to the state. Only a handful of states--Alaska,
    Hawaii, Louisiana, Montana and Minnesota--would qualify for these
    additional funds. There are few guidelines for states on how to use the
    grant funds, including no requirement that states even use the money
    for coverage. Finally, this program and the funding available through
    it would end entirely at the conclusion of 2026, without any plan for
    how to continue coverage for those who do benefit from the program.
    ---------------------------------------------------------------------------
        \1\ KNG Health Consulting, LLC.
        \2\ The draft legislative language provides that the additional
    funds are for states that expanded after December 31, 2016, but the
    summary document indicates that the provision applies to states that
    expanded after December 31, 2015. We assume the date in the draft
    legislative language is a drafting error as no states expanded after
    December 31, 2016.

      Transitioning Medicaid to a Per Capita Cap Financing Model Would
    Reduce Program Funding to Unsustainable Levels Over Time. The
    proposal's per capita spending limits would reduce federal Medicaid
    funding to unsustainable levels over time. From 2020 to 2026, states
    would receive billions less than under current law.\3\ Once even
    stricter caps go into effect, the cuts would jump dramatically and grow
    larger over time. While the proposal would provide just two states--
    Alaska and Hawaii--with increased federal Medicaid funds through an
    increase in their FMAP, for all other states, these cuts would force
    state Medicaid programs to make tough choices about how to manage their
    remaining Medicaid dollars and would result in additional coverage
    losses.
    ---------------------------------------------------------------------------
        \3\ Id.

         Medicaid serves our most vulnerable populations, including
    Americans with chronic conditions such as cancer, the elderly and
    disabled individuals in need of long-term services and support; and the
    program already pays providers significantly less than the cost of
    providing care. The proposed restructuring of the Medicaid program and
    the resulting deep financial cuts will have serious negative
    ---------------------------------------------------------------------------
    consequences for communities across America.

      The Proposal Incentivizes States to Cover Only a Sliver of Those
    Currently Enrolled. The proposed grant program would ultimately provide
    each state with a standard amount of money per ``low-income
    individual,'' subject to some adjustments. The proposal defines a low-
    income individual as someone with income between 45 and 133 percent of
    poverty.\4\
    ---------------------------------------------------------------------------
        \4\ Effectively 50 to 138 percent of poverty when accounting for a
    5 percent income disregard.

         States would be subject to a reduction in their allotment
    depending on how many individuals within this income range do not have
    comprehensive coverage. In addition, based on changes in the September
    24, 2017 draft of the proposal, at least half of the grant funds must
    be used to provide assistance to people with incomes between 45 and 295
    percent of poverty. While we support incentivizing enrollment in
    comprehensive coverage, we question why the proposal does not
    incentivize states to cover individuals below 45 percent of poverty.
    The proposal sponsors suggest that the selected income range
    ``represents the population currently on Medicaid expansion. This
    population disproportionally struggles to access health insurance, and
    is, therefore, a better population to use when assessing need and
    determining state allotments.'' \5\ Presumably, the millions of
    individuals below 45 percent of poverty, including those who lose
    coverage due to the repeal of Medicaid expansion, similarly struggle to
    access coverage.
    ---------------------------------------------------------------------------
        \5\ Graham-Cassidy-Heller-Johnson: Frequently Asked Questions,
    accessed on Sept. 21, 2017 at: https://www.cassidy.senate.govlimo/
    media/doc/GCH%20FAQs%20Final.pdf.

      The Proposal Would Erode Key Protections for Patients and Consumers.
    Under the grant program, states could waive certain consumer
    protections related to essential health benefits and some elements of
    community rating, among other insurance market provisions. As a result,
    insurers could sell inadequate coverage and charge individuals with
    pre-existing conditions any amount in premiums. Changes to the proposal
    introduced on September 24, 2017 fail to ensure that such individuals
    ---------------------------------------------------------------------------
    would not be priced out of coverage.

      The Proposal Does Not Provide States With Adequate Time to Implement
    New Coverage Programs. The law would provide states with less than 2
    years to wind down current coverage programs and develop alternatives.
    We do not believe this provides states with adequate time to address
    the myriad issues they will face, including: to what type of coverage
    model the state would transition; who would be eligible for coverage;
    how the state would handle disenrollment from current coverage
    programs; whether the state would reform insurance market rules; and
    the building of new coverage program infrastructure, among other
    issues. While changes in the September 24, 2017 version of the proposal
    would retain the Health Insurance Marketplace infrastructure as an
    option for states to use, considerable barriers to developing and
    implementing plans remain. For example, in some states, the legislature
    will not meet in 2018.

         Implementing new health-care programs takes far longer than the
    time frame allowed by the proposal. Take, for example, the process
    states already use to contract with managed care organizations to serve
    Medicaid beneficiaries. Not including the initial planning period, the
    process of developing a request for proposals, soliciting and reviewing
    bids, working with plans to develop new products, and enrolling
    beneficiaries into plans often takes 18 months or longer. It is very
    possible that the time constraint alone means that some states will be
    unable to use some or all of their allotments.

      The Proposal Would Not Stabilize the Insurance Market in the Short
    or Long Term. The proposal fails to fund the cost-sharing reductions
    (CSRs) in the short term (2018 and 2019), while providing a separate
    fund to help stabilize the insurance markets in 2019 and 2020 (but not
    2018). CBO previously estimated that failure to fund the CSRs in 2018
    would increase premium rates by 20 percent and increase the federal
    deficit by $6 billion that year.

      Without CBO Analysis, it Is Impossible to Assess Fully the Impact of
    This Proposal. The proposed changes to the health-care system included
    in this proposal may alter dramatically how millions of Americans get
    health-care coverage and how they access care. Beyond those at risk of
    losing coverage, the impact of these changes would be felt throughout
    the health-care system. Without a full CBO analysis, no one fully
    understands the consequences--both intended and unintended--of this
    proposal.

    CONCLUSION

    Health care coverage is vitally important to working Americans and
    their families. They rely on hospitals and health systems to provide
    them with access for their essential health-care needs, including the
    full range of preventive to critical, life-
    saving services. Without coverage, access to these services is at risk,
    and, with it, the quality of life and health of our communities. This
    proposal would strip hundreds of billions of dollars from the health-
    care system and put coverage at risk for some of the nation's most
    vulnerable.

    We urge the Senate to protect our patients and reject this proposal. We
    remain committed to working with you on positive reforms to the health-
    care system.

                                     ______

                           American Lung Association

                 1331 Pennsylvania Avenue, NW, Suite 1425 North

                              Washington, DC 20004

                        Ph: 202-785-3355 F: 202-452-1805

    September 22, 2017

    The Honorable Orrin Hatch
    Chairman
    Committee on Finance
    U.S. Senate
    Washington, DC 20510

    Dear Chairman Hatch:

    The American Lung Association appreciates the opportunity to submit
    testimony for the record on the Graham-Cassidy healthcare bill. The
    American Lung Association strongly opposes this bill and urges the
    Senate to reject it.

    The Lung Association believes that any changes to current law should
    prioritize preserving quality and affordable healthcare coverage for
    all Americans. Instead of proceeding with this legislation, we urge the
    Finance Committee to return to its bipartisan efforts on the Children's
    Health Insurance Program and proceed in a similar, bipartisan effort to
    improve our nation's current healthcare system.

    In March of 2017, the American Lung Association and other leading
    national health groups released a set of joint principles that our
    organizations believe should guide any healthcare legislation. The
    three tenants--affordability, accessibility and adequacy of healthcare
    coverage--must be incorporated into any proposal to alter the current
    system. Unfortunately, the Graham-Cassidy bill does not provide these
    three elements and instead, will negatively impact patients' access to
    adequate and affordable healthcare.
    Protecting People With Pre-Existing Conditions
    Ensuring patients have adequate and affordable healthcare is critical
    to any healthcare reform bill. As an organization representing lung
    disease patients, we recognize that it is of utmost importance. Lung
    diseases such as asthma and COPD can be managed, but patients need to
    have regular clinical services and medication. Patients must be able to
    afford health insurance premiums and have plans offered.

    Current law protects patients with preexisting conditions in a number
    of vital ways. First, it prohibits denying insurance to people with
    pre-existing conditions and it prohibits charging people and families
    with pre-existing conditions more for premiums than healthy people.
    Current law also defines a basic set of 10 benefits that must be
    covered by qualified health plans--these are the essential health
    benefits (EHB).

    The EHB requirements ensure plans cover a baseline of services, so that
    all patients have access to the appropriate care when they need it.
    Since plans are required to cover a baseline of benefits, patients
    don't need to pay more if they are sick to a plan that covers their
    illness.

    The proposed Graham-Cassidy bill would give the Centers for Medicare
    and Medicaid (CMS) a new and expansive waiver authority to allow states
    to definite what qualifies as an EHB. This opens the door for insurance
    companies to provide different tiers of coverage; charging sick
    patients more for a plan that covers their illness--a point that was
    made by insurance company Blue Cross Blue Shield in its statement
    opposing the Graham-Cassidy bill this week.\1\ This is likely to make
    insurance unaffordable for people with pre-existing conditions, which
    is unacceptable for lung disease patients.
    ---------------------------------------------------------------------------
        \1\ Blue Cross Blue Shield Association. (2017). Blue Cross Blue
    Shield Association Statement on Graham-Cassidy Health Care Reform
    Proposal [Press Release]. Retrieved from https://www.bcbs.com/news/
    press-releases/blue-cross-blue-shield-association-statement-graham-
    cassidy-health-care-reform.

    In state-granted waivers, plans would no longer be required to cover
    EHBs including prescription drug coverage and can re-impose annual and
    lifetime caps on coverage, which negatively impact patients with
    illnesses such as lung cancer, asthma and COPD who may rely on costly
    medications to manage their conditions. This would undermine any form
    of meaningful coverage for patients with pre-existing conditions. We
    should not return to an insurance market that often excluded those who
    needed coverage the most.
    State Flexibility/Market-Based Health Care Grant Program
    Current law allows state flexibility to create state marketplaces and
    test innovative ideas for the private marketplace through the 1332
    waiver process. This process requires states to work with their
    legislature and the federal government to design innovate ideas. The
    current process has built-in protections for patients.

    The 1332 waiver process requires soliciting and responding to public
    comment. This gives patients and consumers the ability to provide
    feedback on system changes that will impact their healthcare.
    Additionally, there are four guardrails around 1332 waivers: states are
    required to show how the waiver program will not increase the number of
    people uninsured, not increase healthcare costs, not lower the quality
    of the coverage and not add to the federal deficit.

    The current waiver program allows for states to design programs that
    work best for their states, but still provide patients with the
    protections to receive the healthcare they need. For lung disease
    patients, these protections are critical. They provide that patients
    receive the treatments they need to manage their diseases.

    The Graham-Cassidy bill does not require states to ensure there are
    adequate patient protections in place. As mentioned before, there is no
    federal oversight in the new waiver program that would be created by
    this bill and states only need to have proposals that do not add to the
    deficit.

    Under Graham-Cassidy, states will be allowed to change how much
    premiums can vary based on age, potentially making insurance
    unaffordable for older Americans. The Congressional Budget Office (CBO)
    previously found if states were allowed to increase the rating to a 5:1
    ratio, the annual cost of premiums could increase to $20,500 for a 64-
    year-old buying a silver plan. A premium at this level would price far
    too many people out of the insurance market and is unacceptable.

    In order to fund this new waiver program, the Graham-Cassidy bill will
    siphon the money that is currently funding Medicaid expansion in the 31
    states and the District of Columbia (DC) that chose to expand the
    Medicaid program. This punishes states that implemented the Affordable
    Care Act (ACA) as it was designed. Every state had and still has the
    opportunity to expand their Medicaid program and receive an enhanced
    Medicaid match--and with it, ensure more of its citizens have quality
    and affordable healthcare. We strongly recommend ALL states expand
    Medicaid to increase the number of people with health coverage.
    Instead, the Graham-Cassidy bill moves in the wrong direction and
    reduces the number of people with health coverage. It is harmful to
    millions of patients to take money away from a program that provides
    healthcare to low-income individuals. Congress should work with states
    and CMS to encourage every state to expand to increase the number of
    people with healthcare coverage.
    Market Stabilization
    The proposed bill would destabilize the health insurance market place.
    The
    Graham-Cassidy bill repeals the Advanced Premium Tax Credits (APTC),
    which help families with incomes up to 400 percent of the federal
    poverty level pay for insurance premiums. The bill would also remove
    the individual and employer mandate that encourages people to buy
    insurance. And lastly, the bill does not fund the cost sharing
    reductions (CSRs). The removal of these three provisions spell disaster
    for state marketplaces. Without a robust marketplace, patients will not
    have any opportunity to purchase coverage.

    Repealing the APTCs will make it more expensive for lower-middle class
    families to purchase health insurance. By foregoing health insurance,
    patients will not be able to access preventive services, such as
    immunizations, lung cancer screenings and tobacco cessation treatments.
    Without preventive services, there is a much higher likelihood of
    disease and that disease having a worse prognosis. Patients with health
    coverage are better able to manage their chronic disease and avoid
    costly emergency room care and hospital admission.

    In addition, failing to pay the CSRs is irresponsible. These payments
    allow insurers to reduce cost-sharing for people with incomes less than
    250 percent of the federal poverty level. Lung diseases can be
    expensive to treat, but they can be managed. CSR payments allow lower
    income people get the treatment they need, allowing lower income
    patients to not only have coverage, but have actual healthcare.
    Medicaid
    The Graham-Cassidy bill would make the deepest cuts to the Medicaid
    program since its inception by implementing a per-enrollee cap starting
    in 2020, threatening the healthcare of 68 million low-income patients
    who depend on the program for healthcare. The implementation of a per-
    capita cap would significantly cut federal funding to states across the
    board and place a huge cost-sharing burden on states. Between 2020 and
    2026, states would lose $53 billion in Medicaid funding. The strain on
    state budgets pressures states to make difficult decisions to limit
    their Medicaid spending. States would be forced to cut services, reduce
    eligibility or increase cost-sharing for their Medicaid program to keep
    costs down.\2\
    ---------------------------------------------------------------------------
        \2\ Garfield, R., L. Levitt, R. Ridowitz, and G. Claxton.
    (September 21, 2017). State-by-State Estimates of Changes in Federal
    Spending on Health Care Under the Graham-Cassidy Bill. Kaiser Family
    Foundation. Retrieved from http://www.kff.org/health-reform/issue-
    brief/state-by-state-estimates-of-changes-in-federal-spending-on-
    health-care-under-the-graham-cassidy-bill/?utm_cam
    paign=KFF-2017-sept-21-GrahamCassidy-state-
    analysis&utm_source=hs_email&utm_medium=
    email&utm_content=56569375&_hsenc=p2ANqtz-
    8zPzKBNCEcMSoTS44BvZ5dEMU9V3hSK5Dh
    9szFGzXXFfUfDR4tvoitcSuiaJ7zaC3g_Xt0qSoX3yWlv88SobKzecl8pQ&_hsmi=5656937
    5.

    Medicaid is an important source of coverage for patients with serious
    and chronic health needs, especially those living with lung disease
    like asthma. Nearly half of children with asthma are covered by
    Medicaid or CHIP. Medicaid cuts would lead to fewer people with lung
    diseases having quality and affordable coverage, especially if services
    are cut. Medicaid may no longer cover the care and treatments they
    need, including breakthrough therapies and technology that represent a
    new lease in life. A per capita cap will only exacerbate the downward
    pressure on Medicaid budgets and will further reduce access to
    treatments for patients.
    Medicaid Expansion
    Medicaid expansion has been crucial in expanding coverage to more than
    15 million Americans, half of whom are permanently disabled, have
    serious health conditions or in fair or poor health, and approximately
    a third of whom smoke. The Graham-Cassidy bill would end federal match
    funding for Medicaid expansion and marketplace subsidies in 2020, and
    reallocate the funding to states through smaller block grants. These
    block grants provide states flexibility in choosing to use it for
    health coverage or other healthcare purposes, but do not guarantee
    coverage or financial assistance for individuals. The block grant
    funding is also insufficient to maintain current coverage levels.
    Overall, states would lose $107 billion. Individually, states stand to
    lose up to $55 million if they expanded Medicaid. After 2026 no
    additional funding for this population is provided.\3\
    ---------------------------------------------------------------------------
        \3\ Garfield, R., L. Levitt, R. Ridowitz, and G. Claxton.
    (September 21, 2017). State-by-State Estimates of Changes in Federal
    Spending on Health Care Under the Graham-Cassidy Bill. Kaiser Family
    Foundation. Retrieved from http://www.kff.org/health-reform/issue-
    brief/state-by-state-estimates-of-changes-in-federal-spending-on-
    health-care-under-the-graham-cassidy-bill/?utm
    _campaign=KFF-2017-sept-21-GrahamCassidy-state-
    analysis&utm_source=hs_email&utm_medi
    um=email&utm_content=56569375&_hsenc=p2ANqtz-
    8zPzKBNCEcMSoTS44BvZ5dEMU9V3hSK
    5Dh9szFGzXXFfUfDR4tvoitcSuiaJ7zaC3g_Xt0qSoX3yWlv88SobKzecl8pQ&_hsmi=5656
    9375.

    Such a substantial loss in funding would most certainly impact the
    coverage of Medicaid expansion patients, including those with lung
    disease. It is only logical that states would be forced to cover fewer
    services or fewer people with less money. Additionally, seven states
    have ``trigger laws'' that would effectively eliminate Medicaid
    expansion immediately or soon after the expansion match rate is
    eliminated. Patients in these states would lose their healthcare
    coverage without any other options. The elimination of Medicaid
    expansion coupled with the elimination of subsidy assistance in the
    marketplace would result in significant coverage losses.
    Prevention and Public Health Fund
    The ACA dedicated funding for prevention and public health--in an
    attempt to improve the health of Americans and reduce the number of
    Americans with chronic disease. The Prevention and Public Health Fund
    (Prevention Fund) has allowed the Centers for Disease Control and
    Prevention (CDC) to increase its reach, working with patients to
    prevent disease. Prevention is almost always less expensive than
    treatment and is a good investment for patients. The Prevention Fund
    allowed for the designation of more smoke free public spaces, helping
    ensure people, including kids with asthma breathe clean air. It is
    responsible for funding the Tips From Former Smokers Campaign, which
    has helped 500,000 Americans quit smoking. The Prevention Fund
    currently comprises 12 percent of CDC's budget and is critical in
    ensuring that CDC can continue its important and life-saving work.

    The Graham-Cassidy bill threatens the health of far too many lung
    disease patients. It jettisons key patient protections that individuals
    afflicted by lung disease depend on in order to breathe. It is
    irresponsible to move forward on this bill, as it does not protect
    patients. The American Lung Association urges Congress to continue the
    important bipartisan effort to improve our healthcare system rather
    than advancing the Graham-Cassidy bill which would eliminate coverage
    for many Americans and devastate patients with pre-existing conditions.
    The American Lung Association stands by, ready to work with you on
    legislation to ensure all Americans have access to affordable and
    adequate healthcare coverage.

    Sincerely,

    Harold P. Wimmer
    National President and CEO

                     Consensus Healthcare Reform Principles

    Today, millions of individuals, including many with preexisting health
    conditions, can obtain affordable healthcare coverage. Any changes to
    current law should preserve coverage for these individuals, extend
    coverage to those who remain uninsured, and lower costs and improve
    quality for all.

    In addition, any reform measure must support a health care system that
    provides affordable, accessible and adequate healthcare coverage and
    preserves the coverage provided to millions through Medicare and
    Medicaid. The basic elements of meaningful coverage are described
    below.

    Health Insurance Must Be Affordable--Affordable plans ensure patients
    are able to access needed care in a timely manner from an experienced
    provider without undue financial burden. Affordable coverage includes
    reasonable premiums and cost sharing (such as deductibles, copays and
    coinsurance) and limits on out-of-pocket expenses. Adequate financial
    assistance must be available for low-income Americans and individuals
    with preexisting conditions should not be subject to increased premium
    costs based on their disease or health status.

    Health Insurance Must Be Accessible--All people, regardless of
    employment status or geographic location, should be able to gain
    coverage without waiting periods through adequate open and special
    enrollment periods. Patient protections in current law should be
    retained, including prohibitions on preexisting condition exclusions,
    annual and lifetime limits, insurance policy rescissions, gender
    pricing and excessive premiums for older adults. Children should be
    allowed to remain on their parents' health plans until age 26 and
    coverage through Medicare and Medicaid should not be jeopardized
    through excessive cost-shifting, funding cuts, or per capita caps or
    block granting.

    Health Insurance Must Be Adequate and Understandable--All plans should
    be required to cover a full range of needed health benefits with a
    comprehensive and stable network of providers and plan features.
    Guaranteed access to and prioritization of preventive services without
    cost-sharing should be preserved. Information regarding costs and
    coverage must be available, transparent, and understandable to the
    consumer prior to purchasing the plan.

                                     ______

    February 2, 2017

    Dear Senators and Representatives:

    Our organizations write to ask for your support for ensuring access to
    healthcare for the more than tens of millions of Americans living with
    or at risk for lung cancer. As Congress moves forward with its
    discussions regarding healthcare, we ask that you recognize those
    impacted by lung cancer need access to quality and affordable
    healthcare.

    Lung cancer is the nation's leading cause of cancer death of women and
    men, killing more than 158,000 Americans each year. In 2016, an
    estimated 224,000 Americans were diagnosed with lung cancer,
    representing about 13 percent of all cancer diagnoses. The 5-year
    survival rate for lung cancer is 55 percent for people whose cancer is
    detected when the disease is localized in the lungs; however, only 16
    percent of lung cancer cases are diagnosed at this early stage. For
    lung cancer that has already spread, the 5-year survival rate is only 4
    percent.

    To help improve these often-grim statistics, in the last 2 years, the
    Food and Drug Administration has approved eight new drug therapies for
    the treatment of lung cancer--giving new hope to patients and their
    families. Many lung cancer patients are alive today because of key
    healthcare protections currently in effect that eliminated pre-existing
    condition prohibitions, lifetime and annual benefit limits, coverage
    rescissions and access to preventive services, including lung cancer
    screening for individuals at high risk and smoking cessation
    treatments. Together these protections ensure lung cancer patients have
    access to new break-through treatments and early detection. Our
    organizations oppose attempts to weaken or eliminate any of them.

    A stable and affordable insurance marketplace is vital to lung cancer
    patients and their families. Instability in the marketplace because of
    the unknown will jeopardize affordability and access, especially in the
    individual marketplace. We also recognize that proposals that only
    guarantee health insurance for those who are able to retain continuous
    coverage and that may also impose waiting periods on those who do not
    retain such coverage would place barriers to access. Given the
    disabling impact cancer has on a person's life and ability to work,
    these provisions could put patients with lung cancer at risk for losing
    their care.

    We are committed to working with you to ensure that our nation's
    healthcare system will protect individuals with lung cancer and ensure
    they have access to quality and affordable healthcare.

    Thank you.

    Sincerely,

    American Lung Association           Lung Cancer Alliance
    Addario Lung Cancer Medical
    Institute                           Bonnie J. Addario Lung Cancer
                                        Foundation
    Cancer Support Community            Cancer Survivors Against Radon,
                                        Inc. (CanSAR)
    CancerCare                          Caring Ambassadors Program, Inc.
    Citizens for Radioactive Radon
    Reduction, Inc.                     Dusty Joy Foundation (LiveLung)
    Free ME From Lung Cancer            Free to Breathe
    Lung Cancer Circle of Hope          Lung Cancer Initiative
    Lung Cancer Research Council        Lung Cancer Research Foundation
    LUNGevity Foundation                Respiratory Health Association
    Rexanna's Foundation for Fighting
    Lung Cancer                         Upstage Lung Cancer

                                     ______

                       American Nurses Association (ANA)

                              8515 Georgia Avenue

                            Silver Spring, MD 20910

    Introduction

    On behalf of our members and the 3.6 million Registered Nurses, the
    American Nurses Association (ANA) would like to thank Chairman Hatch
    and Ranking Member Wyden for having a hearing on the Graham-Cassidy
    proposal. The hearing will highlight the critical role healthcare
    plays--and will continue to play--in the lives of millions of
    Americans. However, the current proposal would create devastating cuts
    to the current American healthcare system, resulting in a loss of
    coverage for millions of Americans--as a result, ANA opposes the
    Graham-Cassidy proposal.

            As the largest and most trusted healthcare profession, nurses
            directly see the effects of health system reform on patient
            care. ANA denounces the latest Senate proposal as its worst
            yet. This plan rips coverage from millions of Americans, guts
            Medicaid, kills pre-existing conditions protections, and would
            have devastating consequences for patients. Patients deserve
            better and we won't rest until they get it. --ANA President
            Pamela F. Cipriano, Ph.D., RN, NEA-BC, FAAN.

    As written, the legislation would make deep cuts to Medicaid, ending
    the Affordable Care Act's (ACA) expansion and fundamentally changing
    the program to a per-
    capita block grant financing system. In addition, the bill would erode
    critical consumer protections for pre-existing conditions and essential
    health benefits. These costs would result from the absence of a
    streamlined standard for states, and the potential absence of
    preparedness and health system development in states. Lastly, the
    proposal would wipe out subsidies for the purchase of private health
    coverage. The proposal fails to meet ANA's principles for health system
    transformation.

            Tarik Khan--I am a Nurse Practitioner (NP) living in
            Philadelphia. This bill will reverse all of the protections
            that we got with the ACA. The ban on annual and lifetime limits
            has been gotten rid of. They got rid of essential health
            benefits, there is a reason why they are called ``essential''
            health benefits, and they are getting rid of them completely.
            In addition, pre-existing conditions--if you have a pre-
            existing condition, you are going to have to pay exponentially
            more for healthcare, which is not fair. I have patients in
            Philadelphia who are going to lose their health insurance.
            Moreover, million are going to lose their Medicaid. As an NP it
            is something that I can't let happen. I took a pledge to
            advocate for my patients and to look out for their general
            welfare. This bill goes against all of that, so I am here to
            advocate for nursing and our patients.

            Joyce Wilson--I am a Nurse Practitioner. I live and work in
            rural West Virginia with West Virginia Nurses Association and
            ANA advocating for senators to vote no on this proposal,
            because it's going to take coverage away from patients in West
            Virginia. It's especially essential in West Virginia because
            except for New York, we have the second most expanded Medicaid
            in the nation, so 170,000 people got coverage there for the
            first time in their life. In West Virginia, we are usually in
            the top five of the most ``unhealthy states'' in the nation,
            but now we have a chance to turn that around. We have people
            that are getting their A1Cs under control, getting their blood
            pressures under control, their heart disease under control. So
            it's absolutely essential that we do not vote for this bill,
            and I hope that you'll come see us in West Virginia. We have
            other great things, we have beautiful mountains, and we have
            rivers, beautiful people. Therefore, we hope that you will come
            and see us and we hope that you will vote no to take away our
            healthcare.

            Karen Brown--I'm a Registered Nurse, and I live and work in
            Lynchburg, VA. I also represent the Virginia Nurses
            Association, as I am the chapter president for chapter 3.
            Currently, the healthcare covers essential health benefits--
            like wellness checkups, prescription drug coverage, maternal-
            child care, substance abuse treatments, the list is long. With
            the new healthcare bill that is being proposed, essential
            health benefits could be taken away, and that affects every
            single one of us. It impacts you, your family, your health, and
            your community.

    Medicaid Cuts and Elimination of Medicaid Expansion

    The per-capita limits on Medicaid funds for states threaten excessive
    strain on state budgets and reduced coverage for the most vulnerable.
    The per-capita limits directly affect individuals with multiple complex
    conditions. Limiting the federal support for these patients will
    cripple states' financial stability. Without the guarantee of federal
    funds for all Medicaid enrollees, patients will face poorer healthcare
    outcomes and may potentially lose coverage altogether. While the ANA
    supports cost sharing and the economic use of healthcare resources, we
    believe that converting the Medicaid program to a block grant would
    unduly restrict access to healthcare services to the nation's most
    vulnerable citizens and would represent a roll back of the effort to
    ensure access to quality healthcare for all Americans.

    The Graham-Cassidy bill would have a devastating impact on Americans
    who rely upon Medicaid for healthcare coverage. Roughly 70 million
    Americans rely on Medicaid for critical healthcare services in a given
    year. Many of these individuals are children or are elderly, disabled,
    low-income, or a combination of the three. In addition, millions of
    Medicaid recipients are able-bodied adults who do, in fact, hold steady
    employment and provide for families; close to two-thirds of Medicaid
    recipients are employed. The expansion (by most states) of Medicaid
    eligibility to Americans living just above the federal poverty level
    has had a major impact on the number of uninsured Americans and has
    provided needed healthcare services to individuals with complex and
    chronic diseases, including mental health and substance use disorders.
    In short, Medicaid is a vital source of healthcare services for
    American citizens and has improved the lives of millions of Americans.
    Medicaid is also an example of a successful state federal partnership
    and has allowed states the flexibility to run innovative healthcare
    programs--under broad federal guidelines--which best serve the unique
    needs of their citizens.

    The Graham-Cassidy bill would, however, not only undo the progress made
    under Medicaid expansion, but would significantly lessen the ability of
    Medicaid to provide adequate healthcare services. The bill proposes to
    freeze Medicaid expansion immediately, and would prohibit all states
    from keeping expansion in 2020 and beyond. This bill would effectively
    seize healthcare coverage from the nearly 11 million Americans who have
    gained coverage through Medicaid expansion since 2014. Furthermore, the
    bill would limit the amount of federal money available to state
    Medicaid programs for other populations, including the elderly,
    disabled, and children by imposing a per capita cap system and giving
    states the option to convert their Medicaid programs into block grants.
    The growth in funding levels proposed by the bill would not
    realistically meet the needs of the Medicaid population, and would put
    medical care, nursing home care, home- and community-based services,
    and other services and supports at risk.

    Several reports issued in the past 2 days have reiterated the enormous
    impacts of these Medicaid changes. In particular, states that have
    expanded Medicaid, including Alaska, Oregon, Delaware, and Washington,
    would face significantly higher cuts of 25 percent or more between 2020
    and 2026. These cuts would be even starker past 2026, after which
    funding is not appropriated and states would experience a fiscal cliff,
    adding to the swirl of uncertainty created by this bill. What is
    crystal clear, however, is the fact that the Medicaid provisions
    proposed in this bill are enormous and would endanger the healthcare of
    millions of Americans--including children, the elderly, and the
    disabled. These proposed changes to the Medicaid program go against all
    of ANA's principles of health system transformation and would be an
    unmitigated disaster with respect to the health of the nation.

    Impact on Insurance Premiums

    The Graham-Cassidy bill proposes major changes to the U.S. healthcare
    system, including the repeal of the individual mandate, premium tax
    credit subsidies, and cost-sharing reductions. The bill also proposes
    to allow states to waive requirements related to essential health
    benefits, medical underwriting, and age rating, among others. While
    Graham-Cassidy nominally keeps in place provisions of the ACA, it makes
    it much easier for states to seek waivers to opt out of these
    requirements. While this could potentially make premiums slightly less
    expensive for some segments of the population, it would adversely
    affect some of the most vulnerable Americans: those with pre-existing
    conditions. While states would not be permitted to seek a waiver of the
    guarantee issue requirement under current law, the other provisions of
    law that they could waive could essentially price people with pre-
    existing conditions out of the market. Insurers would be able to raise
    premiums based on an individual's medical history while at the same
    time excluding certain benefits necessary to that individual's care. In
    essence, health insurance would be pointless and unattainable. Further,
    given the erosion in funding under the plan's Market-Based Health Care
    Grant Program, states would have less of an ability to assist
    individuals with pre-existing condition or to those with low-incomes.
    This bill would in essence allow for the creation of bifurcated
    healthcare systems in individual states and would negatively affect the
    most vulnerable populations of Americans. This once again goes against
    ANA's principles of health system transformation and moves away from
    creating an equitable system for all Americans.

    Programmatic and Implementation Concerns

    The Graham-Cassidy bill would also put an impossible burden on states
    when it comes to implementation of its provisions. The bill gives very
    broad policy latitude to states when it comes to their own state health
    systems and the implementation of such. However, healthcare is
    complicated. States must decide the types of systems they want to
    implement, the parameters of those systems, and then implement those
    systems. Implementation includes contracting, system building, etc.
    This is an incredibly complicated and long-term process; the Graham-
    Cassidy bill, however, gives states a 2-year window to accomplish all
    of this without so much as a mention of any federal aid or guidelines.
    This is a Herculean task for any state; legislative schedules and other
    policy priorities complicate it further. It is clear that this bill
    cares little about the meaningful provision of care in the states. Such
    a limited and rushed timeframe would be detrimental to the effort of
    implementing the already flawed policy proposals in this bill.

    Pre-Existing Conditions and Essential Health Benefits

    The Graham-Cassidy proposal weakens the pre-existing conditions
    protections included in the ACA. While the requirement for coverage for
    pre-existing conditions remains, patients with such conditions may face
    higher premium costs. The proposal weakens the standards for essential
    health benefits, and limits consistency of regulations on a state-by-
    state basis. These changes are in direct conflict with ANA principles
    that support a consistent and clear set of essential health services
    for all citizens and residents.

    The ACA has incentivized the use of preventive services in order to
    ensure that Americans receive the care they need, when they need it--
    this not only prevents more complex, chronic, and serious health
    conditions in the long term, but also saves money on patient care. The
    Graham-Cassidy proposal repeal would strip these incentives and instead
    put up barriers to receiving critical preventive services.

    Justin Gill, Registered Nurse, and Nurse Practitioner, has seen the
    effect of pre-
    existing conditions on his own family's health. Before the ACA, Justin
    was able to recall when premiums and costs were extremely high for his
    parent's, both of whom had pre-existing conditions. Justin's family had
    to deal with premiums above $1,000 dollars per month, with out of
    pocket costs up to $10,000 dollars. His family faced serious financial
    strain as a result of discrimination for pre-existing conditions. His
    family avoided regular preventative visits, because of the high out-of-
    pocket costs. After the Affordable Care Act, his parents were able to
    access more affordable health insurance without questions related to
    pre-existing conditions.

    Because of this, Justin's father was able to utilize his insurance, and
    was less afraid to have his conditions evaluated. His father was seen
    for problems with chest pain, and required an open-heart surgery.
    Because of tax subsidies and lower out-of-
    pocket costs, Justin's family avoided crushing medical bills. Justin
    saw the irony of his career goals and his family's previous struggles.
    ``I remember going through school to help serve the healthcare needs of
    others, yet I saw the burden of discrimination of pre-existing
    conditions in my own family.'' As a Nurse Practitioner, he has also
    been able to see the impact on his own patients. ``I have seen newly
    insured patients that had access to life saving preventative services
    as a result of the ACA.''

            Pam Cipriano--I am a Registered Nurse and president of the
            American Nurses Association. I carry around with me this list
            of ESSENTIAL HEALTH BENEFITS because people don't understand
            what they are. Benefits like PRESCRIPTION DRUG COVERAGE mean my
            elderly neighbor doesn't have to tell the pharmacist, ``I can't
            pick up my heart medicine because I can't afford it.'' These
            benefits provide ADDICTION TREATMENT to help families coping
            with the heartbreak and overdose deaths addiction often leaves
            in its wake. Guaranteed MENTAL HEALTH SERVICES means my
            patients can get the help they need long before their
            depression spirals into suicide. MATERNITY AND NEWBORN CARE
            means pregnancy is no longer a pre-existing condition, and that
            every new mother and her infant get the care they need--before
            and after childbirth.

    Workforce

    Employment in the healthcare sector has grown quickly in recent years
    in large part due to changes in the ACA and increased patient caseload.
    More nurses working in the healthcare sector allows for higher quality
    care delivery and better patient outcomes. The Graham-Cassidy bill
    would likely result in massive job losses in the healthcare sector,
    affecting the quality of care nurses are able to provide to their
    patients.

          CNM reimbursements under Medicare Part B cut by 35%.
          912,000 healthcare jobs lost by 2019; 1,003,000 healthcare jobs
    lost by 2023.
          RN/APRN job losses: above average employment, gains by 2015 and
    2016 total 107,996 additional jobs (not counting self-employed and
    supervisory positions not included in BLS OES.)

    ANA Principles of Health System Transformation

    Ensure universal access to a standard package of essential healthcare
    services for all citizens and residents. This includes:

          An essential benefits package that provides access to
    comprehensive services, including mental health services.
          Prohibition of the denial of coverage because of a pre-existing
    condition.
          Inclusion of children on parent's health insurance coverage
    until age 26.
          Expansion of Medicaid as a safety net for the most vulnerable,
    including the chronically ill, elderly, and poor.

    Optimize primary, community-based and preventive services while
    supporting the cost-effective use of innovative, technology-driven,
    acute, hospital-based services. This includes:

          Primary healthcare that is focused on developing an engaged
    partnership with the patient.
          Primary healthcare that includes preventive, curative, and
    rehabilitative services delivered in a coordinated manner by members of
    the healthcare team.
          Removing barriers and restrictions that prevent RNs and Advanced
    Practice Registered Nurses (APRNs) from contributing fully to patient
    care in all communities.
          Care coordination services that reduce costs and improve
    outcomes with consistent payment for all qualified health professionals
    delivering such services, including nurses.

    Encourage mechanisms to stimulate economic use of healthcare services
    while supporting those who do not have the means to share in costs.
    This includes:

          A partnership between the government and private sector to bear
    healthcare costs.
          Payment systems that reward quality and the appropriate,
    effective use of resources.
          Beneficiaries paying for a portion of their care to provide an
    incentive for the efficient use of services while ensuring that
    deductibles and co-payments are not a barrier to receiving care.
          Elimination of lifetime caps or annual limits on coverage.
          Federal subsidies based on an income-based sliding scale to
    assist individuals to purchase insurance coverage.

    Ensure a sufficient supply of a skilled workforce dedicated to
    providing high quality healthcare services. This includes:

          An adequate supply of well-educated, well-distributed, and well-
    utilized registered nurses.
          Increased funding, whether grant or loan repayment based, for
    programs and services focused on increasing the primary care workforce.
          Funding to elevate support for increasing nursing faculty and
    workforce diversity.

    Conclusion

    Nurses provide care in virtually every healthcare setting from cradle
    to grave, providing expert, compassionate healthcare services for
    people throughout all stages of life. ANA has asked the Administration
    and Congress repeatedly to keep our patients' access to affordable,
    quality care foremost in their discussions over how to improve our
    nation's healthcare system. It is for the reasons laid out above that
    that the American Nurses Association strongly opposes the Graham-
    Cassidy proposal. This bill would not improve the U.S. healthcare
    delivery system--rather, it would significantly weaken it and would rip
    away access to vital healthcare coverage and patient protections that
    have been put into place over the last 7 years.

    ANA asks the Committee and the Senate to keep our patients' access to
    affordable, quality care foremost in their discussions over how to
    improve our nation's healthcare system. ANA stands ready to work with
    Congress as a constructive voice and positive force for improving
    healthcare delivery, coverage, and affordability for the American
    people.

                                     ______

                        American Thoracic Society (ATS)
    The American Thoracic Society (ATS) appreciates the opportunity to
    submit a statement for the record on the Graham-Cassidy bill.

    The ATS is a medical professional organization of over 16,000 members
    dedicated to the prevention, detection, treatment, cure, and research
    of pulmonary disease, critical care illness, and sleep disordered
    breathing. ATS members pursue this mission of research, education,
    clinical care, and advocacy. The members of the ATS serve a diverse
    population of patients with common respiratory diseases like asthma,
    COPD and sleep apnea, and less common respiratory diseases like
    sarcoidosis, pulmonary hypertension, and LAM. Regardless of the
    disease, all our patients benefit from having affordable health
    insurance. For many of our patients, it is literally a matter of life
    and death. It is with our experience as health care providers and our
    concern for the patients who we treat that we offer the following
    comments.

    The ATS has serious concerns with the Graham-Cassidy legislative
    proposal. We note with grave concern that the Senate appears to be
    willing to consider this legislation without appropriate committee
    hearings, with minimal time for input from the public, including health
    care experts and little to no formal input on the likely short and
    long-term consequences of the proposal. The ATS is deeply concerned
    that the Senate may even consider this legislation without complete
    input from the non-partisan Congressional Budget Office. The ATS
    expects that the proposed legislative repeal of the individual and
    employer mandates will have a large impact on increasing the number of
    uninsured Americans in the next several years. While the magnitude of
    its effect on rising insurance costs is yet to be estimated by CBO, it
    is highly likely that the effects will be significant.

    Further, as drafted, the legislation will erode certain basic health
    insurance reforms like community rating and lifetime caps that have
    improved the private health insurance market for American consumers.
    Both the individual mandate repeal and the erosion of private market
    reforms will lead to millions of Americans losing health insurance in
    the foreseeable future.

    That the Senate, the self-proclaimed ``world's most deliberative
    body,'' would consider major legislation to fundamentally restructure a
    significant part of the U.S. economy and social welfare system without
    input from CBO demeans the reputation of the august body.

    If enacted, this bill would result in a massive transfer of financial
    burden to the states. The ATS notes both Republican and Democratic
    governors have expressed their strong opposition to this proposal. The
    ATS believes the estimated block grant funding provided under this
    proposal is substantially below what is necessary to meet the health
    needs of Americans currently covered and represents a massive unfunded
    mandate on the states. Further, we note that block grant funding ends
    completely in 2026. The ATS is perplexed that the drafters of the
    legislation believe that the health care needs of the American public
    will end in 2026.

    Concerning Medicaid, the Kaiser Family Foundation has estimated that
    the bill would cut up to $180 billion between 2020 and 2026 to states
    that have expanded Medicaid because the bill would redistribute funds
    to non-Medicaid expansion states, and additionally, impose a per-person
    cap on all state Medicaid funding. Medicaid expansion states would lose
    an average of 11 percent in Medicaid funding, but states such as
    California and New York could lose 35 percent of their Medicaid funding
    between 2020 and 2026. The reductions and changes to the Medicaid
    program under the Graham Cassidy bill would force states to make
    significant reductions in Medicaid enrollment, covered benefits and
    provider reimbursement. The Graham-Cassidy bill would decimate the
    social safety net for millions of Americans, including the disabled and
    children. This is unacceptable.

    The Graham-Cassidy bill allows states to waive the ACA's essential
    health benefits and define their own set of covered benefits without
    federal review or approval. Waiving essential health benefits such as
    prescription drug coverage, chronic disease management, laboratory
    services and maternity and pediatric care will lead to reduced coverage
    and much higher costs for needed diagnosis, treatment and preventive
    health care services for many Americans. It would result in some low-
    income patients with chronic diseases such as COPD being unable to
    afford life-
    saving treatments and services. All Americans need access to
    comprehensive diagnosis, treatment and preventive health care. The ATS
    strongly opposes any proposal that weakens coverage of the ACA's
    essential health benefits.

    Finally, the Graham-Cassidy proposal would repeal the ACA's Prevention
    and Public Health Fund, a key source of funding for state and local
    services for treatment of tobacco dependence, education efforts, and
    other critical public health capabilities for the prevention of chronic
    and infectious diseases. The ATS is opposed to any effort to repeal the
    Prevention and Public Health Fund.

    For the reasons, stated above, the ATS opposes the Graham-Cassidy bill.
    We instead urge the Senate to resume the encouraging bipartisan
    negotiations efforts led by Senator Alexander and Senator Murray to
    craft bipartisan solutions to the shortcomings of the Affordable Care
    Act.

                                     ______

                    America's Health Insurance Plans (AHIP)

             601 Pennsylvania Avenue, NW, Suite 500, South Building

                              Washington, DC 20004

                                      and

                   Blue Cross Blue Shield Association (BCBSA)

                               1310 G Street, NW

                              Washington, DC 20005

    On behalf of the two largest associations representing the community of
    health plans across the United States--America's Health Insurance Plans
    (AHIP) and the Blue Cross Blue Shield Association (BCBSA)--we
    appreciate the opportunity to comment on the Graham-Cassidy-Heller-
    Johnson (GCHJ) legislation, which proposes a block grant approach to
    replacing the financial assistance provisions of the Affordable Care
    Act (ACA) and also calls for a per capita cap Medicaid financing system
    beginning in 2020.

    AHIP is the national association whose members provide coverage for
    health care and related services to millions of Americans every day.
    Through these offerings, we improve and protect the health and
    financial security of consumers, families, businesses, communities, and
    the nation. We are committed to market-based solutions and public-
    private partnerships that improve affordability, value, access, and
    well-being for consumers.

    BCBSA is a national federation of 36 independent, community-based and
    locally operated Blue Cross and Blue Shield companies that collectively
    provide health care coverage for one in three Americans. BCBS companies
    have an 85-year history providing coverage across all markets in their
    local communities and are major providers of health coverage in the
    individual market and in the majority of Exchanges.

    In previous separate statements for the committee's September 12th
    hearing, we outlined our recommendations on steps that can be taken in
    the short-term to provide relief to consumers, reduce uncertainty, and
    stabilize the individual health insurance market. We continue to
    believe it is important for Congress to focus on stabilizing the
    individual market for 2018 and 2019 to ensure that Americans have high
    quality, affordable coverage options. This approach would help
    consumers obtain the coverage and care they need, while providing
    Congress and the states an opportunity to fully consider and debate
    longer-term reforms.

    For today's hearing, our statement focuses on: (1) principles that
    Congress should consider in developing legislation that would reform
    and affect the coverage and care of millions of Americans; (2) policy
    and operational concerns associated with the GCHJ proposal; (3) the
    negative impact the bill would have on low-income and vulnerable
    populations covered through Medicaid; and (4) initial research findings
    showing that this proposed legislation would harm many consumers who
    obtain coverage through the individual health insurance market and the
    Medicaid program.

    Principles for Legislation Addressing Coverage and Care for the
    American People

    Throughout this debate, our organizations have been committed to engage
    in a collaborative, constructive way to address existing challenges in
    health care, particularly in the individual market. We have offered
    recommendations and solutions that will best deliver on the goals we
    share: More choices, lower premiums, help for those who need it, and
    lower costs for hardworking taxpayers.

    We believe that legislative proposals that would reform and affect the
    coverage and care of millions of Americans should meet certain
    principles.

    First, reforms must stabilize the individual insurance market.
    Stability in the individual market has always been challenging, and we
    are committed to making this market work. The most important solution
    for short-term stability is to fund cost-sharing reduction benefits,
    which help millions of lower-income people afford the care they need.
    Long term, adopting proven models of success--for example, elements of
    the successful Medicare Part D program, such as reinsurance for high
    dollar claimants--could deliver greater stability, lower costs for
    taxpayers, higher consumer satisfaction, and better health outcomes.

    Second, Medicaid reforms must ensure the program is efficient,
    effective, and has adequate funding to meet the health care needs of
    beneficiaries. Medicaid serves a diverse population of over 70 million
    Americans, including some of the most medically vulnerable among us.
    Any Medicaid reforms must guarantee that states have sufficient
    resources to ensure the continuity of coverage and care that
    beneficiaries depend on. State flexibility can improve the program, but
    solutions must ensure the sustainability of Medicaid and affordability
    in the individual market given how people often move between programs.

    Third, reforms must guarantee access to coverage for ALL Americans,
    including those with pre-existing conditions. No one should be denied
    or priced out of affordable coverage because of their health status. To
    ensure that coverage is more affordable for everyone, strong
    protections must be coupled with strong incentives that encourage
    individuals to maintain continuous coverage.

    Fourth, reforms must provide sufficient time for everyone to prepare--
    from doctors, hospitals, and health plans to consumers, patients, and
    policymakers. States need time to plan, analyze, and make decisions
    that could have profound effects on their residents, local health care
    systems, and on their state budgets. Once this is finalized, states
    need to implement the operational infrastructure, and health plans need
    time to develop new coverage options or modify existing ones and have
    them approved prior to making them available in the market. Concurrent
    with this activity, health care providers need time to understand how
    changes will affect them and their patients. And consumers and patients
    need time to understand how their coverage will change.

    Fifth, reforms should improve affordability by eliminating taxes and
    fees that only serve to raise health care costs or reduce benefits for
    everyone. Congress delivered relief from the health insurance tax for
    2017, and eliminating the tax again for next year will lower premiums
    by an average of $158 per member in the individual market.\1\ Not
    eliminating the health insurance tax will cost consumers $267 billion
    over the next 10 years. Similarly, not eliminating the 40 percent
    excise tax will ultimately affect tens of millions of Americans who
    receive health benefits through employer-sponsored coverage when it
    goes into effect in 2020.
    ---------------------------------------------------------------------------
        \1\ Oliver Wyman, ``Analysis of the Impacts of the ACA's Tax on
    Health Insurance in 2018 and Beyond,'' August 8, 2017, http://
    www.stopthehit.com/wp-content/uploads/2017/08/Oliver-Wyman-2018-HIT-
    Analysis%E2%80%8E-August-8-2017.pdf.

    And finally, reforms should rely on the strengths of the private
    market, not build a bridge to single payer systems. To best serve every
    American, we need both a strong private market and an effective role
    for and partnerships with government. Building on the choice,
    competition and innovation of the private sector and the strength,
    security, and dependability of public programs is a far more effective
    solution than allowing states to eliminate private insurance.

    Policy and Operational Concerns With the GCHJ Proposal

    The GCHJ proposal fails to meet our guiding principles for health
    reform. The bill would have negative consequences on consumers and
    patients by further destabilizing the individual market; cutting
    Medicaid; pulling back on protections for pre-existing conditions; not
    ending taxes on health insurance premiums and benefits; and potentially
    allowing government-controlled, single payer health care to grow.

    Additionally, in our analysis of the bill, we have identified a number
    of policy and operational issues that raise serious concerns about the
    GCHJ proposal and how it would affect health care coverage and costs
    for American families. Below we highlight several highly problematic
    concerns--beyond the issues we addressed in our principles above--that
    need to be carefully considered.
    Unrealistic Expectations for States and Their Programmatic Capabilities
    By March 31, 2019--just 18 months after the possible enactment of the
    legislation--GCHJ would require all states to establish state-specific
    comprehensive health coverage programs to receive federal block grant
    funding and prepare to transfer to a per capita cap Medicaid financing
    system. This extremely short timeframe for implementation would likely
    lead to chaos in both the individual market and Medicaid programs in
    all states; these challenges would be layered on top of extensive
    funding reductions in a majority of states.

    We expect reduced choices for consumers due to the uncertainty about
    whether states will be successful in setting up their programs in time
    to enroll consumers in coverage for January 1, 2020, and their ability
    to attract a broad pool of enrollees into the health insurance market.
    Coverage that is available would have to be priced to account for this
    uncertainty, basically guaranteeing little if any choice for lower
    income consumers. This impact would be even greater in more rural
    locations.

    Starting in 2020, it is unclear how states would reuse the existing
    federal infrastructure to provide tax credits to assist consumers in
    purchasing insurance. States would be required to establish a new
    administrative infrastructure to conduct eligibility determinations,
    deliver subsidies to health plans, facilitate enrollment, and set up
    other programs (e.g., high risk pools or reinsurance programs). It is
    unlikely that states could use the federal infrastructure to administer
    their programs because it was designed to administer federal tax
    credits.

    The amount of work and resources involved in meeting the requirements
    to operationalize the new block grant system cannot be overstated. Not
    only does GCHJ fall far short on the needed timeframe to develop and
    implement such complex systems, it provides very few resources to do
    so. This means that already cash-strapped states would have to invest
    significant funds to even get basic functions running by January 1,
    2020. It is not clear that any state has the capability of doing so
    under these constraints.
    No Incentives for Continuous Coverage
    Repeal of the individual mandate without a replacement would have an
    immediate destabilizing effect on the individual market. GCHJ zeros out
    the individual mandate penalties--retroactive to January 1, 2016--
    without establishing any alternative approach to promoting continuous
    coverage. This would have an immediate impact on the health insurance
    market for the remainder of 2017 and for 2018 where rates have already
    been approved based on the assumption that the existing mandate would
    remain in place.

    GCHJ fails to take any steps to ensure that state programs broaden the
    risk pool as much as possible, ensuring that individuals of all ages
    and health status are insured, not just those who are higher-risk or
    costlier to insure. In fact, GCHJ maintains the existing requirement
    that health plans offer coverage to everyone that applies (i.e.,
    ``guaranteed availability'' and ``guaranteed issue''), thus creating
    more incentives for people to delay purchasing health care coverage
    until they have an immediate health care need. This approach would
    drive up costs for everyone. It creates a regulatory environment in
    which fewer younger, healthier individuals will be incentivized to get
    coverage and the overall pool of people purchasing health insurance
    will be weighted more heavily with older and less healthy people. This
    will lead to further market instability, higher costs, fewer choices,
    and the loss of coverage for millions of Americans.
    Constantly Shifting Budgets and Uncertainty for States
    The block grant formula proposed by GCHJ would undergo several changes
    between 2020 and 2026, and the funding would be completely eliminated
    after 6 years unless Congress reauthorizes the funding. This would
    result in constantly shifting budgets which, in turn, would create a
    high level of uncertainty for states as they try to plan for the
    future. Moreover, states would be faced with difficult choices about
    which populations to serve, especially since the proposed funding
    methodology excludes the working poor--those with incomes under 50% of
    the federal poverty level (FPL)--and those with moderate incomes
    (between 138-400% FPL).

    Starting in 2023, the Secretary of Health and Human Services (HHS)
    would be required to use a risk adjustment formula to significantly
    adjust block grant funding. It is unclear how HHS could develop a risk
    adjustment system across states that would each implement their
    programs differently. This would create even more challenges for plans
    as they develop and price products.

    Even with the required investment for programmatic operations to
    account for the new block grant system, the entire program is set to
    expire in only 6 years. It is difficult to imagine states, health
    plans, and health systems devoting significant resources for a program
    whose long-term viability and funding levels are so uncertain.
    Uncertainty for Existing ACA Programs That Are Not Modified
    The existing ACA risk adjustment program for health plans would remain
    in place under GCHJ, but it would become impossible to implement. To
    work effectively, risk adjustment requires a uniform set of benefits
    and consistent rating approaches to manage against adverse selection.
    The very core of GCHJ seeks to remove uniformity in these areas, making
    a federal risk adjustment program unfeasible.
    Uncertainty for Health Plan Business Planning
    Insurers plan several years in advance before making decisions about
    their participation in new markets. Under GCHJ, the implementation of
    major reforms in 2020 would leave little to no opportunity for health
    plans to determine the potential market or rules of operation before
    they make decisions about the products they offer. Moreover, states
    would have broad flexibility in deciding how to use their block grant
    funding. Some of the potential options, including direct payments to
    providers and a single-payer structure, would remove any role for
    private coverage, thereby taking away valuable coverage options from
    consumers.

    In addition, since states submit their applications for how they will
    use their portion of the market based grants on March 31st of the
    preceding year, it is unclear how insurers will know how this affects
    the pricing for both individual market products and Medicaid managed
    care for the following year given that states and insurers will not
    know the grant amount until much later in the year.
    Negative Impact on Employer-Sponsored Coverage
    While employer-sponsored coverage is not the primary focus of the GCHJ
    proposal, it likely would have a negative impact on the 177 million
    Americans who get their health insurance coverage through work.

    Several factors would cause employees to either lose coverage, face
    higher costs, or see a reduction in benefits:

      Because states can waive essential health benefits, self-insured
    employers would be able to reinstate annual and life-time benefit
    limits that were common before the ACA. This would severely impact
    employees who have an ongoing need for expensive health care services
    and treatments such as chemotherapy.

      GCHJ maintains taxes that directly increase consumer costs and limit
    benefits, including the ACA health insurance tax and the Cadillac tax--
    both of which raise out-of-pocket costs for Americans who get coverage
    through work.

      Under GCHJ, health care providers would be likely to see more
    uninsured patients and would be likely to receive lower reimbursement
    rates under the new systems implemented by states. This, in turn, would
    cause provider payment rates to increase in other markets--including
    the market for employer-sponsored health coverage. This type of cost-
    shifting, from public programs to private payers, would increase under
    GCHJ since there would be more uninsured patients who are unable to pay
    their medical bills and there would be more providers receiving
    reimbursement rates that fail to cover their actual costs of delivering
    medical care.

    Effects on Low-Income and Vulnerable Populations Covered Through
    Medicaid

    The GCHJ proposal would significantly reduce the federal government's
    role in financing health benefits for Medicaid beneficiaries, while
    also limiting the funds available to support private coverage options
    for individuals with modest incomes who are not eligible for Medicaid.

    As we discuss in the next section below, a new analysis from Avalere
    estimates that GCHJ would reduce federal Medicaid funding by $713
    billion over 2020-2026 and by more than $3.5 trillion over 2020-2036 if
    the bill's block grant funding is not reauthorized. The authors
    conclude: ``Funding cuts of this magnitude will force states to re-
    evaluate their Medicaid programs, including the number of individuals
    covered and the generosity of the provided benefits.''

    In examining the impact of these cuts, it is important for policymakers
    to recognize that the individual market and Medicaid are closely
    related with respect to the partial overlap in the populations they
    serve. For example, many low-wage employees do not have access to
    employer-sponsored coverage and need help accessing affordable
    coverage; if their incomes fall due to loss of employment or other
    reasons, Medicaid becomes an important safety net.

    Conversely, individuals with Medicaid who move up the economic ladder
    may lose eligibility and need affordable coverage in the individual
    market. Reducing subsidies for their coverage--as GCHJ proposes--would
    create incentives for people to remain at an income level that
    qualifies for Medicaid coverage and, as a result, have the perverse
    effect of discouraging people from lifting themselves up out of
    poverty.

    Given how the two markets interact with respect to a diverse and often
    vulnerable population, Congress should ensure that federal policies are
    designed to ensure both the long-term stability and affordability of
    the individual market and continued strength and long-term
    sustainability of the Medicaid program. The GCHJ proposal fails to meet
    these objectives.

    Initial Research Findings on the Impact of the GCHJ Proposal

    We believe the extensive reforms in the GCHJ proposal should not be
    fast-tracked for passage by September 30th. Instead, additional time
    should be allowed for the Congressional Budget Office (CBO) to produce
    a comprehensive analysis of the bill and for states to fully understand
    the proposed financial and structural impact to their individual health
    insurance markets and Medicaid programs.

    Research findings by several organizations raise important issues and
    questions that should be examined more closely before the Senate votes
    on the GCHJ bill. Below we highlight a number of these findings, which
    are based on legislative language released on September 13th. An
    updated bill, released on September 24th, appears to be even more
    problematic, proposing to create two separate systems of health
    coverage--one for healthy people and another for sick people. This
    approach is unworkable in any form and would undermine protections for
    those with pre existing medical conditions, increase premiums, and lead
    to widespread terminations of coverage for people currently enrolled in
    the individual market.

    A new study by Avalere estimates that GCHJ would reduce, relative to
    current law, federal Medicaid funding by $713 billion over 2020-2026
    and by more than $3.5 trillion over 2020-2036, if the bill's block
    grant funding is not reauthorized.\2\ For the 2020-2026 time period,
    this includes $593 billion in cuts that are attributed to the proposed
    block grants and $120 billion that are attributed to the proposed
    Medicaid per capita cap system. Avalere estimates that 34 states and
    the District of Columbia would experience Medicaid funding reductions
    through 2026, and all states would see a reduction in their federal
    Medicaid funding by 2036.
    ---------------------------------------------------------------------------
        \2\ Avalere, ``Graham-Cassidy-Heller-Johnson Bill Would Reduce
    Medicaid Funds to States by $713B Over the Next 10 Years,'' Chris
    Sloan, Richard Kane, September 22, 2017, http://avalere.com/expertise/
    managed-care/insights/graham-cassidy-heller-johnson-bill-would-reduce-
    medicaid-funds-to-states-by.

    While discussing the Medicaid funding cuts that 34 states would
    experience in 2020-2026, the Avalere study explains: ``These states
    include all expansion states and three states (Arkansas, Iowa, and
    Maine) that see large reductions in their traditional Medicaid spending
    due to per capita caps. As expansion states are only permitted to use
    15% of their block grant allotments in Medicaid, their total Medicaid
    ---------------------------------------------------------------------------
    funding would be substantially reduced.''

    Another study, released by Manatt Health, outlines the following
    findings: \3\
    ---------------------------------------------------------------------------
        \3\ Manatt Health, ``Update: State Policy and Budget Impacts of New
    Graham-Cassidy Repeal and Replace Proposal,'' September 2017, http://
    www.statenetwork.org/wp-content/uploads/2017/09/SHVS_Graham-Cassidy-
    Sept-2017_Final.pdf.

      Over 2020-2026, the block grant proposed by the GCHJ bill would
    provide 6.4 percent less federal funding than under current law. By
    2026, the gap between current law funding and the proposed block grant
    funding would be 8.9 percent. Over 2020-2026, 29 states would
    experience, relative to current law, a reduction in federal funding
    (with an average reduction of 19 percent) and nine of these states--
    Alaska, Connecticut, Delaware, New Hampshire, New Mexico, New York,
    Oregon, Vermont, and Washington--would see reductions of 25 percent or
    ---------------------------------------------------------------------------
    more.

      Looking beyond 2026, the Manatt study explains: ``States will be at
    full financial risk for funding coverage programs and services
    developed under the block grant when the grant ends in 2026; there is
    no guarantee of whether and at what level federal funding would be
    available beginning in 2027.''

      Finally, this analysis comments: ``States would have broad latitude
    to obtain waivers of ACA provisions, including waivers of ACA benefit
    and rating requirements. In states that obtain waivers, individuals
    with pre-existing conditions could face substantially higher premiums
    or find their policies do not cover essential services.''

    An analysis from Fitch Ratings cautions that ``over time even non-
    expansion states will face budgetary challenges given the proposed
    changes to Medicaid, which will likely accelerate for all states over
    time.'' \4\ Fitch states that Medicaid changes in the GCHJ proposal
    ``could have implications for states' credit quality and for the credit
    quality of related public finance entities that depend on state
    funding.''
    ---------------------------------------------------------------------------
        \4\ Fitch Ratings, ``Latest ACA Bill Includes Medicaid Repeal and
    Replace Provisions for States,'' September 15, 2017, https://
    www.fitchratings.com/site/pr/1029238.

    While discussing the potential for other state-funded activities to be
    affected by Medicaid funding cuts, Fitch states: ``Medicaid changes
    that significantly reduce federal funding to states will cause states
    to consider a broad mix of spending cuts or revenue increases to
    maintain long-term fiscal balance. In a time of already muted revenue
    growth, spending cuts could affect K-12 and higher education the most,
    as those are the other largest areas of state spending outside of
    ---------------------------------------------------------------------------
    Medicaid.''

    An issue brief released by the Kaiser Family Foundation (KFF) provides
    estimates--including state-by-state data--on how federal funding for
    health benefits would be affected by the GCHJ bill's proposals for a
    new block grant program and a Medicaid per capita cap financing
    system.\5\ KFF explains that the deepest cuts would be imposed in
    states that implemented the ACA's Medicaid eligibility expansion. The
    issue brief states: ``There would be a significant redistribution in
    federal funding across states under the block grant. Overall expansion
    states would lose $180 billion for ACA coverage and non-expansion
    states would gain $73 billion over the 2020-2026 period. A typical
    Medicaid expansion state would see an 11% reduction in federal funds
    for coverage compared to an increase of 12% in a typical non-expansion
    state.''
    ---------------------------------------------------------------------------
        \5\ Kaiser Family Foundation, ``State-by-State Estimates of Changes
    in Federal Spending on Health Care Under the Graham-Cassidy Bill,''
    September 2017, http://files.kff.org/attachment/Issue-Brief-State-by-
    State-Estimates-of-Changes-in-Federal-Spending-on-Health-Care-Under-
    the-Graham-Cassidy-Bill.

    Most recently, the Brookings Institution issued a report that analyzed
    the impact on the number of Americans with health insurance coverage
    under the GCHJ proposal.\6\ The authors estimate that, in 2018 and
    2019, the number of insured Americans would fall by 15 million. With
    the transition to the Market-Based Health Care Grant program starting
    in 2020 where federal funding for the exchange marketplaces through
    APTC, CSR, and BHPs along with a portion of the Medicaid expansion
    funding are converted into a block grant, they estimate that the number
    of uninsured individuals would rise to around 21 million per year over
    the 2021-2026 period. Looking out at the effects on insurance coverage
    in 2027 and beyond after the expiration of the block grant funding
    program, upwards of 32 million fewer individuals would have coverage.
    The authors caution that this estimate may be conservative because it
    does not include all of the provisions in the GCHJ proposal, including
    the effects of the per capita caps on Medicaid.
    ---------------------------------------------------------------------------
        \6\ ``How will the Graham-Cassidy proposal affect the number of
    people with health insurance coverage?'', September 22, 2017, https://
    www.brookings.edu/research/how-will-the-graham-cassidy-proposal-affect-
    the-number-of-people-with-health-insurance-coverage/.

    All of these findings raise serious questions and concerns about the
    likely impact of the GCHJ proposal on health care costs and choices for
    consumers who buy coverage in the individual health insurance market
    and the continued role of Medicaid as a health care safety net for low
    income Americans. To answer these questions, we believe it is
    critically important for the Senate to allow time for CBO to conduct a
    comprehensive analysis of this new legislation before voting on its
    approval.

    Conclusion

    While our organizations cannot support the GCHJ proposal given the lack
    of alignment with our principles, we will keep working to find the
    right solutions that reflect the commitment we all share: affordable
    coverage and high-quality care for every American. By working together,
    we can improve health care and deliver the coverage and care that every
    American deserves.

                                     ______

                              The Arc of Colorado

                              1580 Logan St. #730

                                Denver, CO 80203

                           http://www.thearcofco.org/

    The Arc of Colorado, with 14 local chapters of The Arc throughout the
    state, is strongly opposed to provisions reducing access to affordable
    health care and to long term supports and services that are included in
    the revised bill offered by Senators Lindsey Graham (R-SC), Bill
    Cassidy (R-LA), Dean Heller (R-NV), and Ron Johnson (R-WI). This
    dangerous legislation uses per capita caps to deeply cut and radically
    restructure the traditional Medicaid program that individuals with
    intellectual/developmental disabilities rely on to live and work in the
    community. It ends Medicaid expansion which has enabled more than
    400,000 moderate to low income Coloradans pay for health insurance and
    replaces it with a temporary block grant that expires in 2026. It also
    gives states the option to end key consumer protections that have
    helped people with pre-existing conditions, including people with
    disabilities, access the health care services they need.

    A recent study by Avalere shows that for 2020 through 2026, 34 states
    and DC would see funding cuts--Colorado would lose $6 billion by 2026.
    Once the block grant for Medicaid expansion ends in 2027, all states
    would see large cuts (the cut in 2027 alone would be $283 billion).

    Total cuts to federal funding for coverage would total over $4 trillion
    through 2036. Colorado would lose up to $78 billion by that year. Cuts
    to the traditional Medicaid program would be more than $1 trillion over
    2 decades. And looking at the growth rates by population, federal
    funding by 2036 would be 15 percent below current law for people with
    disabilities, 31 percent below current law for children, and 37 percent
    below current law for non-disabled adults. The need won't go away, so
    these cuts would be devastating to state Medicaid systems and mean life
    and death to people with disabilities.

    Nationwide, Medicaid provides essential services to more than 10
    million people with disabilities. People with disabilities rely on
    Medicaid for personal care services, specialized therapies, intensive
    mental health services, special education related services, and other
    needed services that are unavailable through private insurance. With
    greatly reduced federal contributions to Medicaid as proposed under the

    Graham-Cassidy plan, most states would not be able to make up the
    difference.

    Medicaid is the main source of funding for over 77% of the supports and
    services that individuals with intellectual and/or developmental
    disabilities (I/DD) use to live in the community and has been able to
    grow because of the widespread bipartisan support. These supports and
    services provide dignity to people with I/DD by providing help with
    meals, bathing and dressing, toileting, in-home skilled nursing, and
    communication support, to name but a few. These supports are critical
    to people with disabilities to be able to live their life in the
    community. In many cases, they can be the difference between life and
    death.

    We fear that because home and community based services are optional
    services, they will be cut first. States will return to outdated modes
    of serving people with disabilities, congregating large numbers of
    individuals in facilities with inadequate staffing and no real-life
    opportunities.

    The Arc of Colorado is disappointed that the bill also retains the $19
    billion cut of the enhanced federal match in the Community First Choice
    Option, which is a permanent program that provides an enhanced federal
    match to any state that chooses the option to provide additional
    personal assistance services. Instead, the Senate bill includes a new
    home and community based demonstration program. A total of $8 billion
    is available over 4 years to a limited number of states. This is a
    woefully inadequate response to the deep cuts to Medicaid and the
    threat that poses to home and community based services.

    The Arc of Colorado is deeply concerned that the Senate is discussing
    moving forward without a complete analysis by the independent
    Congressional Budget Office (CBO) of the revised bill, known as the
    Graham-Cassidy plan. The Arc is also concerned that there have not been
    hearings or stakeholder input or a comprehensive effort to understand
    the impact of these major changes and the harm it could pose to people
    needing health coverage and Medicaid's long term supports.

    The lives and independence of Coloradoans with disabilities are on the
    line. The Arc of Colorado urges you to oppose the Graham-Cassidy plan
    to preserve health care and access to community living provided under
    Medicaid.

    Marijo Rymer
    Executive Director

                                     ______

                            The Arc of Massachusetts

                                217 South Street

                             Waltham, MA 02453-2710

                                T: 781-891-6270

                                F: 781-891-6271

                            http://thearcofmass.org/

    The Arc of Massachusetts is strongly opposed to provisions reducing
    access to affordable health care and to long term supports and services
    that are included in the revised bill offered by Senators Lindsey
    Graham (R-SC), Bill Cassidy (R-LA), Dean Heller (R-NV), and Ron Johnson
    (R-WI). This dangerous legislation uses per capita caps to deeply cut
    and radically restructure the traditional Medicaid program that
    individuals with I/DD rely on to live and work in the community. It
    ends the Medicaid expansion and the affordability provisions to help
    people pay for private health insurance, and replaces it with a
    temporary block grant that expires in 2026. It also gives states the
    option to end key consumer protections that have helped people with
    pre-existing conditions, including people with disabilities, access the
    health care services they need.

    A recent study by Avalere shows that for 2020 through 2026, 34 states
    and DC would see funding cuts. Once the block grant for Medicaid
    expansion ends in 2027, all states would see large cuts (the cuts in
    2026 in Massachusetts would be $14 billion). Total cuts to
    Massachusetts federal funding for coverage would total over $93 billion
    by 2037. This would mean major reductions in supports and services for
    people with disabilities let alone health care. The need won't go away,
    so these cuts would be devastating to state Medicaid systems and mean
    life and death to people with disabilities.

    Nationwide, Medicaid provides essential services to more than 10
    million people with disabilities. People with disabilities rely on
    Medicaid for personal care services, specialized therapies, intensive
    mental health services, special education related services, and other
    needed services that are unavailable through private insurance. With
    greatly reduced federal contributions to Medicaid as proposed under the

    Graham-Cassidy plan, most states would not be able to make up the
    difference.

    Medicaid is the main source of funding for over 77% of the supports and
    services that individuals with intellectual and/or developmental
    disabilities (I/DD) use to live in the community and has been able to
    grow because of the widespread bipartisan support. These supports and
    services provide dignity to people with I/DD by providing help with
    meals, bathing and dressing, toileting, in-home skilled nursing, and
    communication support, to name but a few. These supports are critical
    to people with disabilities to be able to live their life in the
    community. In many cases, they can be the difference between life and
    death.

    We fear that because home and community based services are optional
    services, they will be cut first. States will return to outdated modes
    of serving people with disabilities, congregating large numbers of
    individuals in facilities with inadequate staffing and no real life
    opportunities.

    The Arc is disappointed that the bill also retains the $19 billion cut
    of the enhanced federal match in the Community First Choice Option,
    which is a permanent program that provides an enhanced federal match to
    any state that chooses the option to provide additional personal
    assistance services. Instead, the Senate bill includes a new home and
    community based demonstration program. A total of $8 billion is
    available over 4 years to a limited number of states. This is a
    woefully inadequate response to the deep cuts to Medicaid and the
    threat that poses to home and community based services.

    The Arc is deeply concerned that the Senate is discussing moving
    forward without a complete analysis by the independent Congressional
    Budget Office (CBO) of the revised bill, known as the Graham-Cassidy
    plan. The Arc is also concerned that there have not been hearings or
    stakeholder input or a comprehensive effort to understand the impact of
    these major changes and the harm it could pose to people needing health
    coverage and Medicaid's long term supports.

    The lives and independence of people with disabilities are on the line.
    The Arc urges you to oppose the Graham-Cassidy plan to preserve health
    care and access to community living provided under Medicaid.

                                     ______

                             The Arc of New Jersey

                             985 Livingston Avenue

                           North Brunswick, NJ 08902

                                 T 732-246-2525

                                 F 732-214-1834

                             http://www.arcnj.org/

    The Arc of New Jersey represents people with intellectual and
    developmental disabilities (I/DD) and their families who are dependent
    on the Medicaid program. With this in mind, we are very concerned by
    the Graham-Cassidy-Heller-Johnson Proposal which would threaten the
    Medicaid program through cuts ushered in under a Block Grant program
    and Per Capita Caps, as well as potentially undermine Essential Health
    Benefits (EHBs). The long term supports and services that keep people
    in the community would not be possible without adequate funding for
    Medicaid and inclusion of EHBs in health insurance plans. In
    particular, if the system were to shift to a Block Grant system, which
    is currently estimated to provide states with 17% fewer funds for their
    Medicaid programs, states would have no choice but to cut services from
    their offerings due to a lack of funding. Under the Graham-Cassidy-
    Heller-Johnson Proposal, New Jersey will see an approximately $112
    billion dollar reduction in funding by the year 2036. As you can
    imagine, this would have a devastating impact on people with I/DD
    living in our state.

    Among the threatened programs, the Graham-Cassidy-Heller-Johnson
    Proposal's cuts to Medicaid most directly endangers Home and Community
    Based Services (HCBS) because while they are cost effective and
    functional, they are not mandatory for states to provide. Additionally,
    since most HCBS programs are delivered by Medicaid waivers, there are
    already a limited number of spots available, leading to wait lists.
    Currently, over half a million people are on waitlists nationwide for
    these programs. Since Graham-Cassidy-Heller-Johnson Proposal would cut
    Medicaid by hundreds of billions of dollars, waitlists would likely
    greatly expand, as states struggle to provide required services to
    eligible individuals before they could even begin to move on to
    providing optional waiver services, like HCBS, to those who need them.

    Along with the Block Grant System, the Graham-Cassidy-Heller-Johnson
    Proposal would move Medicaid to a Per Capita Cap system which places
    limits on how much the federal government can contribute to a state in
    a given year, based on historical data. The rates that the federal
    government can contribute do go up every year, but at a significantly
    lower rate than how state Medicaid costs are estimated to rise, leaving
    states without enough money to cover their Medicaid programs, which
    inevitably leads to cuts in service offerings. The bill would also
    penalize states who spend above the national average on their Medicaid
    program, meaning that states that have residents with greater needs,
    more optional benefits, or a higher cost of living, could be hurt. This
    will put immense pressure on states to cut services and eligibility,
    leaving many individuals with disabilities without vital services.

    Finally, this bill threatens pathways to coverage for children with
    disabilities. Nearly all states disregard parental income for children
    with significant disabilities living at home to provide them Medicaid
    coverage. This option, called the ``Katie Beckett program,'' saves
    parents from having to place their child in institutional care, as
    parental income is automatically disregarded so their child can qualify
    for Medicaid. This program, which allows children to receive the care
    they need while living at home, has proven to be invaluable for New
    Jersey residents and would be at risk under the Graham-Cassidy-Heller-
    Johnson Proposal

    In addition, the Graham-Cassidy-Heller-Johnson Proposal also threatens
    Essential Health Benefits (EHBs) by allowing states to give insurers
    the option to waive the coverage of EHBs, which include both mental
    health services, and habilitative services. Often times, individuals
    with I/DD also have mental health challenges and this is known as dual
    diagnosis. Those with dual diagnosis often need a range of services so
    that they can live successfully in the community. If a state waives
    EHBs such that mental health benefits are excluded altogether from
    plans, mental health parity protections are rendered meaningless
    because mental health parity only applies if plans offer mental health
    benefits. Insurers also have the option not to provide habilitative
    services. Even if plans still include mental health protections and
    habilitative services, if EHBs are not required by the state and not
    included by insurers, insurers could impose lifetime and annual limits
    on these services. Habilitation services are likely to be necessary in
    the long term for families with children with I/DD. Protection against
    lifetime and annual limits only applies to EHBs, so if EHBs are waived,
    limits can be implemented. Bringing back lifetime and annual limits
    leaves families with insurance that does not meet their needs.

    The Graham-Cassidy-Heller-Johnson Proposal will destroy the system as
    we know it and the consequences will be both painful and irreversible.
    With this in mind, we ask you to please vote against this Proposal when
    it comes before you and to do everything you can to beat back any and
    all proposed cuts to Medicaid. Instead of moving the system forward,
    this legislation will reverse years of progress and advancements and
    will reduce the quality of life for individuals with I/DD who already
    face significant challenges.

    We thank you for your time and consideration. In these critical times,
    we ask you to do everything in your power to prevent these proposals
    from becoming a reality.

                                     ______

                            The Arc of Pennsylvania

                         301 Chestnut Street, Suite 403

                              Harrisburg, PA 17101

                                 T 717-234-2621

                              http://thearcpa.org/

    The Arc of Pennsylvania stands with The Arc of the United States and
    the many other organizations opposed to all proposals that reduce
    Medicaid funding and specifically, the bill authored by Senators
    Lindsey Graham, Bill Cassidy, Dean Heller and Ron Johnson. This
    legislation jeopardizes the health care of thousands of Pennsylvanians,
    including people with disabilities. For 68 years, The Arc of
    Pennsylvania has worked to ensure that children and adults with
    developmental disabilities including autism and intellectual disability
    receive the supports and services they need, are included in their
    community, and have control over their own lives. This bill jeopardizes
    all that we have worked for and achieved over the past 68 years.

    This proposal while shifting significant responsibility onto states;
    institutes a block grant that expires in 2026. Our recent experiences
    in Pennsylvania have led us to be wary of block grants. They are often
    espoused to offer flexibility however much of the flexibility offered
    is already available in the current system and the block grant actually
    translates to cuts in funding. The block grant in the Graham-Cassidy
    proposal is a significant cut in Medicaid funding to Pennsylvania.

    The Arc of Pennsylvania is concerned about the ability of block grants
    to adjust when there are changes in needs, such as natural disasters,
    health care epidemics, or economic recessions. With a capitation,
    legislation, often challenging to pass, would be necessary for Medicaid
    to provide additional financial help when the need in Pennsylvania
    increases. Pennsylvania's data demonstrates that our population is
    aging and the acuity of people receiving disability services is
    becoming more severe over time. Certainly, this past year's hurricanes
    and the national opioid epidemic have made states more aware of the
    critical role of Medicaid.

    The Arc has a long history of promoting pre-natal care and we
    especially promote the avoidance of drinking alcoholic beverages during
    pregnancy. We are very concerned that states would have options
    regarding the coverage of essential benefits including pre-natal care.
    Understanding the established scientific research regarding the
    benefits of early pre-natal care and the impact of addiction treatment
    on developing fetuses, we strongly request reconsideration of your plan
    and require states to provide this essential health benefit coverage.

    In Pennsylvania, our Early Intervention program, serving children birth
    through 5 years of age, significant portions of special education, and
    our entire adult system for people with disabilities all rely on
    Medicaid funding. Cuts to Medicaid impact 722,000 people with
    disabilities in Pennsylvania. It is estimated that Pennsylvania alone
    will lose $15 billion in federal funding by 2027 if Graham-Cassidy is
    passed. This will result in an extreme shift in funding to our state
    budget. Our state legislature would be tasked to replace this funding
    or be forced to cut services, reduce payments, or completely eliminate
    coverage for some of our most vulnerable citizens. Our legislators will
    be tasked with very difficult decisions--who is most deserving of
    health care? Our children? People with disabilities? People in a mental
    health crisis? Those with addictions? Working age taxpayer adults with
    disabilities? Our seniors? Our worry is that children born with
    disabilities will not receive the critical services they need at an
    early age and that adults with disabilities will be relegated to large
    congregate facilities if they receive services at all.

    Three months into this fiscal year, Pennsylvania still does not have a
    state budget. Two years ago, it took 9 months for a state budget to be
    finalized. Clearly, with garnering sufficient state resources being an
    almost insurmountable challenge, we have to believe that Medicaid cuts
    would only exacerbate our already existing 5,000-
    person emergency waiting list for persons with intellectual disability.
    We appreciate that the Graham-Cassidy bill includes language exempting
    children with disabilities from the per capita cap but in Pennsylvania,
    we already have a huge cliff effect for those turning 21, transitioning
    from entitled children's Medicaid services to unfunded adult services
    with long waiting lists.

    The Arc of Pennsylvania is deeply disappointed that the Senate is
    discussing a move forward without a complete analysis by the
    independent Congressional Budget Office. There needs to be sufficient
    hearings with stakeholder involvement to provide input on the impact of
    the Graham-Cassidy-Heller-Johnson proposal.

    We have been communicating with our members throughout the weekend and
    continue to hear how they are deeply concerned that their circumstances
    have not been adequately listened to or addressed. While imperfect, the
    Affordable Care Act (ACA) created many life-saving changes for our
    members. The elimination of life time caps, the assurance that they
    would not have higher premiums for having pre-existing conditions, and
    the guaranteed portability of insurance if they had to change jobs,
    were life changing to our members. They want desperately to know that
    their legislators understand the impacts of any decision related to
    Medicaid and its impact on their lives.

    The Arc of Pennsylvania, with over 8,000 members and 33 local chapters,
    is our state's largest disability advocacy organization. We work to
    protect and enhance the rights of people with disabilities so that they
    can live, learn, work, and thrive in their community. We believe that
    capitation of Medicaid funding to Pennsylvania threatens the very
    disability service system that we have fought so long to build. The Arc
    of Pennsylvania urges you to oppose the Graham Cassidy plan and to
    preserve health care and access to community living provided under
    Medicaid. If you have any questions, please contact Maureen Cronin,
    Executive Director, The Arc of Pennsylvania at 717-234-2621 or
    mcronin@thearcpa.org.

                                     ______

                               The Arc Tennessee

                        545 Mainstream Drive, Suite 100

                              Nashville, TN 37228

    The Arc Tennessee is strongly opposed to provisions reducing access to
    affordable health care and to long term supports and services that are
    included in the revised bill offered by Senators Lindsey Graham (R-SC),
    Bill Cassidy (R-LA), Dean Heller (R-NV), and Ron Johnson (R-WI). This
    dangerous legislation uses per capita caps to deeply cut and radically
    restructure the traditional Medicaid program that individuals with I/DD
    rely on to live and work in the community. It ends the Medicaid
    expansion and the affordability provisions to help people pay for
    private health insurance, and replaces it with a temporary block grant
    that expires in 2026. It also gives states the option to end key
    consumer protections that have helped people with pre-existing
    conditions, including people with disabilities, access the health care
    services they need.

    A recent study by Avalere shows that for 2020 through 2026, 34 states
    and DC would see funding cuts. Once the block grant for Medicaid
    expansion ends in 2027, all states would see large cuts (the cut in
    2027 alone would be $283 billion). Total cuts to federal funding for
    coverage would total over $4 trillion through 2036. Cuts to the
    traditional Medicaid program would be more than $1 trillion over 2
    decades. And looking at the growth rates by population, federal funding
    by 2036 would be 15 percent below current law for people with
    disabilities, 31 percent below current law for kids, and 37 percent
    below current law for non-disabled adults. The need won't go away, so
    these cuts would be devastating to state Medicaid systems and mean life
    and death to people with disabilities.

    In Tennessee, there are at least 102,000 people with intellectual and
    developmental disabilities and Medicaid (TennCare) is the primary
    source of essential health care and long-term services for this
    population. Tennesseans with disabilities rely on TennCare not only for
    basic healthcare, but also for personal care services, specialized
    therapies, intensive mental health services, special education related
    services, and other needed services that are unavailable through
    private insurance. With greatly reduced federal contributions to
    Medicaid as proposed under the Graham-
    Cassidy plan, Tennessee wound not be able to make up the difference, no
    matter what flexibility is offered. The federal government currently
    matches $2 for every $1 Tennessee invests in the TennCare program, and
    TennCare is already nationally recognized as one of the most
    efficiently run programs in the country.

    TennCare is the main source of funding for over 55% of the supports and
    services that individuals with intellectual and/or developmental
    disabilities (I/DD) use to live in the community and has been able to
    grow because of the widespread bipartisan support. These supports and
    services provide dignity to people with I/DD by providing help with
    meals, bathing and dressing, toileting, in-home skilled nursing, and
    communication support, to name but a few. These supports are critical
    to people with disabilities to be able to live their life in the
    community. In many cases, they can be the difference between life and
    death.

    Given that home and community based services are optional under
    TennCare, they will be the first to be cut from the program. These cuts
    will force Tennessee to return to outdated models of service that
    segregate large numbers of individuals with I/DD in facilities with
    inadequate staffing and no real-life opportunities.

    The Arc Tennessee is concerned that the Senate may move forward without
    a complete analysis by the independent Congressional Budget Office
    (CBO) of the revised bill, known as the Graham-Cassidy plan. We are
    also concerned that there have not been hearings or stakeholder input
    or a comprehensive effort to understand the impact of these major
    changes and the harm it could pose to people needing health coverage
    and Medicaid's long term supports.

    The lives and independence of people with I/DD are on the line. The
    progress we have made the last several decades is in danger of being
    completely reversed. The Arc Tennessee urges you to oppose the Graham-
    Cassidy plan, to preserve health care and the access to community
    living provided under Medicaid, and to work in a bi-partisan manner to
    deliver healthcare legislation that goes through the normal
    congressional processes.

    Submitted on behalf of The Arc Tennessee by Carrie Hobbs Guiden,
    Executive Director

                                     ______

                          The Arc of the United States

                         1825 K Street, NW, Suite 1200

                              Washington, DC 20006

                                 T 202-534-3700

                                 F 202-534-3731

                            https://www.thearc.org/

    The Arc of the United States (The Arc) is strongly opposed to
    provisions reducing access to affordable health care and to long term
    supports and services that are included in the revised bill offered by
    Senators Lindsey Graham (R-SC), Bill Cassidy (R-LA), Dean Heller (R-
    NV), and Ron Johnson (R-WI). This dangerous legislation uses per capita
    caps to deeply cut and radically restructure the traditional Medicaid
    program that individuals with I/DD rely on to live and work in the
    community. It ends the Medicaid expansion and the affordability
    provisions to help people pay for private health insurance, and
    replaces it with a temporary block grant that expires in 2026. It also
    gives states the option to end key consumer protections that have
    helped people with pre-existing conditions, including people with
    disabilities, access the health care services they need.

    The Arc is deeply concerned that the Senate is discussing moving
    forward, outside of regular order, without a complete analysis by the
    independent Congressional Budget Office (CBO) of the revised bill,
    known as the Graham-Cassidy plan. The Arc is also concerned that there
    have not been hearings or stakeholder input to assess the bill. Given
    the rush to pass the bill before September 30th, CBO will not have time
    to do a complete analysis of the bill's impact on people needing health
    coverage and Medicaid's long term supports.

    Health care consultants and think tanks have tried to fill the CBO gap
    by providing analysis that consistently demonstrates the negative
    impact on states, including how deep cuts to the Medicaid program would
    be over time. For example, a recent study by Avalere showed that for
    2020 through 2026, 34 states and DC would see funding cuts. Once the
    block grant for Medicaid expansion ends in 2027, all states would see
    large cuts (the cut in 2027 alone would be $283 billion). Total cuts to
    federal funding for coverage would total over $4 trillion through 2036.
    Cuts to the traditional Medicaid program would be more than $1 trillion
    over two decades. And looking at the growth rates by population,
    federal funding by 2036 would be 15 percent below current law for
    people with disabilities, 31 percent below current law for kids, and 37
    percent below current law for non-disabled adults. The need won't go
    away, so these cuts would be devastating to state Medicaid systems and
    mean life and death to people with disabilities.

    Nationwide, Medicaid provides essential services to more than 10
    million people with disabilities. People with disabilities rely on
    Medicaid for personal care services, specialized therapies, intensive
    mental health services, special education related services, and other
    needed services that are unavailable through private insurance. With
    greatly reduced federal contributions to Medicaid as proposed under the

    Graham-Cassidy plan, most states would not be able to make up the
    difference. Cuts to Medicaid, including to home and community based
    services, would force a return to outdated modes of serving people with
    disabilities, such as institutional care and segregated services.

    Cutting and capping Medicaid will force longer waiting lists for
    services in many states. The Arc has worked in a bipartisan manner for
    decades at the federal, state, and local level to build a home and
    community based system and reduce waiting lists. Waiting lists exist
    because the Section 1915 waiver authority allows states to limit
    eligibility for services and waive the requirement that all eligible
    people in the state receive comparable services. The problems with
    waiting lists are not related to the expansion of the Medicaid program
    to childless adults. The Medicaid expansion allowed millions of people
    with chronic illnesses and disabilities to gain access to health care.
    Allegations that the Medicaid expansion are causing waiting lists are
    false.

    The Arc does not believe, within the radical restructuring of the
    Medicaid program and the deep cuts, that any eligible population can be
    protected. The Graham-
    Cassidy bill includes language exempting children with disabilities
    from the per capita cap. If this language is intended to target the 1.2
    million children who are eligible for Supplemental Security Income
    (SSI), it would leave out many children who have health needs or
    disabilities and do not meet SSI's strict income and disability
    standards but who become Medicaid eligible through many different
    eligibility pathways.

    This ``carve out'' implicitly acknowledges that Medicaid under per
    capita caps is unacceptable for children with disabilities. These
    children grow up to be adults and will face a devastated Medicaid
    program. States will not be able to make up the difference from the
    deep cuts under per capita caps and will not be able to protect any
    group. States will be focused on keeping Medicaid spending under the
    cap, or face penalties. The Senate bill's cuts are greater over time
    and, to make up for this massive loss of federal funding, states will
    be forced to cut services, eligibility groups, reimbursement rates for
    providers, make across the board cuts, or take other actions to cut
    costs. These cuts will impact the doctors, hospitals, therapists, and
    other providers that serve these children. While the traditional match
    may be an incentive for some states to continue serving children with
    disabilities, there is no specific language in the bill that provides
    protections against tightening eligibility for these children or
    cutting their services and supports.

    The Arc is disappointed that the bill also retains the $19 billion cut
    of the enhanced federal match in the Community First Choice Option,
    which is a permanent program that provides an enhanced federal match to
    any state that chooses the option to provide additional personal
    assistance services. Instead, the Senate bill includes a new home and
    community based demonstration program. A total of $8 billion is
    available over 4 years to a limited number of states. This is a
    woefully inadequate response to the deep cuts to Medicaid and the
    threat that poses to home and community based services.

    In addition, the Graham-Cassidy plan ends the Medicaid expansion and
    the current tax credits and cost sharing reductions that assist low
    income individuals purchase health insurance in 2020, replacing this
    assistance with a block grant that would reduce funding by $239 billion
    by 2026. After 2026, there would be no federal funding to help the
    millions of Americans, including millions with disabilities, who rely
    on Medicaid expansion and marketplace coverage to access health care.
    These are people who previously fell through the cracks in our system,
    such as individuals with disabilities in a mandatory waiting period
    before their Medicare coverage begins and millions of people with a
    behavioral health condition who previously had no pathway to steady
    coverage. Also, millions of family caregivers who work caring for a
    child or older adult with a disability and hundreds of thousands of low
    wage direct care workers who serve people with disabilities gained
    coverage through the Medicaid expansion. Medicaid expansion helps
    stabilize our long-term care support networks by keeping caregivers
    healthy and reducing turnover.

    Likewise, marketplace coverage ensures that people with disabilities
    can buy comprehensive and affordable health care and have equal access
    to much needed health care including examinations, therapies to regain
    abilities after an illness or injury, and affordable medications. We
    have serious concerns about the Graham-Cassidy private market
    provisions, including the state waiver authority to eliminate
    protections for people with pre-existing conditions (including people
    with disabilities), older adults, and people who need access to
    essential health benefits. The nondiscrimination provisions and health
    insurance reforms, the expanded access to long term supports and
    services, and the expanded availability of comprehensive and affordable
    health care have helped many more individuals with disabilities live in
    the community and be successful in school and the work place. No longer
    do individuals with disabilities and their families have to make very
    difficult choices about whether to pay their mortgage, declare
    bankruptcy, or choose between buying groceries and paying for needed
    medications.

    The lives and independence of people with disabilities are on the line.
    The Arc urges you to oppose the Graham-Cassidy plan to preserve health
    care and access to community living provided under Medicaid.

    The Arc is the largest national community-based organization advocating
    for and serving people with intellectual and developmental disabilities
    and their families. We have more than 650 state and local chapters
    across the United States. If you have any questions, please contact
    Julie Ward, Director of Health Policy (ward@
    thearc.org).

                                     ______

                               The Arc Wisconsin

                                  P.O. Box 201

                              Stoughton, WI 53589

                               https://arcwi.org/

    September 22, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Re: Hearing to consider the Graham-Cassidy-Heller-Johnson Proposal

    Dear Chairman Hatch, Ranking Member Wyden, Members of the Committee:

    The Arc Wisconsin is urging you to preserve the funding structure for
    the Medicaid program and the critical services and supports it provides
    to people with intellectual and/or developmental disabilities (I/DD) in
    Wisconsin and nationwide. Specifically, people with I/DD in Wisconsin
    rely on Medicaid funded programs like Family Care, IRIS, Children's
    Long-Term Supports, BadgerCare, occupational, physical, and speech
    therapies, autism supports, and more. More than 1 million Wisconsin
    residents depend on Medicaid for their health insurance and funding for
    essential community based care. Two-thirds of Medicaid funding goes to
    support people with disabilities and older adults.

    The Arc Wisconsin has 15 local chapters and many of them provide
    essential Medicaid services to people with I/DD. We are located in Eau
    Claire, La Crosse, Richland Center, Fond du Lac, Monroe County, Green
    County, Waupaca County, Washington County, Mineral Point, Lincoln
    County, Racine, Dane County, Dodge County and Dunn County. The Arc Fond
    du Lac is an example of a chapter that employs more than 50 workers and
    receives more than 70% of their operating revenue through the Medicaid
    program to provide day and residential services to very vulnerable
    people.

    Wisconsin currently receives a 60% funding match from the federal
    government for all its Medicaid programming which includes flexible
    waivers that allow individuals and families with disabilities to get
    supports in the community that help them to be healthy, allow them to
    live in their own homes and keep them out of institutions. These
    community-based waiver programs, serving more than 70,000 older adults
    and people with disabilities and nearly 7,000 children with
    disabilities in Wisconsin, are considered optional under Medicaid and
    are predicted to be at risk for elimination through the per capita caps
    proposed in the Graham-Cassidy bill.

    Wisconsin has worked hard to eliminate waiting lists for community
    services for people with the most significant disabilities. This is
    unheard of in most other states. By 2018 no adult with a disability who
    qualifies for Family Care and IRIS long-term care will have to wait for
    supports in our state. The Wisconsin state budget passed this month
    includes new funding to eliminate waiting for children with significant
    disabilities, including autism and other developmental disabilities.
    Unfortunately, analysts of Graham-Cassidy have predicted that states
    will likely respond to per capita cap funding restrictions in Medicaid
    by instituting waiting lists for services.

    Although early estimates of Graham-Cassidy show Wisconsin may not lose
    funding immediately, by 2027 Medicaid per capita cap cuts become
    increasingly severe for our state. Wisconsin stands to lose
    $2,909,000,000 (or nearly $3 billion) by 2027 and $29 billion by 2036.

    Nationwide, Medicaid provides essential services to more than 10
    million people with disabilities. The disability community and
    bipartisan Congressional leaders have worked together for decades to
    ensure that adults and children with disabilities have access to home
    and community-based services that allow them to live, work, and receive
    an education in the community. People with disabilities rely on
    Medicaid for nursing and personal care services, specialized therapies,
    intensive mental health services, special education related services,
    and other needed services that are unavailable through private
    insurance.

    On behalf of people with I/DD we ask that you consider the impact of
    billions of dollars in Medicaid funding reductions in Wisconsin and all
    states. With reduced federal spending, we worry that Wisconsin
    taxpayers will not be able to make up the difference to maintain our
    system of supports. We fear that Wisconsin will be forced to return to
    outdated modes of serving people with disabilities, such as
    institutional care and segregated services.

    The cutting and capping of the Medicaid program over time affects each
    state budget differently. It is clear that the proposal will mean
    significantly less federal support for any future efforts to rebalance
    spending from institutional services to community spending. It is not
    likely that states will be able to address the problems of low
    reimbursement rates for providers of home and community based services
    or to address the need to provide adequate wages for the direct support
    workers who provide these critical community services. Quality of care
    will surely suffer.

    Thank you for considering the harmful consequences per capita caps
    would have on individual with disabilities, children, and families in
    Wisconsin. We ask that you vote NO on any legislation that cuts or caps
    Medicaid.

    Sincerely,

    Lisa Pugh
    Executive Director

    David Boelter, Executive Director   Kelli Stein, Executive Director
    David Oldenburg, President          The Arc of Racine County
    The Arc Fond du Lac

    Ken Hobbs, President                Debra J. Hanzel, President
    The Arc-Dane County                 Richland County Arc

    Mary Bakalars, Administrative
    Coordinator                         Marit Waack, Executive Director
    The Arc La Crosse                   The Arc Eau Claire

    Margaret Galle, President           Julie Briggs, Executive Director
    Arc of Southwestern Wisconsin       Cindy Rowe, President
                                        The Arc Greater Columbia County

                                     ______

                              Arthritis Foundation

                          1615 L Street, NW, Suite 320

                              Washington, DC 20036

    On behalf of the 54 million adults and children with arthritis in the
    United States, the Arthritis Foundation welcomes the opportunity to
    submit a statement for the record as the committee debates the latest
    proposal to repeal and replace the Affordable Care Act.

    The Arthritis Foundation continues to be opposed to the legislation
    advanced by Senators Bill Cassidy and Lindsay Graham and is deeply
    concerned about the potential weakening of important patient
    protections that are guaranteed under current law. Because of the
    waiver language in this bill, states could eliminate essential health
    benefits such as prescription drug coverage--which patients with
    inflammatory forms of arthritis and other rheumatic illnesses rely on
    to manage their disease and live healthy, productive lives. People with
    rheumatoid arthritis, for instance, rely on biologic therapies for
    their care, and the downstream effects of an incomplete essential
    health benefits package would be harmful to appropriate care and
    treatment. Although the legislation does not eliminate the current pre-
    existing condition ban, it opens the door for states to permit health
    insurers to deny coverage associated with some conditions. Alarmingly,
    this means insurers could impose premium surcharges based on a
    patient's medical history or health status.

    We are also concerned about the significant cuts to Medicaid should
    this bill become law. Due to an anticipated Congressional Budget Office
    score that will be incomplete, senators and all Americans are forced to
    turn to independent analyses for information on the impacts to coverage
    and cost. Per an analysis released by Avalere Health, for example, the
    legislation fundamentally changes the traditional approach to funding
    Medicaid and penalizes states that expanded Medicaid in favor of states
    that chose not to do so. Thus, federal funding to states would decline
    by an estimated $215 billion over the 2020-2026 period, after which a
    funding cliff requires the block grants to be reappropriated by
    Congress.

    Importantly, the haste in which this bill is moving for consideration
    by the Senate has halted any bipartisan efforts to stabilize the
    insurance markets over the short term or move forward on a 5-year
    extension of the Children's Health Insurance Program before the end of
    the month. Over the course of the year, the Arthritis Foundation has
    continually advocated for patient-centered health reforms guided by six
    legislative principles. These principles were developed following
    surveys and focus groups of patients with arthritis and have informed
    our position on the legislation before the Committee. In August, we
    detailed several bipartisan recommendations to strengthen and improve
    current law. These policies included:

          Stabilizing the insurance marketplace through continued cost-
    sharing reduction payments to provide insurers certainty, prevent
    significant increases in premiums and ensure sufficient consumer choice
    in the marketplace.

          Ensuring outreach and engagement programs designed to enroll
    individuals in health care plans, both to incentivize healthy
    individuals to buy insurance, and to ensure that people with chronic
    conditions choose the plans that best suit their needs, thereby
    achieving a balanced risk pool.

          Providing additional flexibility for health savings accounts
    (HSAs) so that individuals with chronic illnesses like arthritis have
    enough flexibility with their plan to feel confident their health care
    needs are met. The legislation before the Committee includes some
    policies in this area, such as increasing the annual contribution limit
    to the maximum sum of an annual deductible and out-of-pocket expenses
    permitted under an HDHP, or allowing the use of HSA funds to pay for
    premiums. Focus groups conducted by the Arthritis Foundation have found
    that patients with these plans would find value in these flexibilities,
    among other important changes to HDHP/HSA plans.

          Addressing the proliferation of specialty tiers and rising
    levels of coinsurance through policy solutions that would use a capped
    copayment structure rather than coinsurance and permit a patient's
    cost-sharing responsibility to be spread evenly over the course of the
    plan year.

        Patients are the ultimate stakeholders in health care. Advancing a
    bill that bypasses the full legislative process and fails to capture
    the important voice of the patient community is deeply concerning. As
    ever, the Arthritis Foundation stands ready to work with the Committee
    to develop meaningful legislation and advance bipartisan solutions to
    strengthen our health care system. Please contact Vincent Pacileo,
    Director of Federal Affairs, at vpacileo@arthritis.org or 202-887-2910,
    with questions or for more information.

    Sincerely,

    Anna Hyde
    Vice President, Advocacy and Access

                                     ______

               Association of Maternal and Child Health Programs

                          1825 K Street, NW, Suite 250

                              Washington, DC 20006

                               Main 202-775-0436

                                Fax 202-478-5120

                             http://www.amchp.org/

    The Association of Maternal and Child Health Programs (AMCHP) has
    serious concerns that provisions included in the Graham-Cassidy-Heller-
    Johnson proposal would have a negative impact on maternal and child
    health populations. Adding potentially millions of additional Americans
    to the ranks of the uninsured would strain an already stretched safety
    net, reduce opportunities for prevention and early intervention, and
    undermine improvements that are promoting continuity of care for women
    of reproductive age and children with special health care needs.

    Eliminating the Prevention and Public Health Fund would create an
    immediate 12 percent gap in the budget for the Centers for Disease
    Control and Prevention (CDC) which would in turn force the CDC to
    defund critical state and local public health efforts.

    The potential for eliminating the requirement to cover Essential Health
    Benefits (EHBs) for services such as clinical preventive services,
    mental health, and maternity care is particularly troubling. Assurance
    of coverage for these services is critical to increasing the likelihood
    that pregnant women receive appropriate medical care and that all
    babies have a healthy start to life. Waiving the EHBs would return us
    to a situation like prior to 2013 when only nine states required
    coverage and only 12 percent of individual market plans included
    maternity coverage--this at a time when the U.S. has one of the highest
    infant mortality rates among industrialized countries and an increasing
    maternal mortality rate. In addition, the bill weakens protections for
    individuals with pre-existing conditions by allowing states to waive
    the current prohibition against charging higher premiums based on
    health status. This is particularly concerning for the maternal and
    child health community, as insurers would once again be allowed to
    charge women more for having had a prior pregnancy or families more for
    having a child born with special health needs.

                                     ______

                       Letter Submitted by Kristine Beck
    To: Senate Finance Committee

    Re: Testimony submitted for consideration to the hearing to consider
    the Graham-Cassidy-Heller-Johnson proposal on September 25, 2017

    Dear Senate Finance Committee Members:

    I am writing to express my opposition to the Graham-Cassidy-Heller-
    Johnson proposal. I am deeply concerned, particularly about the
    potential cuts to Medicaid. Medicaid protects tens of millions of our
    most vulnerable citizens: the elderly, people with disabilities, and
    young children. I serve Wisconsin's Medicaid population, and every day
    I see how it provides life-saving care, from dialysis to chemotherapy
    to cardiac surgery, and on and on. Cuts and caps will end up depriving
    thousands of Wisconsin residents of the care they need to live with
    dignity and independence.

    Closer to home, I have a niece and a brother-in-law who rely on
    Medicaid for their healthcare. It would break my heart to see them
    forgoing treatment for kidney disease or cancer because Medicaid was
    curtailed.

    I am also concerned about the potential end of protections for people
    with pre-
    existing conditions. That protection has saved lives and has averted
    cruel, needless medical bankruptcies. I myself have a pre-existing
    condition. If I were unable to receive healthcare for my condition, I
    quite possibly could die within a few years. Ending protections for
    people with pre-existing conditions is cruel and unnecessary.

    Further, I am alarmed about the speed and secrecy with which this
    Proposal was developed. Such an important issue, the very lives of our
    citizens, warrants an open and deliberate process.

    Please slow down and allow the voices of our citizens to be heard and
    their needs considered. We deserve at least that much respect.

                                     ______

                           Blue Shield of California

                                50 Beale Street

                            San Francisco, CA 94105

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Dear Senate Committee on Finance:

    Our mission at Blue Shield of California is to ensure that all
    Californians have access to high quality health care at an affordable
    price. We have consistently maintained that this is the standard
    against which we measure all health care policy proposals. We are
    therefore writing to express our strong opposition to the Cassidy-
    Graham proposal that the Senate may soon consider. We believe this
    proposal will cause millions of Californians to lose their health
    insurance coverage while requiring major state tax increases over the
    long-term to fund basic levels of access. This would undo much of the
    substantial progress California has made expanding coverage in recent
    years.

    The bill from Senator Cassidy and Senator Graham would bring about an
    unprecedented cut and redistribution of federal funding. Paradoxically,
    because of California's success in reducing the percentage of
    uninsured, our state will feel the brunt of the extreme cuts in
    spending this bill would mandate.

    Independent estimates show that California would see a $78 billion cut
    by 2026, when compared to current law.\1\ In contrast, Texas--which has
    done little to expand coverage to the uninsured--would receive a $35
    billion increase.\2\ In total dollars, California would see nearly $30
    billion more in cuts than any other state. As with previous repeal and
    replace bills, the result would be that lower-income individuals and
    families trying to work their way into the middle class would lose
    their insurance coverage. The proposal would also cut off funding
    entirely in 2027. While supporters say that this considerable
    appropriation will be re-authorized easily, if recent history is a
    guide, the need to reauthorize what would be a $2 trillion program will
    instead lead to even more political turmoil and uncertainty for those
    with coverage and for states seeking to provide health care to their
    most vulnerable citizens.
    ---------------------------------------------------------------------------
        \1\ Avalere Analysis of Cassidy-Graham bill, September 20, 2017.
        \2\ This is true even though analyses show that California is a
    donor state in federal taxes while Texas currently receives more back
    from the federal government than it pays. See Dallas Morning News,
    ``Texas Can No Longer Complain That it Gives More Than It Gets From the
    Federal Government,'' August 2012.

    In short, none of us need an official CBO score to know that funding
    reductions of this magnitude will ultimately lead to millions of
    Californians losing coverage. No amount of state flexibility nor
    promises of future government action can possibly fill that financial
    void. We should all be seeking ways to maintain and expand coverage to
    ---------------------------------------------------------------------------
    high quality, sustainably affordable health care.

    We continue to believe that bipartisan compromise can result in
    improvements to these critical health care programs that will make them
    sustainably affordable and fiscally responsible in the long-term, while
    preserving coverage for the most vulnerable among us. The recent
    Alexander-Murray hearings have shown remarkable agreement among diverse
    stakeholders around areas of potential compromise, including funding
    the cost sharing reduction benefit, providing more flexibility for
    states to innovate within appropriate guardrails, and addressing high-
    cost enrollees. We believe Congress should continue to focus on
    building from areas of consensus rather than again pursuing a partisan
    and divisive path.

    We recognize that we still have further to go to guarantee affordable
    coverage for all Californians. However, this bill would take us further
    away from that goal, and for that reason we strongly oppose it.

    Sincerely,

    Gary Cohen
    Vice President, Government Affairs

                                     ______

                Blue Cross Blue Shield of Massachusetts (BCBSMA)

    September 22, 2017

    The Honorable Orrin Hatch           The Honorable Ron Wyden
    Chairman                            Ranking Member
    Committee on Finance                Committee on Finance
    U.S. Senate                         U.S. Senate
    219 Dirsken Senate Office Building  219 Dirksen Senate Office Building
    Washington, DC 20510                Washington, DC 20510

    Dear Chairman Hatch and Ranking Member Wyden:

    On behalf of Blue Cross Blue Shield of Massachusetts (``BCBSMA''), I am
    writing in opposition to the ``Graham-Cassidy-Heller-Johnson'' proposal
    scheduled for a hearing before the Senate Finance Committee. When
    considered both in the short and long term, the measure will
    destabilize state insurance markets and undermine the ability to
    provide quality, affordable coverage and care, regardless of condition.
    As a nation, we've reached a historically high insured rate among our
    citizens--this bill will jeopardize these meaningful gains in coverage.

    At BCBSMA, we are proud of our history as a not-for-profit organization
    that was founded 80 years ago by a group of community-minded business
    leaders. Our history--and our future--is one of collaborating with the
    community to improve the health and quality of care that our members,
    and all citizens of the Commonwealth, receive. Providing coverage to
    almost 3 million customers, at BCBSMA, our vision is a transformed
    health care system that provides safe, timely, effective, affordable,
    patient-centered care for all.

    Prior to the Affordable Care Act (``ACA'') being passed in 2010, BCBSMA
    weighed in extensively with the Senate Finance Committee, as well as
    other committees of jurisdiction in the Senate and House of
    Representatives. We have continued to do so over the past several years
    including input to the Senate Finance Committee this past May. Given
    our experience in Massachusetts at reforming the health care system and
    Massachusetts' continued success in providing insurance coverage to
    over 97% of our residents, we believe we are uniquely qualified to
    offer our thoughts and insights on these issues. While not a
    comprehensive list of the many challenges of the proposal, our views on
    the top three provisions that will both negatively undermine the
    markets and directly impact the health of Americans across the nation
    are expressed below:

    First, instead of stabilizing the individual market in the short-term--
    a goal shared by both Republican and Democrat policymakers at the state
    and federal levels, as well almost every health care association and
    think tank--repeal of the individual mandate will immediately
    destabilize the market as products and rates have been approved based
    on the assumption that the mandate is in place. Moreover, without the
    individual mandate or any policy to encourage younger and healthier
    people to enroll and maintain coverage, the risk pool will deteriorate
    and drive up costs for those with insurance coverage. Additionally, in
    the short-term, the proposal does not provide certainty on cost-sharing
    reduction (CSR) payments, continuing the ongoing uncertainty as the
    2018 open enrollment period quickly approaches.

    Second, federal spending cuts to states are dramatic and severe. These
    cuts will create fiscal cliffs for states and will have a profound
    impact on the most vulnerable of our residents and neighbors--the
    disabled, the elderly, and the working poor. With under 2 years to plan
    for the budgetary, programmatic, and enrollment challenges created by
    this punitive policy, states and the beneficiaries served by these
    programs will face substantial chaos. Importantly, the impact is not
    limited to Medicaid; the impact to the individual market will also be
    acute.

    Notably, while designed to offer states ``flexibility,'' the block
    grants proposed by the measure directly penalize states that expanded
    their Medicaid program. This approach puts politics over policy at the
    expense of those most in need of care. Moreover, the funding formula
    also fails to account for broader health care policy trends that are
    outside the control of states, such as, but not limited to, growth in
    the volume and intensity of services per person, or the aging of the
    population.

    Finally, the inclusion of a provision that gives states the ability to
    waive out of fundamental consumer protections, including the
    prohibition on medical underwriting with only a statement of how the
    state will ``intend'' to maintain access to ``adequate'' and
    ``affordable'' coverage is unnecessary and divisive. As our CEO, Andrew
    Dreyfus, eloquently noted in an op-ed published by The Hill at the time
    that the Senate was considering this issue earlier this summer--

            Rather than allowing pre-existing medical conditions to again
            divide us, let's acknowledge that illness is actually a great
            equalizer. From birth to death, no one is immune from the risks
            of disabling injury or chronic illness. It may befall you, your
            spouse, your parent, or your child. If it's not your family,
            it's your co-worker, your friend, or your neighbor. That's one
            of the reasons individuals and families so easily bond with
            people facing similar medical challenges, regardless of their
            political beliefs or economic background, and it's why tens of
            millions of people join together to donate and raise money for
            efforts to find cures and support treatment. We're all in it
            together.

            A return to charging higher premiums for people with pre-
            existing conditions reinforces the mistaken notion that serious
            illness stems largely from personal choice. Most illness and
            disability is due not to choice but to bad luck and bad
            circumstances--the accidents of birth and life, including
            genes, economic and social factors, workplace conditions, and
            exposure to infection and toxins. Even for those illnesses
            where personal choice can matter, chance still plays a big
            role. Some people manage to avoid serious illness and live long
            lives despite unhealthy habits and poor choices, while others
            who lead much healthier lifestyles may not be nearly as
            fortunate.

            A fair, stable health insurance system requires an adequate
            number of both sick and healthy people who contribute to the
            pool of funds available to pay medical claims. That's not the
            case in some of the state marketplaces where individuals can
            buy coverage--too few healthy, lower-cost people have enrolled
            to balance the higher costs of their sicker population. So it's
            perfectly legitimate for Congress to consider better ways to
            encourage healthy individuals to buy and maintain insurance and
            there are a variety of available mechanisms to achieve this
            goal. What Congress must not and need not do, however, is
            return us to the days when insurers could increase premiums for
            individuals with pre-existing conditions. We should take this
            option out of the policy conversation and out of our healthcare
            system for good. We should agree that, whether we are healthy
            or sick, we are all created equal, and our health insurance
            system should reflect this American principle.

    Blue Cross Blue Shield of Massachusetts remains committed to working
    with Congress toward the goal of ensuring access to affordable, quality
    health care for the citizens of Massachusetts and the nation and urge
    our elected leaders to continue working in a bipartisan manner to
    achieve this outcome.

    Very Truly Yours,

    Deirdre W. Savage
    Vice President

                                     ______

                      Brain Injury Association of America

                        1608 Spring Hill Road, Suite 110

                                Vienna, VA 22182

                             Phone: (703) 761-0750

                              Fax: (703) 761-0755

                            https://www.biausa.org/

    Chairman Hatch, Ranking Member Wyden, and Members of the Finance
    Committee:

    The Brain Injury Association of America (BIAA) is the nation's oldest
    and largest brain injury advocacy organization leading the fight to
    make comprehensive rehabilitation accessible to patients with brain
    injury. BIAA thanks Chairman Hatch for his continued sponsorship of the
    TBI Act, the only federal legislation addressing the needs of 5.3
    million Americans who live with a disability because of TBI.

    BIAA is strongly opposed to H.R. 1628, the Graham-Cassidy-Heller-
    Johnson proposal. The legislation would seriously undermine health care
    coverage in the individual market by allowing states to control
    consumer protections, by systematically dismantling the Medicaid
    expansion under the Patient Protection and Affordable Care Act (ACA),
    and shifting the original Medicaid program to a per capita caps
    formula. Taken together, these measures would lead to significantly
    less coverage of rehabilitation services and devices.

    Traumatic brain injury (TBI) is a misdiagnosed, misunderstood, under-
    funded, neurological disease affecting at least 2.5 million children
    and adults in the U.S. each year. Depending on type and severity, brain
    injuries can lead to physical, cognitive, psychosocial, or behavioral
    impairments ranging from balance and coordination problems to loss of
    hearing, vision, or speech. Fatigue, memory loss, concentration
    difficulty, anxiety, depression, impulsivity, and impaired judgment are
    also common after brain injury. Even so-called ``mild'' injuries can
    have devastating consequences that require intensive treatment and
    long-term care. Often called the ``silent epidemic,'' brain injury
    affects people in ways that are invisible. The injury can lower
    performance at school and at work, interfere with personal
    relationships, and bring financial ruin.

    For many people with brain injury, rehabilitation is the single most
    effective treatment to restore function and arrest, reverse or mitigate
    disease-causative and
    disease-accelerative processes subsequent to injury. Rehabilitation is
    provided in a variety of settings, depending on the needs of the
    individual, including acute care hospitals, inpatient rehabilitation
    centers, and nonhospital alternative medical delivery settings, such as
    residential/transitional rehabilitation programs and day treatment
    programs. Cognitive rehabilitation is a systematically applied set of
    medical and therapeutic services designed to improve cognitive
    functioning. Cognitive rehabilitation can play a key role in treatment
    and management of behavioral, emotional and psychosocial problems
    including problems of suicide and substance abuse.

    BIAA stresses the importance of maintaining access to rehabilitation
    services and devices as an essential health benefit in any repeal and
    replacement of ACA that advances in the House and Senate.

    The ACA created in statute the Essential Health Benefits (EHB) category
    of ``rehabilitative and habilitative services and devices.'' ACA,
    Section 1302(b).

            Rehabilitation services and devices--Rehabilitative services,
            including devices, on the other hand, are provided to help a
            person regain, maintain, or prevent deterioration of a skill or
            function that has been acquired but then lost or impaired due
            to illness, injury, or disabling condition.\1\
    ---------------------------------------------------------------------------
        \1\ http://www.gpo.gov/fdsys/pkg/FR-2015-02-27/pdf/2015-03751.pdf,
    at 10811.

    For the first time, this definition established a uniform understanding
    of the federal meaning of rehabilitation services and devices that
    became a standard for national insurance coverage, setting a floor for
    plans sold under the ACA exchanges. The definition has been adopted by
    states for use in Medicaid expansion programs. BIAA supports the
    preservation of the EHB category of ``rehabilitative and habilitative
    services and devices'' and the subsequent regulatory definition and
    related interpretations duly promulgated, as a standard of coverage for
    rehabilitation under any version of ACA replacement legislation. BIAA
    believes that adopting the uniform federal definition of rehabilitation
    services and devices minimizes the variability in benefits across
    states and uncertainty in coverage for children and adults in need of
    ---------------------------------------------------------------------------
    rehabilitation.

    Thank you for considering our concerns as you debate this monumental
    legislation that will impact the lives of so many. Please contact Amy
    Colberg, Director of Government Affairs, acolberg@biausa.org with any
    questions.

                                     ______

                    Letter Submitted by Ruth Hong Brininger
    Dear Senate Committee on Finance,

    I am the mother of two young boys--3 years and 19 months of age. I am
    writing to urge you to NOT pass the Graham-Cassidy-Heller-Johnson
    proposal. You cannot allow the states to waive protections that the
    Affordable Care Act put into place for those with pre-existing
    conditions nor make cuts to the Medicaid program from the federal
    budget.

    My three year-old was born 5 weeks premature and will continue to need
    healthcare services at every stage of life. Ever since, he's needed
    care from an adenoid removal to a tonsillectomy. He currently receives
    speech therapy through an individualized education plan (IEP) in
    preschool. As part of his IEP evaluation while he did not reach the
    threshold to receive occupational therapy through the school system, he
    receives OT weekly through our local children's hospital to help him
    with his gross motor skills. Without coverage, he would not receive the
    critical services to be healthy, grow and develop among his peers.

    My 19 month old is diagnosed with mild-to-moderate bronchomalacia.
    Fifty percent of his airways collapse due to weakened cartilage. He's
    had his fair share of procedures and visits to urgent care. He has
    daily medication, rescue meds, and an emergency plan due to respiratory
    illnesses that exacerbate his bronchomalacia. Luckily, he's able to
    receive the critical care he needs because he's protected by the
    prohibition of states to waive critical healthcare services to those
    with pre-existing conditions.

    I couldn't imagine what a family who may not have coverage or those who
    rely upon Medicaid would do if their children were subjected to the
    health conditions that my children live with every day. I urge you to
    vote NO on the Graham-Cassidy-Heller-Johnson proposal.

    A concerned constituent,

    Ruth Hong Brininger

                                     ______

                             Charles Bruner, Ph.D.
                  Health Equity and Young Children Initiative
    While some of the focus of the Graham-Cassidy bill is related to
    provisions specific to the Affordable Care Act and its insurance
    mandate, the bill also makes huge and irreparable changes to Medicaid,
    which has been a 50-year state-federal partnership in providing health
    care to the country's most vulnerable citizens. Graham-Cassidy turns
    the Medicaid program over to the states as a block grant, with one-
    quarter less funding. For Iowa, the state in which I live, this will be
    an estimated reduction in federal support of $525 million in 2026,
    alone.

    Currently, Medicaid covers 65 percent of all frail seniors who live in
    nursing homes. Medicaid covers more than 80 percent of all people with
    serious disabilities--physical and mental--that require them to be in
    institutional or group care or receive extensive and ongoing home
    health services. Medicaid and CHIP (the federal child health insurance
    program, known in Iowa as hawk-i) cover half of all children in the
    United States, the vast majority in working families, where those
    employed in the family do not have access to family health insurance
    coverage through their employer or simply cannot afford what is
    offered. This, in large measure, is because the average cost of such
    family coverage is more than $15,000 per year (which neither employers
    nor their employees can afford to pick up, particularly for small and
    lower-wage businesses).

    Although the Graham-Cassidy bill has not been scored for its impact by
    the nonpartisan Congressional Budget Office, that score is expected to
    show it will increase the number of uninsured Americans by more than 20
    million. Its impacts, however, will be far more than that in the actual
    care that will be available--for seniors, persons with disabilities,
    and children. Even if states are able to continue some level of
    coverage for these groups, the reductions in federal funding will
    result in more restrictions, less care, and poorer health.

    This is the reason that Graham-Cassidy is opposed by organizations from
    A to Z (from AARP to Zero to Three and virtually every other organized
    group representing health consumers and health advocates), as well as
    medical providers (from primary care practitioners to hospitals and
    community health centers).

    Even if someone is not himself or herself covered by Medicaid, the
    effects of these cuts to Medicaid will have an effect, driving up
    health insurance costs, as hospitals and other providers lose revenue
    while still being expected to provide emergency services as charity
    care (or as bad debt). Virtually everyone knows someone who, because of
    a disability or infirmity, depends upon Medicaid for life-preserving
    care and will be threatened by this legislation.

    If Congress even hinted at cutting Medicare by one-quarter and turning
    it over to the states, the outcries would be enormous. Instead, members
    of Congress take great pride in Medicare and often campaign on
    protecting and improving it.

    Today, the outcries are pretty enormous against the Graham-Cassidy
    bill. Members of Congress should begin to take equivalent pride in
    Medicaid and look at ways to protect and improve, not destroy, it.

    That means rejecting the Graham-Cassidy bill and, instead, working to
    develop health care policies that can improve health quality and
    achieving better health outcomes while encouraging innovations and
    reforms that are more cost-effective in achieving those ends.

                                     ______

                        Letter Submitted by Anne Cahill

    The Honorable Orrin G. Hatch, Chairman
    U.S. Senate Committee on Finance

    The Honorable Ron Wyden, Ranking Member
    U.S. Senate Committee on Finance

    Dear Senator Hatch and Senator Wyden:

    As a parent of a daughter with a pre-existing condition, I want to
    express my strong opposition to the Graham-Cassidy-Heller-Johnson
    healthcare bill. This bill would end the Federal protections for
    persons with pre-existing conditions, would allow states to reintroduce
    annual and lifetime caps, and allow insurance companies to charge women
    more for their coverage. In addition, the essential benefits
    established by the Affordable Care Act (ACA) would no longer be
    federally mandated. Prior to ACA, 75 percent of the individual
    insurance plans did not offer maternity care.

    The Graham-Cassidy-Heller-Johnson healthcare bill also ends all cost
    sharing payments to low income Americans. My daughter works full time
    for a small business and purchases her health insurance through the ACA
    marketplace. She currently receives a cost sharing payment that
    comprises about 19% of the total cost of her monthly insurance premium.
    This is actually a smaller benefit then that she would receive if she
    worked for an employer who allowed her to pay for her health insurance
    premiums with pre-tax dollars. Why are the ACA cost sharing payments
    considered ``bad'' or ``welfare'' but not the tax subsidies being
    received by other Americans who pay for premiums with pre-tax dollars?

    The nonpartisan experts who have reviewed the Graham-Cassidy-Heller-
    Johnson healthcare bill say that it will increase the cost of health
    insurance to individuals and tens of millions of Americans will lose
    coverage. This is not the direction our country should be moving in.
    These healthcare experts include: the Centers for Medicare and Medicaid
    Services, the National Association of Medicaid Directors, the
    Commonwealth Fund, the Kaiser Family Foundation, the Center on Budget
    and Policy Priorities, the Center for American Progress, AARP,
    Brookings, Avalere, the American Academy of Actuaries, and the American
    Enterprise Institute. In addition, at least two major health insurance
    providers, Blue Cross Blue Shield and Kaiser Permanente, the American
    Hospital Association and a number of physician associations have
    released statements opposing the Graham-Cassidy-Heller-Johnson
    healthcare bill.

    Finally, I strongly object to how the Graham-Cassidy-Heller-Johnson
    healthcare bill is being rushed through with limited discussion, and
    little outside input. It is being brought up for a vote before a score
    is released by the Congressional Budget Office. Healthcare reform is
    too important for it to be treated in this manner. The decisions the
    Senate makes on healthcare will not only affect who receives coverage
    but will also affect who lives or dies.

    My daughter currently can hold down a full time position and is self-
    supporting because her illness is kept in remission by the care she
    receives. The Graham-
    Cassidy-Heller-Johnson healthcare bill would make her care unaffordable
    resulting in a relapse of her illness and quite possibly a long painful
    death. Please don't tell me that the state high risk care pools for
    persons with pre-existing conditions would take care of her. The U.S.
    has tried that model and it failed miserably because these pools were
    grossly underfunded. The Graham-Cassidy-Heller-Johnson healthcare bill
    reduces funding dramatically to most of the states; this does not bode
    well for high risk pools.

    Please do not pass the Graham-Cassidy-Heller-Johnson healthcare bill.

    Sincerely,

    Anne Cahill

                                     ______

                            Center for Fiscal Equity

                        Statement of Michael G. Bindner

    Chairman Hatch and Ranking Member Wyden, thank you for the opportunity
    to submit these comments for the record to the Committee on Finance.

    We write in strong opposition to the bill as presented. It combines the
    worst features of the House-passed bill, the bills recently rejected by
    the Senate, and the kind of state by state deals designed to add
    objecting Senators to the bill's supporters that were so roundly
    criticized when health care reform was initially passed. Because the
    balance is now so delicate and bipartisanship impossible given recent
    remarks by certain members and the Speaker of the House, any hint of
    bicameralism is gone, just like when the Affordable Care Act was
    passed. The majority has become what it most despised about passing
    Obamacare.

    The news is not all bad, of course. There is a way to end the high
    unearned-income surtax, roll back pre-existing condition reforms and
    transform Medicaid so that it is not an onerous future obligation to
    the States, but without actually killing lower income Americans or at
    least forcing hospitals to care for them in the most expensive manner
    and billing them into bankruptcy (which you cannot end because it is in
    the Constitution).

    This method was initially proposed by President Obama but rejected in
    his own party, oddly to pick up conservative Democratic votes in the
    Senate (which did not ultimately help their reelections). That method
    is a subsidized Public Option. It could include all with pre-existing
    conditions or the inability to pay even the most basic insurance (while
    ending the ability to write garbage policies that will never pay off).
    All other Medicaid for Seniors, the Disabled and those in long-term
    care could be federalized in exchange for ending the state and local
    tax deduction (SALT) as part of tax reform. Indeed, this whole process
    could be married into tax reform in such a way as to help that reform
    pass bipartisanly.

    We are sure that by now the Committee is well aware of our four-part
    tax reform proposal. Only one element applies to subsidizing the public
    option and replacing the high unearned income surtaxes, our proposed
    Net Business Receipts Tax.

    The NBRT is essentially a subtraction VAT with additional tax
    expenditures for family support, health care, and the private delivery
    of governmental services, to fund entitlement spending and replace
    income tax filing for most people (including people who file without
    paying), the corporate income tax, business tax filing through
    individual income taxes, and the employer contribution to OASI, all
    payroll taxes for hospital insurance, disability insurance,
    unemployment insurance and survivors under age 60.

    Unlike a VAT, an NBRT would not be visible on receipts and should not
    be zero rated at the border--nor should it be applied to imports. While
    both collect from consumers, the unit of analysis for the NBRT should
    be the business rather than the transaction. As such, its application
    should be universal--covering both public companies who currently file
    business income taxes and private companies who currently file their
    business expenses on individual returns.

    Employees would all be covered and participants in government funded
    remedial education programs would receive coverage and tax credits
    through the training providers health plan as if they were employees.
    There will be no more separate Medicaid programs for the poor who are
    able to learn or work. Those who cannot will be covered by the public
    option.

    Thank you for the opportunity to address the committee. We are, of
    course, available for direct testimony or to answer questions by
    members and staff.

                                     ______

                        Children's Hospital Association

                          600 13th St., NW, Suite 500

                              Washington, DC 20005

                                  202-753-5500

                      https://www.childrenshospitals.org/

                   The Nation's Children's Hospitals Oppose
                       Graham-Cassidy-Heller-Johnson Bill

    The nation's children's hospitals, representing 220 hospitals
    nationwide, stand in strong opposition to legislation introduced by
    Senators Lindsay Graham, R-SC, Bill Cassidy, R-LA, Dean Heller, R-NV,
    and Ron Johnson, R-WI. The bill threatens the health care of over 30
    million children who rely on Medicaid and millions more who will be
    negatively impacted by changes in consumer protections that guarantee
    they receive the pediatric care they require.

    The Medicaid provisions in the Graham-Cassidy-Heller-Johnson bill
    closely mirror those included in the Better Care Reconciliation Act
    (BCRA), legislation already considered and rejected by the Senate.
    Under current law, Medicaid guarantees meaningful coverage for eligible
    populations, such as low-income children and disabled children, and
    flexes up and down based on shifts in the economy and need. By
    converting Medicaid to a capped program limiting funding to states, the
    bill removes the certainty states count on to provide health care
    coverage to the most vulnerable children, including those impacted by
    natural disasters and public health emergencies like we are
    experiencing today.

    Through the Medicaid per capita cap and the new state block grant, the
    bill drastically reduces funding for states, especially in the long
    term, with a funding cliff beginning in 2027, but does not provide the
    mechanisms and support to actually improve care provided to vulnerable
    children and their families. The bill is short sighted and will result
    in long-term costs and sicker adults when children are unable to access
    medically necessary care.

    Previous analysis of the impact of the per capita cap model that is the
    basis for the Graham-Cassidy-Heller-Johnson bill estimates the cut to
    Medicaid for children at more than $40 billion by 2026, and more recent
    analyses show a 31 percent decline in Medicaid spending on kids by
    2036. Per enrollee, children are already the lowest funded Medicaid
    population, and the capped funding provisions risk their financing more
    so than adults' given children represent nearly 50 percent of Medicaid
    enrollees. This steep decline in our investment in children undermines
    their health coverage, benefits and access. It results in severe
    economic pressures on states and risks the funding of health care for
    all children. We need to invest in our nation's children as the next
    generation of leaders, not shortchange their development and potential.

    Today, a record 95 percent of children in America have health coverage.
    But the Graham-Cassidy-Heller-Johnson health care bill will move us
    backwards. Our nation's children certainly deserve more.

    This proposal additionally risks further decentralization of the
    national pediatric quality information and cross-state referrals so
    essential to improved care for our sickest children, including those in
    military families. The legislation also weakens important health
    services programs for all children, including those covered by private
    insurance, with millions of children in working families no longer
    assured access to specialized pediatric services regardless of any
    underlying medical condition.

    On behalf of the millions of children and families we serve, we ask the
    Senate Finance Committee to reject the Graham-Cassidy-Heller-Johnson
    bill or any bill that cuts Medicaid for children and undermines their
    long-term health. The nation's children's hospitals look forward to
    working with congressional leaders of both parties to improve Medicaid
    for children and families through positive reforms.

                                     ______

                   Consortium for Citizens With Disabilities

                         1825 K Street, NW, Suite 1200

                              Washington, DC 20006

    Dear Chairman Hatch, Ranking Member Wyden, and members of the Senate
    Finance Committee:

    Thank you for this opportunity to submit a statement for the record
    regarding the September 25, 2017 hearing titled ``Hearing to Consider
    the Graham-Cassidy-Heller-Johnson Proposal.''

    The Consortium for Citizens with Disabilities (CCD) is the largest
    coalition of national organizations working together to advocate for
    federal public policy that ensures the self-determination, in
    dependence, empowerment, integration and inclusion of children and
    adults with disabilities in all aspects of society. The undersigned
    members of the Consortium for Citizens with Disabilities (CCD) write to
    express strong opposition to the Graham-Cassidy-Heller-Johnson (GCHJ)
    proposal.

    As we have previously commented on multiple House and Senate proposals,
    we cannot overstate the danger facing the millions of adults and
    children with disabilities if the proposal's Medicaid provisions are
    adopted. The proposal's imposition of a per capita cap and the
    elimination of the adult Medicaid expansion would decimate a program
    that has provided essential healthcare and long term services and
    supports to millions of adults and children with disabilities for
    decades. We are also extremely concerned about the changes proposed to
    the private individual health insurance market and the tax credits that
    currently assist low-income individuals, including individuals with
    disabilities, to purchase insurance.

    Some 10 million people with disabilities and, often, their families,
    depend on the critical services that Medicaid provides for their
    health, functioning, independence, and well-being. For decades, the
    disability community and bipartisan Congressional leaders have worked
    together to ensure that people with disabilities of all ages have
    access to home- and community-based services (HCBS) that allow them to
    live, work, go to school, and participate in their communities instead
    of passing their days in institutions. Medicaid has been a key driver
    of innovations in cost-effective community-based care, and is now the
    primary program covering HCBS in the United States. Older adults and
    people with disabilities rely on Medicaid for nursing and personal care
    services, specialized therapies, intensive mental health services,
    special education services, and other needed services that are
    unavailable through private insurance.

    Like other proposals considered by the Senate, the GCHJ bill upends
    those critical supports. Per capita caps--which have nothing to do with
    the Affordable Care Act--would radically restructure the financing of
    the traditional Medicaid program and divorce the federal contribution
    from the actual costs of meeting people's health care needs. Caps are
    designed solely to cut federal Medicaid support to states, ending a
    decades-long state/federal partnership to improve opportunities and
    outcomes for our most vulnerable. Slashing federal funds will instigate
    state budget crises that stifle the planning and upfront investments
    required to create more efficient care systems. Caps will force states
    to cut services and eligibility, which will put the lives, health, and
    independence of people with disabilities at significant risk. In fact,
    because HCBS (including waivers) are optional Medicaid services, they
    will likely be among the first targets when states are addressing
    budgetary shortfalls. The structure of GCHJ's cap--like the structure
    in previous bills--makes cuts worse after it reduces the growth rate in
    2025. Independent experts have estimated the Graham-Cassidy per capita
    cap alone would cut federal supports to states by $53 billion \1\ $175
    billion \2\ by 2026, with steeper cuts increasing to $1.1 trillion \3\
    to $3.2 trillion \4\ by 2036.
    ---------------------------------------------------------------------------
        \1\ Kaiser Family Foundation, ``State-by-State Estimates of Changes
    in Federal Spending on Health Care Under the Graham-Cassidy Bill''
    (September 2017), available at http://files.kff.org/attachment/Issue-
    Brief-State-by-State-Estimates-of-Changes-in-Federal-Spending-on-
    Health-Care-Under-the-Graham-Cassidy-Bill.
        \2\ Center on Budget and Policy Priorities, ``Like Other ACA Repeal
    Bills, Cassidy-Graham Would Cap and Deeply Cut Medicaid'' (September
    21, 2017), available at https://www.cbpp.org/research/health/like-
    other-aca-repeal-bills-cassidy-graham-would-cap-and-deeply-cut-
    medicaid#.
        \3\ Id.
        \4\ AARP, ``Sounding the Alarm: The New Senate Health Care Bill
    Could Cut $3.2 Trillion From Medicaid by 2036'' (September 19, 2017),
    available at http://blog.aarp.org/2017/09/19/sounding-the-alarm-the-
    new-senate-health-care-bill-could-cut-3-2-trillion-from-medicaid-by-
    2036/.

    Limited carve outs and targeted funding pots included in GCHJ pale in
    comparison to the scope of these cuts. For example, GCHJ offers a 4-
    year $8 billion dollar demonstration to expand Medicaid home and
    community-based services--which is not even half of the $19 billion cut
    to the Community First Choice option that eight states have implemented
    to expand access to necessary in-home services for people with
    disabilities.\5\ All individuals on Medicaid will be impacted by cuts
    of this magnitude, despite any limited, temporary demonstration funding
    or restricted funding carve out for a fraction of the children with
    disabilities that Medicaid supports. Throwing billions in extra
    temporary funds cannot curb the inevitable, long-term loss of critical
    Medicaid services that people with disabilities will face as a result
    of per capita caps.
    ---------------------------------------------------------------------------
        \5\ Congressional Budget Office, ``Cost Estimate for HR. 1628,'' 33
    (June 26, 2017).

    In addition, GCHJ ends the Medicaid Expansion and the current tax
    credits and cost sharing reductions that assist low income individuals
    purchase health insurance in 2020. It replaces this assistance with a
    block grant that would reduce federal funding by $239 billion by
    2026.\6\ After 2026, Graham-Cassidy cuts off federal funding for people
    who today rely on Medicaid expansion and Marketplace coverage,
    including millions with disabilities. These are people who previously
    fell through the cracks in our system, such as individuals with
    disabilities in a mandatory waiting period before their Medicare
    coverage begins and millions of people with a behavioral health
    condition who previously had no pathway to steady coverage. Also,
    millions of family caregivers and hundreds of thousands of low-wage
    direct care workers who serve older adults and people with disabilities
    gained coverage through the Medicaid expansion. Medicaid expansion
    helps stabilize our long-term care support networks by keeping
    caregivers healthy and reducing turnover, but would end under Graham-
    Cassidy.
    ---------------------------------------------------------------------------
        \6\ The Commonwealth Fund, ``Graham-Cassidy: Radical Change in the
    Federal-State Health Relationship'' (September 22, 2017), available at
    http://www.commonwealthfund.org/publications/blog/2017/sep/graham-
    cassidy-and-the-states.

    Likewise, Marketplace coverage ensures that people with disabilities
    can buy comprehensive and affordable health care and have equal access
    to much needed health care including examinations, therapies to regain
    abilities after an illness or injury, and affordable medications. We
    have serious concerns about GCHJ private market provisions, including
    the state waiver authority to eliminate protections for people with
    preexisting conditions (including people with disabilities), older
    adults, and people who need access to essential health benefits. The
    nondiscrimination provisions and health insurance reforms, the expanded
    access to long term supports and services, and the expanded
    availability of comprehensive and affordable health care have helped
    many more individuals with disabilities live in the community and be
    successful in school and the work place. No longer do individuals with
    disabilities and their families have to make very difficult choices
    about whether to pay their mortgage, declare bankruptcy, or choose
    ---------------------------------------------------------------------------
    between buying groceries and paying for needed medications.

    In short, GCHJ makes health insurance less affordable for millions of
    people, particularly people with disabilities, older adults, and those
    with chronic health conditions. The cumulative effect of the private
    insurance and Medicaid proposals will leave people with disabilities
    without care and without choices, caught between Medicaid cuts,
    unaffordable private insurance, and limited high risk pools. Based on
    prior Congressional Budget Office scores, the Brookings Institute
    estimates GCHJ would lead to 15 million fewer individuals having health
    insurance from 2018-2019, 21 million fewer individuals from 2020-2026,
    and 32 million fewer individuals from 2027 onwards.\7\
    ---------------------------------------------------------------------------
        \7\ The Brookings Institute, ``How Will the Graham-Cassidy Proposal
    Affect the Number of People With Health Insurance Coverage?''
    (September 22, 2017), available at http://www.
    brookings.edu/research/how-will-the-graham-cassidy-proposal-affect-the-
    number-of-people-with-health-insurance-coverage/.

    Finally, we are extremely disappointed that the proposal has not been
    considered under regular order and in fact threatens to usurp an active
    bipartisan effort to bolster Marketplace coverage. The Senate has a
    longstanding history of deliberating policy proposals through
    transparent processes, including public hearings, open comment periods
    on discussion drafts, and multi-stakeholder meetings. We are
    particularly concerned that Senators are expressing support of this
    proposal without a Congressional Budget Office (CBO) score that
    thoroughly examines the short and long term financial and coverage
    impacts. The complete restructuring proposed for the individual private
    insurance market is likely to have repercussions on coverage that prior
    CBO estimates do not take into account. The Senate Health Education
    Labor and Pensions Committee has begun a bipartisan process examining
    how to strengthen the Affordable Care Act. We ask all Senators to
    reject this proposal and instead engage in the process of regular order
    and work toward bipartisan solutions that ensure that all adults and
    ---------------------------------------------------------------------------
    children with disabilities have access to the healthcare they need.

    Sincerely,

    ACCSES
    Advance CLASS/Allies for Independence
    American Association of People with Disabilities
    American Association on Health and Disability
    American Association on Intellectual and Developmental Disabilities
    American Civil Liberties Union
    American Congress of Rehabilitation Medicine
    American Dance Therapy Association
    American Foundation for the Blind
    American Music Therapy Association
    American Network of Community Options and Resources
    American Occupational Therapy Association
    American Psychological Association
    American Therapeutic Recreation Association
    Association of Assistive Technology Act Programs
    Association of People Supporting Employment First
    Association of University Centers on Disabilities
    Autism Society
    Autism Speaks
    Autistic Self Advocacy Network
    Bazelon Center for Mental Health Law
    Brain Injury Association of America
    Center for Public Representation
    Children and Adults with Attention-Deficit Hyperactivity Disorder
    Christopher and Dana Reeve Foundation
    Community Legal Services of Philadelphia
    Conference of Educational Administrators of Schools and Programs for
    the Deaf
    Council for Exceptional Children
    Council of Administrators of Special Education
    Disability Rights Education and Defense Fund
    Division for Early Childhood of the Council for Exceptional Children
    Easterseals
    Epilepsy Foundation
    Family Voices
    Higher Education Consortium for Special Education
    Institute for Educational Leadership
    Jewish Federations of North America
    Justice in Aging
    Learning Disabilities Association of America
    Lupus Foundation of America
    Lutheran Services in America Disability Network
    Mental Health America
    National Academy of Elder Law Attorneys
    National Alliance on Mental Illness
    National Association for the Advancement of Orthotics and Prosthetics
    National Association of Councils on Developmental Disabilities
    National Association of School Psychologists
    National Association of State Directors of Developmental Disabilities
    Services
    National Association of State Directors of Special Education
    National Association of State Head Injury Administrators
    National Center for Learning Disabilities
    National Committee to Preserve Social Security and Medicare
    National Council for Behavioral Health
    National Council on Aging
    National Council on Independent Living
    National Disability Institute
    National Disability Rights Network
    National Down Syndrome Congress
    National Down Syndrome Society
    National Health Law Program
    National Multiple Sclerosis Society
    National Organization of Social Security Claimants' Representatives
    National Respite Coalition
    Paralyzed Veterans of America
    Parent to Parent USA
    School Social Work Association of America
    SourceAmerica
    Special Needs Alliance
    TASH
    Teacher Education Division of the Council for Exceptional Children
    The Advocacy Institute
    The Arc of the United States
    The Michael J. Fox Foundation for Parkinson's Research
    United Cerebral Palsy
    United Spinal Association

                                     ______

                     Letter Submitted by Arlene J. Crawford

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Re:  Hearing to consider Graham-Cassidy-Heller-Johnson proposal,
    Monday, September 25, 2017

    Senator Hatch and members of the Senate Finance Committee:

    I am writing to share my views on the above-mentioned bill. I strongly
    oppose this legislation. I not only oppose the contents, I oppose the
    backhanded and unethical way it has been crafted and advanced.

    Treating the lives and health of American citizens as some sort of
    political football is repulsive. Valuing slogans and political points
    above careful and considered governance is a shameful and willful
    failure to fulfill jobs you were elected to do.

    I have been an independent voter without party affiliation since I
    started voting during the Reagan era. Through all those years, I have
    been open to candidates of either party, and have voted for both
    Republicans and Democrats.

    The Republican Party is destroying any claim they have to being a
    respectable option by pushing a hastily-written, unscored, undebated
    bill through Congress in a blatantly partisan way. You have had
    literally years to prepare legislation to tackle the problems the U.S.
    has with the healthcare sector, and you wasted them. You don't get
    credit for throwing together a half-assed Hail Mary pass now.

    Patriotic catchphrases about how states are so amazingly innovative
    don't matter--treating healthcare and insurance as the life-altering
    topics they are for most Americans does. Write a bipartisan bill, hold
    hearings, gather input, accept and debate amendments, get a CBO score.
    If the GOP continues to try to run the country like their personal
    fiefdom, I will never again vote for anyone with an (R) after their
    name on the ballot for local dog catcher, much less any higher office.

    Sincerely,

    Arlene J. Crawford

                                     ______

                           Cystic Fibrosis Foundation

                      4550 Montgomery Avenue, Suite 1100 N

                               Bethesda, MD 20814

            Statement Submitted by Preston W. Campbell, III, M.D.,
                     President and Chief Executive Officer

    Dear Chairman Hatch and Ranking Member Wyden:

    We are gravely concerned about the bill under discussion today, known
    as the Graham, Cassidy, Heller, Johnson proposal (Graham/Cassidy).
    Specifically, this bill:

          Does not protect patients with pre-existing conditions.
          Devastates the Medicaid safety-net.
          Opens the door to annual and lifetime coverage caps.
          Repeals the guarantee of essential health benefits.
          Could result in states bringing back high risk pools.

    Such policies would be devastating for people with cystic fibrosis (CF)
    and hamper their ability to access adequate, affordable health
    insurance.

    Please bear in mind the needs of people with CF as you consider this
    proposal. The stakes are incredibly high for our community, which
    relies on access to vital health care services to maintain health and
    well being. It is imperative that any policy changes move us closer to
    a system that improves care for everyone, including those who need it
    most.
    Our Principles
    We believe the health insurance market should meet the following
    standards, in order to protect the lives and well-being of people with
    cystic fibrosis:

          Adequacy: Adequate health insurance covers therapies and care
    delivered by an accredited care team using the latest research,
    clinical guidelines, and best practices.
          Affordability: Affordable health plans help ensure access to
    needed care in a timely manner from an experienced provider without
    undue financial burden.
          Availability: Available health coverage provides adequate
    benefits at an affordable cost regardless of an individual's income,
    employment, health status or geographic location.

    People with cystic fibrosis are living longer, healthier lives than
    ever before. But these gains in health and longevity depend on people
    with CF receiving uninterrupted, multidisciplinary care at an
    accredited CF care center--and that requires adequate, affordable
    health insurance to be available for patients. For those with cystic
    fibrosis, health care coverage is a necessity, not a luxury, and
    interruptions in coverage can lead to lapses in care, irreversible lung
    damage, and costly hospitalizations.
    Graham/Cassidy Does Not Protect Patients With Pre-existing Conditions
    Protections in current law guarantee that people with cystic fibrosis
    and other diseases cannot be denied health insurance, charged higher
    premiums, or denied coverage of specific services because of their
    health. All three of these policies are absolutely essential for people
    with CF--no single policy is sufficient on its own.

    Unfortunately, the Graham/Cassidy proposal would undo these critical
    protections in current law by letting insurers charge higher premiums
    to those with pre-existing conditions if a state chooses to waive that
    protection. This could easily put coverage financially out of reach for
    people with cystic fibrosis who purchase coverage in the individual
    market, jeopardizing their access to lifesaving treatments that allow
    them to maintain their health. Such a proposal also undermines other
    protections for people with pre-existing conditions that would remain
    in law, as a guarantee of coverage is utterly useless if that coverage
    is unaffordable.
    Graham/Cassidy Devastates the Medicaid Safety-Net
    Medicaid is a crucial source of coverage for patients with serious and
    chronic health care needs, including over 50 percent of children and
    one-third of adults living with cystic fibrosis.\1\ For many
    individuals with CF, Medicaid serves as a payer of last resort by
    filling important gaps in coverage left by private health plans. For
    instance, Medicaid helps people living with the disease to afford the
    increasingly costly co-pays and co-insurance rates for prescription
    medications and inpatient and outpatient care. People with CF are
    eligible for Medicaid through various pathways, including through
    income-related and disability criteria.
    ---------------------------------------------------------------------------
        \1\ Cystic Fibrosis Foundation Patient Registry. 2015 Annual Data
    Report. (Online). 2016. Available at: https://www.cff.org/Our-Research/
    CF-Patient-Registry/2015-Patient-Registry-Annual-
    Data-Report.pdf.

    The proposal to convert federal financing of Medicaid to a per capita
    cap system is deeply troubling, as this policy would reduce federal
    funding for Medicaid by hundreds of billions of dollars.\2\ There is no
    magic bullet that will somehow allow states to provide the same level
    of services to the same populations with less money. This proposal will
    force states to either make up the difference with their own funds--a
    seemingly insurmountable hurdle in many states--or cut their programs
    by reducing the number of people they serve and the benefits they
    provide.
    ---------------------------------------------------------------------------
        \2\ Congressional Budget Office. Re: H.R. 1628, the Better Care
    Reconciliation Act: An Amendment in the Nature of a Substitute
    (ERN17500), as posted on the website of the Senate Committee on the
    Budget on July 20, 2017. (Online). July 2017. Available at: https://
    www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/52941-
    hr1628bcra.pdf. The proposal to convert Medicaid financing to a per
    capita cap system in Graham/Cassidy is identical to the proposal in
    this bill.

    For patients with CF, this means that Medicaid may no longer cover the
    care and treatments they need, including breakthrough therapies and
    technology. This could be devastating for people with CF who face a
    pipeline of promising new treatments that could help them live longer,
    healthier lives than ever before. The CF community already experiences
    instances in which Medicaid programs deny patients, oftentimes
    children, the critical therapies they need because of budget
    constraints. A per capita cap will only exacerbate the downward
    pressure on Medicaid budgets and will further reduce access to these
    ---------------------------------------------------------------------------
    therapies for patients.

    Preserving Medicaid expansion is equally vital. Nearly half of adults
    covered by the Medicaid expansion are permanently disabled, have
    serious physical or mental conditions, or are in fair or poor
    health.\3\ The Graham/Cassidy proposal would remove the option for
    Medicaid expansion in states that did not expand and eliminate
    expansion programs in states that already chose to expand--an even more
    drastic proposal than earlier health care bills in the Senate. This
    would result in millions of patients losing vital coverage they depend
    upon to maintain their health.
    ---------------------------------------------------------------------------
        \3\ Brantley, Erin, et al. ``Myths About the Medicaid Expansion and
    the `Able-Bodied'.'' Health Affairs blog. (Online) March 2017.
    Available at: http://healthaffairs.org/blog/2017/03/06/myths-about-the-
    medicaid-expansion-and-the-able-bodied/.
    ---------------------------------------------------------------------------
    Graham/Cassidy Opens the Door to Annual and Lifetime Coverage Caps
    The current prohibition on annual and lifetime benefit caps is critical
    to ensuring access to health care for people with CF. Health care costs
    can accumulate very quickly for people with CF, making it easy to reach
    such coverage caps. For instance, a father of two daughters with CF
    reported that together his children hit over $1 million a year in
    medical expenses. The result of such caps can be devastating--leaving
    people with CF stranded without any health care coverage.

    Unfortunately, by explicitly allowing states to amend essential health
    benefit (EHB) standards, Graham/Cassidy creates a back door for
    insurers to reinstate annual or lifetime coverage caps. In its analysis
    of earlier Senate bills that would have made it easier for states to
    change EHB standards, the Congressional Budget Office noted that the
    prohibition on annual and lifetime limits only applies to essential
    health benefits and changes to this standard could expose patients to
    large increases in out-of-pocket spending.\4\ Services included in the
    current EHB definition are critical for people with CF, including
    prescription drugs, hospitalization, and mental health care. If a state
    deemed any of these services ``non-essential'' and insurers imposed
    coverage caps on these benefits, people with CF could quickly find
    themselves unable to access this vital care.
    ---------------------------------------------------------------------------
        \4\ Congressional Budget Office. H.R. 1628, American Health Care
    Act of 2017. (Online). May 2017. Available at: https://www.cbo.gov/
    system/files/115th-congress-2017-2018/costestimate/hr1628aspassed.pdf.
    ---------------------------------------------------------------------------
    Graham/Cassidy Repeals the Guarantee of Essential Health Benefits
    Moreover, in addition to opening the door to annual and lifetime
    coverage caps, eliminating the guarantee of essential health benefit
    coverage for exchange plans would segment the market into plans for
    sick people and plans for healthy people. As described above, people
    with CF need adequate health insurance that covers the specialized,
    multi-disciplinary care they need to maintain their health.

    Removing the guarantee of essential health benefits as a coverage floor
    would result in insurers selling skimpier plans alongside traditional
    health care plans. People with CF and others with chronic diseases
    would be more likely to purchase traditional plans, while healthier
    individuals would be more likely to purchase the skimpier plans. This
    will drive up the cost of plans needed by people with CF and
    potentially make coverage unaffordable.
    Graham/Cassidy Could Result in States Bringing Back High-Risk Pools
    Due to the broad scope of the market-based health care grants, Graham/
    Cassidy allows states to use the block grants to establish high-risk
    pools. High-risk pools, which put people with serious health conditions
    into a separate insurance market, do not work for people with CF and
    other chronic diseases and are not an acceptable form of coverage.
    Prior experience with high-risk pools demonstrates that the coverage
    was unaffordable due to high premiums, usually 150-200 percent of the
    average non-group rate.\5\ High-risk pools also often had waiting
    periods of up to 12 months, leaving patients struggling to access
    critical services while they were waiting for coverage. Finally,
    funding constraints resulted in strict enrollment caps and lifetime
    coverage limits in many states, causing some individuals to go without
    needed coverage either because they could not enroll or they hit their
    lifetime cap.\6\
    ---------------------------------------------------------------------------
        \5\ National Association of State Comprehensive Health Insurance
    Plans. Comprehensive Health Insurance for High-Risk Individuals. 2011.
    Available at: http://naschip.org/2011/Quick%20
    Checks/25/Premium%20Rate%20Setting%20Methodology%2010.pdf.
        \6\ Schwartz, Tanya. ``State High-Risk Pools: An Overview.'' Kaiser
    Commission on Medicaid and the Uninsured. January 2010. Available at:
    https://kaiserfamilyfoundation.files.wordpress.
    com/2013/01/8041.pdf.

    Thank you for your consideration. We stand ready to work with members
    ---------------------------------------------------------------------------
    of the Senate Finance Committee as they consider this proposal.

                                     ______

                       Disability Rights California (DRC)

                              LEGAL ADVOCACY UNIT

                            1330 Broadway, Suite 500

                               Oakland, CA 94612

                              Tel: (510) 267-1200

                              TTY: (800) 719-5798

                          Intake Line: (800) 776-5746

                              Fax: (510) 267-1201

                      https://www.disabilityrightsca.org/

    Dear Chairman Hatch, Ranking Member Wyden, and Honorable Senate Finance
    Committee Members:

    We write to urge you to reject the Graham-Cassidy-Heller-Johnson bill,
    which will have devastating effects on Californians with disabilities.

    Disability Rights California (DRC) is the protection and advocacy
    agency for California, established to protect, advocate for and advance
    the human, legal and service rights of Californians with disabilities.
    Since 1978, Disability Rights California has provided essential legal
    services to people with disabilities. In the last year, Disability
    Rights California provided legal assistance to nearly 26,000
    Californians with disabilities. A significant focus of our work is
    ensuring access to critical health and long-term services and supports.
    Here is one example of our work.

    Mrs. Jones called DRC because her husband had become disabled from a
    stroke. She had depleted her savings paying for home care and was on
    the verge of declaring bankruptcy. Mr. Jones' retirement pension was
    not enough to pay for all of his care needs. DRC assisted Mrs. Jones to
    apply for Medi-Cal (California's Medicaid program) for her husband, who
    became eligible under the ``spousal impoverishment'' provision of the
    Affordable Care Act. By receiving Medi-Cal, Mrs. Jones can hire
    attendants to help Care for her husband at home, instead of placing him
    in a nursing home, which would be more costly and result in a
    devastating separation from his home and family.

    The Graham-Cassidy-Heller-Johnson proposal, which would repeal the
    Affordable Care Act (ACA) and fundamentally change Medicaid, will be
    catastrophic for Californians with disabilities. If this bill passes,
    states will no longer be required to offer essential health benefits
    such as mental health and substance abuse treatment; it will undermine
    and eliminate protections for people with pre-existing conditions; the
    subsidies for health insurance exchanges will end; and cost sharing
    reduction for low income individuals will be eliminated. The bill will
    also decimate the Medicaid program, ending more than 50 years of a
    federal-state partnership ensuring health care coverage for low-income
    and disabled Americans. Instead, California's Medicaid program would
    face enormous cuts through block grants and per capita cuts, and the
    ACA's Medicaid expansion would end. In California, 14.1 million people,
    including children and adults with disabilities and seniors, receive
    their health care services through Medi-Cal (California's Medicaid
    program). Almost 4 million people gained coverage through the ACA
    expansion of Medi-Cal. The health and economic consequences of this
    proposal for individuals with disabilities and our state will be
    devastating.

    The Graham-Cassidy bill proposes to redistribute federal resources from
    large populous states (who took advantage of the ACA in order to serve
    their residents and ensure coverage to as many needy people as
    possible) and will result in California losing $28 billion dollars
    through 2026, then jumping to $57.5 billion in 2027.\1\ The California
    Department of Health Care Services' analysis concluded: ``Simply
    stated, this proposal is the most devastating of the three federal
    health care proposals that we have evaluated this year.'' \2\
    ---------------------------------------------------------------------------
        \1\ http://laborcenter.berkeley.edu/the-gops-last-ditch-effort-to-
    repeal-the-affordable-care-act-is-the-worst one-yet-for-california/.
        \2\ http://www.dhcs.ca.gov/Documents/
    Graham_Cassidy_Impact_Memo_DHCS_092217.pdf at 1.

    The Congressional Budget Office estimates Medicaid would be cut by over
    a quarter (26%) by 2026 and over a third (35%) by 2036. The per capita
    caps proposal would shift the responsibility for 100% of the costs
    above the per-beneficiary cap back to the state. It would also not
    account or adjust for increasing health care costs, an aging
    ---------------------------------------------------------------------------
    population, or public health emergencies.

    In addition, Graham-Cassidy directly threatens the 2.3 million people
    who buy coverage in the individual market, in which 1.5 million are in
    Covered California (1.2 million who get ACA tax subsidies.)

    California will lose a total cumulative cut of $114.6 billion between
    2020 and 2027, and another $5-6 million annually in subsidies now
    available through Covered California.\3\ In total, 6.7 million
    Californians would lose coverage in 2027; this will disproportionately
    hurt those in areas of the state with the highest Medi-Cal enrollment,
    including the Central Valley, Imperial Valley, and parts of Los
    Angeles.\4\
    ---------------------------------------------------------------------------
        \3\ http://laborcenter.berkeley.edu/the-gops-last-ditch-effort-to-
    repeal-the-affordable-care-act-is-the-worst-one-yet-for-california/.
        \4\ http://laborcenter.berkeley.edu/the-gops-last-ditch-effort-to-
    repeal-the-affordable-care-act-is-the-worst-one-yet-for-california/.

    This proposal will be even more detrimental to people with disabilities
    and California's economy than earlier health care proposals. Medi-Cal
    is the primary funder of critical home- and community-based services
    (HCBS), ensuring that people with disabilities both young and old can
    receive services that allow them to live in their own homes, go to
    ---------------------------------------------------------------------------
    school, work, and participate in their communities.

    These HCBS services are optional under Medicaid and states could
    eliminate them under the Graham-Cassidy bill. Because private insurance
    largely does not cover the nursing and personal care services,
    specialized therapies, intensive mental health services, special
    education services, and other needed services, people with disabilities
    must rely on Medicaid HCBS services. For example, according to the
    California Department of Health Care Services:

            California's [In-Home Supportive Services attendant care]
            program is the largest in the country, and is the core of our
            home- and community-based system that allows the elderly and
            disabled to remain in their homes rather than be placed in a
            more costly institutional care setting. \5\
    ---------------------------------------------------------------------------
        \5\ http://www.dhcs.ca.gov/Documents/
    Graham_Cassidy_Impact_Memo_DHCS_092217.pdf at 4.

    These services are now in imminent danger. Cuts to critical and cost-
    effective Medicaid HCBS services like IHSS will result in waitlists,
    and will force people into more expensive institutions, resulting in
    the unnecessary movement of people away from their families and home
    ---------------------------------------------------------------------------
    communities.

    We urge you to protect Californians with disabilities and reject this
    proposal, as well as any other attempt to gut the fundamental and life-
    saving benefits provided to millions through Medicaid and the ACA.

    Sincerely,

    Catherine Blakemore
    Executive Director

                                     ______

                          Disability Rights Ohio (DRO)

                         50 W. Broad Street, Suite 1400

                           Columbus, Ohio 43215-5923

                          614-466-7264 or 800-282-9181

                                FAX 614-644-1888

                        TTY 614-728-2553 or 800-858-3542

                      http://www.disabilityrightsohio.org/

    Chairman Hatch, Ranking Member Wyden, and members of the United States
    Senate Committee on Finance, thank you for the opportunity to provide
    written testimony in opposition to the Graham-Cassidy-Heller-Johnson
    (``GCHJ'') health care proposal. Disability Rights Ohio (``DRO'') urges
    the members of the committee NOT to support this bill. If enacted, this
    legislation would be devastating to the over 3 million people in Ohio
    served by Medicaid including people with disabilities. Medicaid
    provides these individuals the opportunity to live and work in their
    communities; any cuts, like those proposed in GCHJ, have the potential
    to force people with disabilities back into institutionalized settings.
    Moreover, expansion of Medicaid has allowed approximately 700,000
    Ohioans, many of them with disabilities, to receive health care. This
    has allowed Ohio to provide treatment for individuals caught in the
    opioid epidemic, who frequently experience co-morbidity with mental and
    physical illness, and who were not receiving medical care prior to the
    expansion.

    BACKGROUND

    _______________________________________________________________________

    Disability Rights Ohio is a non-profit corporation registered in the
    state of Ohio. It is designated by Ohio's Governor under the
    Developmental Disabilities Act and other federal laws as the system to
    protect and advocate for the rights of people with disabilities in
    Ohio. DRO's mission is to advocate for the human, civil, and legal
    rights of people with disabilities in Ohio. We have broad experience
    providing legal and policy advocacy for our clients and their families,
    and as a result DRO has a unique perspective on the importance of
    adequate health care and in particular, Medicaid for Ohioans with
    disabilities.

    This is true in the general sense, as our clients often rely on
    Medicaid for health insurance. But this also can assist the individual
    to become more independent and a productive member of society through
    programs like Medicaid Buy-in, which allows people with disabilities to
    gain employment without losing necessary health care that may not be
    provided by an employer. The health care exchanges have also provided a
    meaningful opportunity for people with disabilities to gain health
    insurance without regard to pre-existing conditions (i.e., their
    disability).

    In addition, the large majority of long term services and supports
    (LTSS) for elders and people with disabilities in Ohio are paid for
    through Medicaid. While the state has a way to go, Ohio has been making
    progress in rebalancing its LTSS away from institutions and into home
    and community based services. The Americans with Disabilities Act of
    1990 (``ADA'') requires equal opportunity and access for people with
    disabilities, and undue segregation in an institutional placement is
    discrimination under the ADA. The state's programs must be designed to
    promote integration into the community. HCBS Waivers are the main
    driver of this change, and in Ohio cuts to Medicaid will, with
    certainty, limit progress in this area and reduce the effectiveness of
    Ohio's efforts, and force people with disabilities back into
    institutionalized settings.

    This testimony will be divided into two sections. First, it will
    demonstrate the importance of Medicaid in the lives of people with
    disabilities in Ohio by sharing two reports DRO published showing how
    Medicaid helps individuals become fully integrated into their
    communities. Second it will focus on the major concerns with the GCHJ
    proposal and the devastating impact it would have on people with
    disabilities.

    MEDICAID MATTERS

    _______________________________________________________________________

    Medicaid is intrinsically important for the over 38,000 people with
    disabilities in Ohio who are served through Medicaid waivers. These
    waivers allow people with disabilities the ability to live and work in
    their communities. Because of this, DRO published two (2) reports that
    detail how Medicaid helps people with disabilities in Ohio: Medicaid
    Matters \1\ and Medicaid Myths.\2\
    ---------------------------------------------------------------------------
        \1\ The full publication can be viewed on our website at: http://
    www.disabilityrightsohio.org/assets/documents/
    dro_justin_martin_medicaid_booklet.pdf.
        \2\ The full publication can be viewed on our website at: http://
    www.disabilityrightsohio.org/assets/documents/
    dro_medicaidmyths_2017.pdf.

    DRO's Medicaid Myths publication shows the various ways that Medicaid
    provides services to people with disabilities and allows them the
    opportunity to live and work in their communities. One way is through
    HCBS waivers that provide service and supports to people with
    disabilities in their home. This essential service allows for
    individuals to remain in their homes and be fully integrated into their
    communities, while diverting them from being placed unnecessarily in
    institutional settings. Another way is through essential in-school
    services to children with disabilities. These services help children to
    learn alongside their peers in traditional school environments,
    supporting the requirement in federal law of full inclusion of children
    ---------------------------------------------------------------------------
    with disabilities in their schools.

    DRO's Medicaid Matters details the incredible story of Justin Martin.
    He attends Kenyon College with plans to become an inspiring teacher.
    Justin's HCBS waiver allows him the ability to go to college alongside
    his peers and receive the necessary supports he needs to be successful.
    This would not be attainable without Medicaid. With the waiver, Justin
    will graduate and obtain a job in the community and contribute like any
    other adult his age. Cuts to Medicaid would stop countless other people
    with disabilities like Justin from obtaining this same kind of success.

    To retain the success of Medicaid in helping people with disabilities
    live and work in their communities, as shared in the DRO publications,
    members of the United States Senate Committee on Finance should NOT
    support the GCHJ proposal, which would weaken the Medicaid program and
    prevent people with disabilities from being fully integrated in their
    communities.

    NEGATIVE IMPLICATIONS

    _______________________________________________________________________

    The GCHJ proposal has multiple provisions that would drastically impact
    the lives of people with disabilities. Ohio has an obligation under
    Olmstead to provide services to people with disabilities in community-
    based settings. GCHJ makes drastic cuts and changes to the Medicaid
    program that would create devastating impacts on the lives of people
    with disabilities who live and work in their communities. The following
    is a list of provisions in the GCHJ proposal that are concerning and
    problematic for people with disabilities in Ohio.

    Implementing per capita caps. Per capita caps would inhibit Ohio's
    ability to pay for rising costs in services like accommodations to help
    individuals in and out of the shower in the home, wheelchair ramps, and
    personal care aides, all of which are needed to allow for individuals
    to live at home and work in their communities. HCBS waivers are not
    required services and per capita caps will force Ohio to make drastic
    cuts, preventing people with disabilities to live and work in their
    communities. Cuts to essential in-home care services puts individuals
    who need LTSS at risk of institutionalization.

    Ohio already has as many as 40,000 individuals on waitlists for home
    and community-based services. Even those who meet the requirements to
    receive a waiver can be put on a waitlist if there is not an open
    ``slot.'' Cuts to Medicaid ensure that more people will be waiting for
    essential benefits that are necessary for them live and work in their
    communities.

    Eliminating coverage for those with mental illness. GCHJ eliminates
    Medicaid expansion in 2020 and with it ends coverage for the over
    700,000 people who are served in Ohio through the program, including
    those who have mental illness and are receiving services in home and
    community-based settings. Currently, Ohio receives a 90% matching rate
    for Medicaid expansion enrollees, the GCHJ proposal would end this
    matching rate in 2020 and states would be required to pay for 100% of
    these services. With an already limited state budget, Ohio would be
    forced to make severe cuts to this program, if not eliminate it.

    The GCHJ threatens the ability of people with disabilities to receive
    basic health care, including mental health and addiction services;
    sustain employment; and to live in their communities. Progress has been
    made to fully integrated people with disabilities and states are
    obligated to continue this work. Cuts to Medicaid will severely hamper
    further progress.

    CONCLUSION

    _______________________________________________________________________

    DRO understands the current health care system can be improved, but
    block grants and cuts are not the answer. There is already a bipartisan
    effort being made in the Senate to address the real concerns with our
    health care system. By focusing efforts on this process and away from
    undue and unnecessary cuts to Medicaid, effective reforms can be made.

    DRO hopes the stories we have shared provide insight as to how
    important Medicaid is to the lives of people with disabilities. GCHJ
    would be extremely detrimental to the lives of people with disabilities
    in Ohio. We urge members of the committee to oppose GCHJ.

    Thank you for allowing DRO the opportunity to provide testimony on the
    GCHJ proposal. If you have any questions or want to discuss this matter
    further, please contact me at your convenience.

                                     ______

                       Disability Rights Wisconsin (DRW)

                        131 W. Wilson Street, Suite 700

                               Madison, WI 53703

                                  608-267-0214

                                608-267-0368 FAX

                       http://www.disabilityrightswi.org/

    Hon. Orrin Hatch, Hon. Ron Wyden, and Members of the United States
    Senate Committee on Finance:

    On behalf of Disability Rights Wisconsin (DRW), the Protection and
    Advocacy system for people with disabilities, we urge you to reject the
    Graham-Cassidy-Heller-Johnson proposal. Medicaid and the protections
    provided by the Affordable Care Act are vital to people with
    disabilities. This proposal will cut and cap Medicaid, eliminate
    protections for people with pre-existing conditions, threaten Home and
    Community Based Services relied upon by people with disabilities and
    senior, permit annual and lifetime limits on health care coverage,
    cause millions of Americans to lose their health insurance, and allow
    states to waive Essential Health Benefits.

    Here are some important facts about Wisconsinites with disabilities and
    Medicaid programs:

          One in five Wisconsinites who have a disability, are older
    adults, are children, or are low-income working adults rely on Medicaid
    for health care and other essential supports.
          Wisconsin has 1.2 million people in Medicaid who could be hurt
    by these cuts, including children with disabilities.
          Children with disabilities rely on Medicaid for essential
    therapies, prescription drugs, home and community based services, and
    screening, diagnostic, and treatment services. Wisconsin has the lowest
    per capita Medicaid spending on children in the nation and that rate
    would be locked in.
          Adults with a disability are more likely to be low-income, have
    less access to health care, and report higher health risk factors and
    chronic conditions.
          Medicaid programs in Wisconsin (like BadgerCare, SeniorCare,
    MAPP, Family Care, IRIS, children's waivers) help people with
    disabilities and older adults with basic health care and therapies, and
    often with daily living supports and personal cares like getting out of
    bed, going to the bathroom, respite, help with meals, transportation,
    and employment supports.
          Home and Community Based Services, unlike institutional
    services, are optional. But our HCBS Medicaid programs have allowed
    thousands of Wisconsin residents with disabilities and older adults to
    stay in their homes. By staying in their homes, they avoid costly
    institutional care at significant savings to taxpayers.
          Medicaid helps public schools provide special education services
    and related services to 100,000 students in Wisconsin. School districts
    in Wisconsin receive over $107 million dollars from Medicaid annually
    for these important services.

    DRW opposes the restructuring and capping of Medicaid funds.

    The GCHJ would radically restructure Medicaid and divorce the federal
    contribution from the actual costs of meeting people's health care
    needs. The structure of GCHJ's cap--like the structure in previous
    bills--makes cuts worse after it reduces the growth rate in 2025. The
    Brookings Institution reports a projected reduction in Medicaid funding
    to states of $713 billion through 2026, with steeper cuts the following
    years, amounting to a $3.5 trillion cut by 2036 if block grant funding
    is not reauthorized,\1\ and that such caps would cause tens of millions
    of Americans to lose Medicaid coverage.
    ---------------------------------------------------------------------------
        \1\ https://www.brookings.edu/research/how-will-the-graham-cassidy-
    proposal-affect-the-number-of-people-with-health-insurance-coverage/.

    Limited carve outs and targeted funding pots included in GCHJ pale in
    comparison to the scope of these cuts. For example, GCHJ offers a 4-
    year $8 billion dollar demonstration to expand. Medicaid home and
    community-based services--which not even half of the $19 billion cut to
    the Community First Choice option that eight states have implemented to
    expand access to necessary in-home services for people with
    disabilities. All individuals on Medicaid will be impacted by cuts to
    this magnitude, despite any limited, temporary demonstration funding or
    restricted funding carve out for a fraction of the children with
    disabilities that Medicaid supports. Throwing billions in extra
    temporary funds cannot curb the inevitable, long-term loss of critical
    Medicaid services that people with disabilities will face as a result
    ---------------------------------------------------------------------------
    of per capita caps.

    DRW is deeply concerned that as more costs shift to the state in a
    Medicaid per capita cap system, Wisconsin will need to implement
    drastic cost-saving measures, such as creating wait lists for services,
    reducing essential services and supports from the current benefit
    package, cutting or restricting optional Home and Community Based
    Services programs, or cutting provider rates.

    The GCHJ bill threatens the progress that Wisconsin has made in
    providing cost-effective services to adults and children with
    disabilities through Medicaid.

    Wisconsin has been a national leader in ending waiting lists for long
    term care supports for adults and children with disabilities and frail
    elders, as well as a historic expansion of community based mental
    health and substance abuse disorder services. These cost-effective
    investments have decreased reliance on costly institutional and crisis
    services. People with disabilities rely on specific supports only
    available to them through Medicaid. For decades, Wisconsin has made
    progress supporting people with disabilities in home and community
    based settings instead of in expensive institutional care facilities.
    Wisconsin has already utilized significant flexibility under current
    law that has led to cost-savings and innovation in our Medicaid
    programs, including BadgerCare and Family Care and IRIS as waiver
    programs.

    While we agree that changes to Medicaid law that allow decisions to be
    made closer to people's lives and needs is an important improvement,
    the GCHJ proposal to change Medicaid to a per capita cap will not be
    adequately funded to accomplish sustainable quality of care. Medicaid
    per capita caps jeopardize decades of progress that have helped people
    with disabilities reduce their health disparities, increase their
    ability to live safely in their own homes, and experience improved
    inclusion in Wisconsin community life.

    DRW is concerned that allowing states to waive Essential Health
    Benefits and permit annual and lifetime limits will harm people with
    disabilities who access private health insurance.

    Under the GCHJ, states would receive a short-term block grant (known as
    a
    Market-based Health Care Grant Program) to create their own health care
    system. How these block grants would be structured and how they would
    ultimately affect Wisconsinites and our state budget are entirely
    unknown. However, the GCHJ would allow states to roll back a number of
    consumer protections for people with pre-existing conditions, including
    making essential benefits optional. Two and a half million
    Wisconsinites have a pre-existing condition. If essential benefits are
    not required, insurance plans will not be required to cover vital
    services such as prescription drugs, hospitalization, outpatient
    services, mental health services, and AODA treatment.

    The Affordable Care Act has significantly improved access for children
    and adults with disabilities to comprehensive and high quality private
    insurance, thereby expanding opportunities to live independently and
    maintain employment. Given its rollback of protections and limited
    funds, the GCHJ proposal would likely result in plans that cover less
    and cost more, limiting access for many people with disabilities who
    have significant health care costs and a modest income. As insurance
    coverage shrinks and its cost increases, Medicaid may be their only
    option at a time when Medicaid funding is being slashed.

    The GCHJ would allow states funds for high risk pools--but this funding
    would NOT fix the loss of funding in Medicaid.

    High Risk Insurance Pools have been tested--and have failed--in
    Wisconsin. They could not provide affordable, comprehensive insurance
    coverage for many people with disabilities and people with pre-existing
    conditions. Wisconsin's experience with the health insurance risk
    sharing plan (HIRSP) demonstrates that the high costs and limited
    benefits associated with high-risk pool coverage resulted in delayed or
    forgone care and adverse outcomes for enrollees. Many also accrued
    medical debt despite having insurance. In addition, restrictive
    eligibility requirements excluded many Wisconsinites with pre-existing
    health conditions, and left them with no viable option for adequate
    health insurance coverage. Wisconsin's old HIRSP is similar to the
    high-risk insurance pools being proposed currently by Congress to cover
    people with pre-existing conditions, and it failed to provide
    affordable, comprehensive insurance coverage for many people.

    Quickly moving forward with the GCHJ upends an ongoing bipartisan
    process to address health care in the U.S. and does not allow for true
    analysis to fully understand its' impact.

    The Congressional Budget Office has not yet had a chance to assess the
    impact the latest amendments will have on coverage, namely how many
    Americans will lose coverage (or have more limited coverage) and the
    actual cost of this proposal. It is fiscally irresponsible and
    unethical to vote on such a wide-reaching and life-changing proposal
    without this vital information.

    We hope that any efforts to reform health care can move forward in a
    bipartisan, transparent, and patient-centered manner and with people
    with disabilities at the table. The following principles should be
    incorporated into any future proposals:

          People with pre-existing conditions must not be discriminated
    against--either in access, premium setting, or cost sharing.
          All essential health benefits currently covered by the ACA,
    including habilitation services, and mental health and substance use
    disorder services, must continue to be universally available.
          The new system must be simple, straight forward, and at least as
    easy to navigate as the ACA for people with disabilities.
          Young adults must be permitted to stay on their parents'
    policies until age 26.
          There can be no annual or lifetime limits on coverage.
          Maintain accessibility standards for diagnostic medical
    equipment so people can access preventative health care screenings and
    appropriate diagnostic testing.
          Universal coverage must be maintained.
          Funding of the new system cannot have a negative impact on
    employer health plans as they cover working people with disabilities.
          Information about and application for the replacement system
    must be completely accessible to people with disabilities.
          The provisions of the ACA that resulted in the closing of the
    Medicare Part D ``donut hole'' must be retained.

    We ask for continued bipartisan hearings on the topics of health care,
    Medicaid, and community based long-term services and supports where the
    voices and experiences of adults and children with disabilities are
    included. Improving the ACA and improving health care for the country
    should be the goal; moving forward with the GCHJ will only lead to harm
    for millions of Americans, including people with disabilities. We
    believe reform is possible without having to cut Medicaid, eliminate
    health insurance coverage for people who have it, or remove protections
    for people with preexisting conditions. Please feel free to contact me
    if you would like to discuss these ideas further and meet with people
    with disabilities who have ideas on how to improve our health care
    system and who would be directly impacted by changes to Medicaid and
    any other health care reform. We are available to share other common-
    sense ideas to sustain Medicaid and to address the real cost drivers
    for health care. In the meantime, we ask members of the U.S. Senate to
    immediately reject the Graham-Cassidy-Heller-Johnson proposal because
    of its harmful effects on Americans who rely on affordable and adequate
    health care in their daily lives. We are especially concerned that
    people with disabilities, many of whom rely on Medicaid coverage to
    live full, healthy, and integrated lives in their communities will be
    harmed when this proposal cuts Medicaid.

    Respectfully,

    Daniel Idzikowski                   Amy Devine
    Executive Director                  Public Policy Coordinator

                                     ______

                   Doctors Organized for Healthcare Solutions

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200
    September 19, 2017

    Dear Chairperson Senator Orrin Hatch, Ranking Member Senator Ron Wyden,
    and Members of the Committee:
    Who We Are
    We are 450 practicing physicians, all caring for over half a million
    Americans in Cleveland, Ohio. We are not part of any formal medical
    society or movement. Rather, these hundreds of doctors have met,
    learned, and acted in response to the needs of the patients of our
    community for over 13 years. Some have described DOCHS as the nation's
    largest local group of volunteer physicians devoted to improved health
    care policy, for the benefit of the patients we serve.
    What We Stand For
        1.  No American should die for not being insured.
        2.  No American should go bankrupt for getting sick.
    Our Concerns
    Our concern is simply stated:
    As practicing doctors, we seek policies that save lives and reduce
    harm.

    We know now that in today's America, not having insurance can cost you
    your life.\1\,\2\ The level of that risk is now known as
    well, it is in the range of 1:500. That is, for every 500 Americans cut
    off from health care coverage, one will die. If a policy cuts 20
    million Americans off insurance, it will lead to the death of 40,000
    people. It is also true that if a policy adds 20 million people to
    those insured, 40,000 lives will be saved.
    ---------------------------------------------------------------------------
        \1\ Woolhandler, S., Himmelstein, D.U., ``The Relationship of
    Health and Mortality: Is Lack of Insurance Deadly?'', Annals of
    Internal Medicine, Doi: 10.7326/M17-1403, http://annals.org/aim, July
    2017.
        \2\ Sommers, B.D., Gawande, A.A., Baiker, K., ``Health Insurance
    Coverage and Health--What the Recent Evidence Tells Us,'' New England
    Journal of Medicine, Doi: 10.1056/NJEMsb1706645, August 2017.

    This information reflects actual observations in a vast before-and-
    after experiment, the passage of the ACA added millions to the number
    insured, and mortality rates could then be examined, yielding the
    results. It should be noted that with coverage came not only life,
    bankruptcies from becoming ill dropped as much as 50%.
    Our Recommendations
    Our key recommendations derive from the two core values stated above.
    As with our stated concerns, the 450 doctors of DOHCS do hope there is
    no controversy, no partisan divide on these points. Every day, in our
    exam rooms, we see patients seeking help when faced with serious health
    challenges, not once have we seen a person come down with an illness
    turn to us hoping they were not insured.

    To reach these key recommendations we urge the United States Senate
    Committee on Finance to adopt the following actions:

    Given that the Affordable Care Act has left Americans in a better
    situation to face inevitable illnesses than they faced 10 years ago,
    and that the Affordable Care Act requires improvements if we are to
    deliver to Americans actual health and financial security, we urge the
    following steps be taken by the Committee on Finance:

        1.  Increase the percentage of Americans covered by health care
    insurance every year.
        2.  Decrease the rate of rise, and actual amount of, health care
    insurance premiums.
        3.  Stabilize the markets for those buying health care insurance as
    individuals, not as employees (the exchanges).
        4.  Maintain the minimum standard of coverage defined by the ACA's
    Essential Minimum Benefits.
        5.  Continue the elimination of pre-existing condition as a
    concept.
        6.  Protect the integrity of Medicaid.

         Further, DOHCS would be interested in looking at state waivers
    (both 1115 and 1332) to the ACA but only if they do not violate the
    above necessary steps. Waivers must increase the number of Americans
    covered by health care insurance, decrease premium costs, and maintain
    current essential health benefit definitions for plans.

    We, the 450 doctors who care for over half a million Americans who live
    in the Cleveland, Ohio area turn to you, members of the United States
    Senate Committee on Finance, because more than anyone else at this
    moment in time, you hold the fates of the people we care for in your
    hands. Your hearings open a rare moment of opportunity to achieve real
    progress, to make lives better, to reduce death from losing insurance,
    and to reduce the risk of financial ruin from getting sick.

    Our patients, right now, rely on the actions you will take. We, their
    doctors, have made our recommendations and will be watching, on behalf
    of our patients to see if you do save their lives.

    Sincerely,

    Arthur Lavin, M.D.
    Michael Devereaux, M.D.
    Co-Chairpersons, Doctors for Health Care Solutions

                                     ______

    Two Real Life Scenarios From a Doctor: What Can Happen to a Child and a
    Father Without Health Insurance

    By Arthur Lavin, M.D.

    September 2017

    (This is based on real life experiences, but names and identifying
    details are changed to protect privacy)

    The Death of a 3 Year Old for Not being Insured

    My toddler lies in my arms, and my husband and I know these are our
    last moments with him.

    His story began 3 years ago when we found out that after many years of
    trying, I was finally pregnant, what a time to remember the joy we
    felt, the doors opening to a future with a child. We were so happy
    then.

    About 3 months prior to delivery of our son, we found that he had a
    rare heart defect, but the good news was that there were surgeons in
    the country who could fix the problem. In the same day we were
    terrified and offered real hope.

    My husband works hard, as do I. Each of us have a job in the insurance
    industry, doing mostly clerical work. We work hard, but don't make that
    much money. Before our son was born, we were never all that worried
    about health insurance, after all we are young and healthy, who needs
    to worry?

    But once we found our son had such a serious health condition, one that
    held his precious life in its grip, we began to see insurance as one of
    the most important resources, one that held our son's life in balance.

    During those incredibly tense times, we were so glad to find out that
    recent legislation opened the door to hard-working families like ours
    to obtain insurance that would open the door to our son getting his
    life-saving surgery.

    It turned out to be more difficult that we ever could imagine. Soon
    after he was born, a law passed some years ago in Congress went into
    effect. Our family lost its insurance. We were told when it passed that
    a brilliant future awaited, that we would chuck government provided
    insurance and we would see the flowering of new plans that the free
    market would create. I don't know much about how all that works, all I
    know is that now, when our child's life hung in the balance, the GOP
    health plan has cut us off.

    Without insurance we have spent all we could raise to see specialists,
    and we have depended on the free care ER's have had to provide during
    the emergencies we experienced. Our son has spent his whole life very
    blue, since his heart condition keeps oxygen from getting to his body.
    The specialists have helped, they have prescribed medicines that have
    kept him alive for the first months of life, and the ER's have taken
    life-saving actions. But Andrew can't live without the special surgery,
    and that surgery costs over $250,000. We don't have the money, and our
    country has told us they cannot help.

    Who can believe it, but solely because of a law passed, my husband and
    I are now sitting at home with our dear Andrew on our laps, watching
    him struggle to breathe. Over time, the lack of oxygen has stunted his
    growth, so although he is 15 months old, he barely weighs over 10
    pounds. What makes this all so unbearable are memories of sitting in
    our specialist's waiting room and seeing older kids with a similar
    problem, who had insurance before the GOP plan went into effect, who
    got their surgery, and are running around the office.

    That could have been Andrew, but instead, Andrew has been sentenced to
    this tragic end. As we prepare for the last moments, we try to comfort
    Andrew who is far more blue than ever, each breath takes all he has
    just to get it in and out of his frail body. He is clearly so
    uncomfortable. As he has gotten older, and his body was withered, his
    eyes seem to get bigger and they turn to us with all the love he has
    always had for us. There is some comfort in that connection.

    Soon, his breaths become more irregular, and turn into gasps. His body
    shakes, and we know the end is near. After a few hours, he eyes close
    and we begin to hug him goodbye. A few more gasps and Andrew is no
    more.

    This scenario represents one of the estimated 44,000 deaths that will
    occur if the GOP health bill becomes law. We know the official
    estimates establish that 22 million Americans will lose health
    insurance as a result of this bill, and that about 1 in 500 people who
    lose insurance will die as a result of this happening. Andrew's story
    will be one of these 44,000 stories.

    What sort of country, what sort of people, would support stripping
    Andrew of his life-saving surgery, and handing that $250,000 over to a
    handful of already astoundingly wealthy people? Apparently that country
    is America, and those people are us. We have a lot to answer to the Mom
    and Dad of Andrew. May we find the courage and ability to stop this
    from happening to them.

                                     ______

    The Death of a 35 Year Old Because He Had No Insurance

    Michael was a very healthy young man in his thirties. In 2007, he found
    health insurance too expensive to purchase and given his health, he
    decided not to purchase any.

    In the summer of that year he found a mole on his skin that seemed to
    be larger than usual with some darkening of its color. He felt fine, in
    fact he was recently engaged. Later that year he was married and early
    in 2008 his wife became pregnant. During that year, the mole kept
    growing and by the fall, he decided to go to the ER, where he know care
    could be covered.

    The ER found the mole looked deeply worrisome, and had a dermatology
    team come to see him while he was at the ER. The team biopsied the mole
    and found it was melanoma. Not only was it melanoma, but the cancer had
    spread deep into the skin.

    At this time, he tried to obtain health insurance, but no plan would
    cover his melanoma, it was considered a ``pre-existing condition.'' But
    with his life at stake, just as his family was forming, he proceeded
    with the very expensive process of completing his diagnostic processes
    and initiating the urgently required therapies.

    As his wife's pregnancy progressed, Michael found that his melanoma had
    spread not only deeply into his skin, but through his body. He and his
    wife were stunned. Had he seen a doctor the prior summer, they now knew
    the melanoma might have been removed in plenty of time to remove a
    potential threat to his life. They also knew he delayed this
    appointment because he had no insurance.

    With diagnosis complete, Michael began his therapies. Options were
    limited given how advanced the melanoma had spread. The therapies
    slowed the progress of the cancer, but it was far too late to stop it.
    By the end of 2008 Michael was deadly ill.

    Fortunately the therapies did slow the progress of cancer sufficiently
    to allow him to be alive to see the birth of his healthy and happy baby
    son. His wife and his son were the bright spots in his diminishing
    life.

    Three months after their baby was born, Michael began to slip into loss
    of organ function that would in a few weeks take his life.

    Michael knew this was happening, and so did his wife. They clung to
    each moment of time together, he was astounded every day to see the
    progress his son was making, knowing these steps would be the last he
    would be privileged to share, to be alive to see.

    One evening, Michael began to struggle to breath. His wife, now a new
    mother, held him in her arms. She played their special songs and she
    sang to him. Their baby boy was in a bassinet right next to his father,
    Michael. As she sang, Michael felt a warm ease begin to settle over
    him, his breathing calmed, and grew more shallow. Michael and his wife
    knew was the end, and they gazed into each other's eyes as he took his
    last breath and then breathed no more. He shook in her arms as she
    wept.

    Now the son has become a young school aged boy. He still misses his
    Daddy, and his Mom continues to wonder why his death had to be.

    Again, this scenario represents one of the estimated 44,000 deaths that
    will occur if the GOP health bill becomes law. We know the official
    estimates establish that 22 million Americans will lose health
    insurance as a result of this bill, and that about 1 in 500 people who
    lose insurance will die as a result of this happening. And so Michael's
    story will be one of these 44,000 stories.

    What sort of country, what sort of people, would support stripping
    Michael of life-saving melanoma detection services, and handing the
    cost of this simple service to a handful of incredibly wealthy people?
    Once again the answer is that apparently that country is America, and
    those people are us. We have a lot to answer to this family. May we
    find the courage and ability to stop this from happening to those in
    the same position.

                                     ______

     Annals of Internal Medicine                Medicine and Public Issues

    The Relationship of Health Insurance and Mortality: Is Lack of
    Insurance Deadly?

         Steffie Woolhandler, M.D., MPH, and David U. Himmelstein, M.D.

    About 28 million Americans are currently uninsured, and millions more
    could lose coverage under policy reforms proposed in Congress. At the
    same time, a growing number of policy leaders have called for going
    beyond the Affordable Care Act to a single-payer national health
    insurance system that would cover every American. These policy debates
    lend particular salience to studies evaluating the health effects of
    insurance coverage. In 2002, an Institute of Medicine review concluded
    that lack of insurance increases mortality, but several relevant
    studies have appeared since that time. This article summarizes current
    evidence concerning the relationship of insurance and mortality. The
    evidence strengthens confidence in the Institute of Medicine's
    conclusion that health insurance saves lives: The odds of dying among
    the insured relative to the uninsured is 0.71 to 0.97.

    Ann Intern Med. doi:10.7326/M17-1403
    Annals.org
    For author affiliations, see end of text.
    This article was published at Annals.org on 27 June 2017.
    _______________________________________________________________________

        At present, about 28 million Americans are uninured. Repeal of the
    Affordable Care Act would probably increase this number, while
    enactment of proposed single-payer legislation (1) would reduce it. The
    public spotlight on how policy changes affect the number of uninsured
    reflects a widespread assumption that insurance improves health.

        A landmark 2002 Institute of Medicine (IOM) report on the effects
    of insurance coverage on the health status of nonelderly adults
    buttressed this assumption (2). The IOM committee responsible for the
    report found consistent evidence from 130 (mostly observational)
    studies that ``the uninsured have poorer health and shortened lives''
    and that gaining coverage would decrease their all-cause mortality (2).

    The IOM committee also reviewed evidence on the effects of health
    insurance in specific circumstances and medical conditions. It
    concluded that uninsured patients, even when acutely ill or seriously
    injured, can not always obtain needed care and that coverage improves
    the uptake of essential preventive services and chronic disease
    management. The report found that uninsured patients with cancer
    presented with more advanced disease and experienced worse outcomes,
    including mortality; that uninsured patients with diabetes,
    cardiovascular disease, end-stage renal disease, HIV infection, and
    mental illness (the five other conditions reviewed in depth) had worse
    outcomes than did insured patients; and that uninsured inpatients
    received less and worse-quality care and had higher mortality both
    during their hospital stays and after discharge.

    At the time of the IOM report, only one adequately controlled
    observational study had examined the effect of coverage on all-cause
    mortality. In this review, we summarize key evidence on this issue
    (Table 1), focusing on studies that have appeared since the IOM report
    and other previous reviews (3-6). Although not reviewed in detail here,
    more recent studies generally support the earlier reviews' conclusions
    that insurance coverage improves mortality in several specific
    conditions (such as trauma [7] and breast cancer [8]), augments the use
    of recommended care (9), and improves several measures of health status
    (10, 11).

    Methods

    We searched PubMed and Google Scholar on May 19, 2017, for English-
    language articles by using the following terms: ``[(uninsured) or
    (health insurance) or (uninsurance) or (insurance)] and [(mortality) or
    (life expectancy) or (death rates)].'' After identifying relevant
    articles, we searched their bibliographies and used Google Scholar's
    ``cited by'' feature to identify additional relevant articles. We
    limited our scope to articles reporting data on the United States,
    quasi-experimental studies of insurance expansions in other wealthy
    nations, and recent cross-national studies. We contacted the authors of
    4 studies to clarify their published reports on mortality outcomes.

    We excluded most observational studies that compared uninsured persons
    with those insured by Medicaid, Medicare, or the Department of Veterans
    Affairs because preexisting disability or illness can make an
    individual eligible for these programs. Hence, relative to those who
    are uninsured, publicly insured Americans have, on average, worse
    baseline health, thereby confounding comparisons. Conversely,
    comparisons of the uninsured to persons with private insurance (which
    is often obtained through employment) may be confounded by a ``healthy
    worker'' effect: that is, that persons may lose coverage because they
    are ill and cannot maintain employment. Nonetheless, most analysts of
    the relationship between uninsurance and mortality have viewed the
    privately insured as the best available comparator, with statistical
    controls for employment, income, health status, and other potential
    confounders.

    Finally, we focus primarily on nonelderly adults because most studies
    have been limited to this group, and this group is likely to experience
    large gains or losses of coverage from health reforms. Since the advent
    of Medicare in 1966, almost all elderly Americans have been covered,
    precluding studies of uninsured seniors. Although Medicare's
    implementation may not have accelerated the secular decline in seniors'
    mortality (12), the relevance of this experience, which predates many
    modern-day therapies, is unclear.

    Children have also been excluded from most recent analyses of the
    relationship of insurance to mortality. Deaths in this population
    beyond the neonatal period are so rare that studies would need to
    evaluate a huge number of uninsured children to reach firm conclusions,
    and high coverage rates make assembling such a cohort difficult. The
    few studies addressing the effect of insurance on child survival have
    found that coverage lowers mortality (13-15) and few policy leaders
    contest the importance of covering children.

    Randomized, Controlled Trials

    Only one well-conducted randomized, controlled trial (RCT)--the Oregon
    Health Insurance Experiment (OHIE)--has assessed the effect of
    uninsurance on health outcomes (10, 16). In 2008, the state of Oregon
    opened a limited number of Medicaid slots to poor, able-bodied,
    uninsured adults aged 19 to 64 years. The state held a lottery among
    persons on a Medicaid waiting list, with winners allowed to apply for a
    slot. The OHIE researchers took advantage of this natural experiment to
    assess the effect of winning the lottery on the 74,922 lottery
    participants.

    Many lottery winners did not enroll in Medicaid, and 14.1% of lottery
    losers obtained Medicaid through other routes (some also got private
    coverage). Hence, the difference in the ``dose'' of Medicaid coverage
    was modest, an absolute difference of about 25%; to adjust for this,
    the OHIE researchers multiplied outcome differences by about 4 (10).

    At 1 year of follow-up, the death rate among lottery losers was 0.8%,
    and the winners' death rate was 0.032% lower, a ``dose-adjusted''
    difference of 0.13 percentage points annually (17). This difference was
    not statistically significant, an unsurprising finding given the OHIE's
    low power to detect mortality effects because of the cohort's low
    mortality rate, the low dose of insurance, and the short follow-up.

    The findings on other health measures, obtained from in-person
    interviews and brief examinations on a subsample of 12,229 individuals
    in the Portland area, help inform the mortality results. Most physical
    health measures were similar among lottery winners and losers in the
    subsample. However, winners had better self-rated health, were more
    likely to have diabetes diagnosed and treated with medication, and were
    much less likely to screen positive for depression (10). Medicaid
    coverage was associated with a nonsignificant decrease of 0.52 (95% CI,
    2.97 to -1.93) mm Hg in systolic blood pressure and 0.81 (95% CI, 2.65
    to -1.04) mm Hg in diastolic blood pressure (10). In addition to the
    low dose of insurance, these wide CIs reflect the lack of baseline
    blood pressure data; this precludes analyses that take advantage of
    paired measures on each individual, which would reduce the variance of
    estimates.

    In sum, the OHIE yields a (nonsignificant) point estimate that Medicaid
    coverage reduced mortality by 0.13 percentage points, equivalent to a
    (nonsignificant) odds ratio of 0.84.

    _______________________________________________________________________
    Key Summary Points
    In several specific conditions, the uninsured have worse survival, and
    the lack of coverage is associated with lower use of recommended
    preventive services.

    The Oregon Health Insurance Experiment, the only available randomized,
    controlled trial that has assessed the health effects of insurance,
    suggests that insurance may cause a clinically important decrease in
    mortality, but wide CIs preclude firm conclusions.

    The two National Health and Nutrition Examination Study analyses that
    include physicians' assessments of base-line health show substantial
    mortality improvements associated with coverage. A cohort study that
    used only self-reported baseline health measures for risk adjustment
    found a nonsignificant coverage effect.

    Most, but not all, analyses of data from the longitudinal Health and
    Retirement Study have found that coverage in the near-elderly slowed
    health decline and decreased mortality.

    Two difference-in-difference studies in the United States and one in
    Canada compared mortality trends in matched locations with and without
    coverage expansions. All three found large reductions in mortality
    associated with increased coverage.

    A mounting body of evidence indicates that lack of health insurance
    decreases survival, and it seems unlikely that definitive randomized,
    controlled trials can be done. Hence, policy debate must rely on the
    best evidence from observational and quasi-experimental studies.
    _______________________________________________________________________

    Two older RCTs are also relevant to the effect of insurance and access
    to care on mortality, although neither directly compared insured and
    uninsured persons. In the RAND Health Insurance Experiment, random
    assignment to full (first-dollar) coverage reduced diastolic blood
    pressure by an average of 0.8 mm Hg (P < 0.05) relative to persons
    randomly assigned to plans that required cost sharing (18), an effect
    size similar to the blood pressure findings in the OHIE. Unlike the
    OHIE, the RAND Health Insurance Experiment obtained base line blood
    pressure readings, allowing researchers to determine that for
    participants with hypertension at baseline, full coverage reduced
    diastolic blood pressure by 1.9 mm Hg, mostly because of better
    hypertension detection (19); the effect was larger among low income
    (3.5 mm Hg) than high-income (1.1 mm Hg) participants (19).

    The Hypertension Detection and Follow-up Program also suggests that
    removing financial barriers to primary care in populations with high
    rates of uninsurance may reduce mortality. That population-based RCT
    carried out in the 1970s screened almost all residents of 14
    communities, with oversampling of predominantly black and poor
    locations. Persons with hypertension were randomly assigned to free
    stepped care in special clinics or referral to usual care. Although the
    clinics' staff treated only hypertension-related problems, they
    provided informal advice and ``friendly referrals'' for other medical
    issues (20). Strikingly, all-cause mortality was reduced by 17% in the
    intervention group, with similar reductions in deaths due to
    cardiovascular and noncardiovascular conditions (21).

     Table 1. Summary of Studies on Relationship Between Insurance Coverage
                           Pand All-Cause Mortality *

                                                   Estimated
                                                   Mortality
     Study, Year                    Information    Effect of
     (Reference)    Participants    on  Baseline   Coverage      Comments
                                       Health         vs.
                                                   Uninsured

    RCTs
      Oregon       74,922          Retrospective  OR, 0.84    Study was
       Health       nondisabled     survey of a    (NS)        underpowered
       Insurance    adults on       subsample;                 because of
       Experiment   waiting list    no baseline                crossovers
       , 2013,      for Medicaid    blood                      between
       2011, 2012                   pressure or                insured and
       (10, 16,                     other                      uninsured
       17)                          measurements               groups, low
                                                               mortality
                                                               rate, short
                                                               follow-up.
                                                               Coverage was
                                                               associated
                                                               with
                                                               nonsignifican
                                                               tly lower
                                                               (0.81 mm Hg)
                                                               average
                                                               diastolic
                                                               blood
                                                               pressure
    Quasi-
     experimental
     studies,
     population-
     based
      Sommers et   Nonelderly      None at        RR of       Study examined
       al., 2012,   adults in       individual     death       Medicaid
       2017 (29,    states          level;         expansion/  expansions
       30)          expanding       compared       nonexpans   that preceded
                    Medicaid        trends in      ion         the ACA's
                    (Arizona, New   death rates    states,     expansions
                    York, Maine)    in expansion   0.939  (P
                    and             with those     = 0.001)
                    comparison      in
                    states          neighboring
                                    states
      Sommers et   Nonelderly      None at        RR for      The 2006
       al., 2014    adults in       individual     death in    reform
       (31)         Massachusetts   level;         Massachus   expanded
                    and             compared       etts        Medicaid and
                    comparison      trends in      counties/   implemented
                    counties        death rates    matched     subsidized
                                    in             counties,   coverage for
                                    Massachusett   0.971 (P    low-income
                                    s with those   = 0.003)    persons
                                    in matched
                                    control
                                    counties
      Hanratty,    Newborns in     None at        RR for      Estimates
       1996 (51)    Canadian        individual     death,      varied
                    provinces       level;         0.95 or     slightly
                    expanding       compared       0.96  (P    depending on
                    coverage at     infant         < 0.05      how time
                    different       mortality      for both)   trends were
                    times           trends pre-                modeled
                                    vs.
                                    postreform
    Quasi-
     experimental
     studies,
     clinic
     cohorts
      Lurie et     186 clinic      Clinic-based   OR at 1 y,  Large effect
       al., 1984,   patients        data           0.23 (NS)   probably
       1986 (40,    terminated                                 reflects very
       41)          from Medicaid                              high baseline
                    vs. 109 who                                risk. Among
                    remained                                   terminated
                    eligible                                   patients with
                                                               hypertension,
                                                               average
                                                               diastolic
                                                               blood
                                                               pressure
                                                               increased 10
                                                               mm Hg at 6 mo
                                                               vs. decrease
                                                               of 5 mm Hg
                                                               among
                                                               controls (P =
                                                               0.003)
      Fihn and     157 patients    Clinic-based   OR not      Marked
       Wicher,      terminated      data           calculabl   deterioration
       1988 (42)    from                           e from      in blood
                    outpatient VA                  published   pressure
                    care vs. 74                    data; per   control among
                    controls                       authors,    terminated
                                                   ``at        patients
                                                   least 6%
                                                   of
                                                   terminate
                                                   d
                                                   patients
                                                   died''
      Quasi-       Several         Repeated       Conflictin  Studies
       experiment   cohorts         questionnair   g           compared
       al studies   followed for    es linked to   results;    mortality
       using        varying time    Medicare       some        before age 65
       longitudin   periods from    records and    found       y and
       al data      age  51y        National       lower       relative
       from the                     Death Index;   deaths      changes in
       Health and                   no             among       death rates
       Retirement                   examination    insured,    after
       Study (26,                   or             and         acquisition
       32-37)                       laboratory     others      of Medicare
                                    data           were null   eligibility.
                                                               Different
                                                               analytic
                                                               strategies
                                                               yielded
                                                               different
                                                               conclusions
    Population-
     based cohort
     follow-up
     studies
      Sorlie et    CPS             None other     HR for      No data on
       al., 1994    respondents     than being     employed    smoking,
       (23)         1982-1985       employed       white       health status
                                                   women,      or other non-
                                                   0.83        demographic
                                                   (NS); HR    predictors of
                                                   for         mortality at
                                                   employed    baseline
                                                   white
                                                   men, 0.77
                                                    (P =
                                                   0.05)
      Franks et    NHANES          Surveys,       HR, 0.8 (P  Controls for
       al., 1993    respondents     physical       = 0.05)     baseline
       (27)         1971-1975       examinations               health status
                                    , and lab                  included
                                    test results               physician-
                                                               assessed
                                                               morbidity
      Kronick,     NHIS            Questionnaire  HR, 0.91    Control for
       2009 (24)    respondents     s only         P(P <       sell-rated
                    1986-2000                      0.05;       health may
                                                   without     bias findings
                                                   control     because this
                                                   for self-   variable is
                                                   rated       probably
                                                   health)     confounded by
                                                   and 0.97    coverage
                                                   (NS;
                                                   including
                                                   self-
                                                   rated
                                                   health)
      Wilper et    NHANES          Surveys and    HR, 0.71    Controls for
       al, 2009     respondents     physician-     P(P <       baseline
       (28)         1988-1994       rated health   0.05)       health status
                                    after a                    included
                                    physical                   physician-
                                    examination                assessed
                                                               health status

    ACA = Affordable Care Act; CPS = Current Population Survey; HR = hazard
      ratio; NHANES = National Health and Nutrition Examination Study; NHIS
      = National Health Interview Survey; NS = nonsignificant; OR = odds
      ratio; RR = relative risk; VA = Department of Veterans Affairs.
    * For studies not reporting ORs, HRs, or RRs, the authors computed them
      from data in the original report.

    Finally, a flawed RCT carried out by the Social Security Administration
    starting in 2006 bears brief mention. That study randomly assigned
    people who were receiving Social Security disability income and were in
    the waiting period for Medicare coverage to receive immediate or
    delayed coverage (22). Unfortunately, randomization apparently failed,
    with many more patients with cancer assigned to the immediate coverage
    than to the control group, precluding reliable interpretation of the
    mortality results (11). Interestingly, persons receiving immediate
    coverage had rapid and significant improvements in most measures of
    self-reported health (11).

    Mortality Follow-Up of Population-Based Health Surveys

    Several routinely collected federal surveys that include information
    about health insurance coverage have been linked to the National Death
    Index, allowing researchers to compare the mortality rates over several
    years of respondents with and without coverage at the time of the
    initial survey. One weakness of these studies is their lack of
    information about the subsequent acquisition or loss of coverage, which
    many people cycle into and out of over time. This dilutes coverage
    differences and may lead to underestimation of the effects of insurance
    coverage.

    Sorlie and colleagues (23) analyzed mortality among respondents to the
    1982-1985 Current Population Survey, with follow-up through 1987. In
    analyses limited to employed persons, the relative risk for death
    associated with being uninsured was 1.3 for white men and 1.2 for white
    women (neither overall figures nor those for minorities were reported)
    (23). The study's lack of data on important determinants of health,
    such as smoking, and its reliance on employment status as the only
    proxy for baseline health status weaken confidence in its conclusions.

    Kronick used data from the 1986-2000 National Health Interview Surveys,
    with mortality follow-up through 2002 (24). The mortality hazard ratio
    for uninsured versus insured individuals was 1.10 (95% CI, 1.03 to
    1.19) after adjustment for demographic variables, smoking, and body
    mass index. The hazard ratio fell to 1.03 (95% CI, 0.95 to 1.12) after
    additional adjustment for baseline health, defined by using self-
    reported disability and self-rated health. Although the self-rated
    health scale is known to be a valid predictor of mortality (25), it may
    introduce inaccuracies in comparisons of uninsured versus insured
    persons. Recent data (10, 11, 16, 26) indicate that gaining coverage
    improves self-rated health, before improvements in objective measures
    of physical health are detectable (or plausible). This suggests that
    uninsurance may cause people to underrate their health, perhaps because
    of anxiety or the inability to gain reassurance about minor symptoms.
    Analyses, such as Kronick's, that rely on self-rated health for risk
    adjustment therefore may inadvertently compare relatively sick insured
    persons to relatively healthy uninsured persons, obscuring outcome
    differences caused by coverage. Studies that include more objective
    measures of baseline health should be less subject to any such bias.

    Mortality Follow-Up of Population-Based Health Examination Surveys

    Two studies have analyzed the effect of uninsurance on mortality using
    data from the National Health and Nutrition Examination Survey
    (NHANES), which obtains data from physical examination and laboratory
    tests among participants.

    Franks and colleagues (27) analyzed the 1971-1975 NHANES, with
    mortality follow-up through 1987. They compared mortality of uninsured
    and privately insured adults older than age 25 years, adjusted for
    demographic characteristics, self-rated health, smoking, obesity,
    leisure time exercise, and alcohol consumption. In addition, their
    models controlled for evidence of morbidity determined by laboratory
    testing and medical examinations performed by NHANES staff. By 1987,
    9.6% of the insured and 18.4% of the uninsured had died. After
    adjustment for baseline characteristics and health status, the hazard
    ratio for uninsurance was 1.25 (95% CI, 1.00 to 1.55).

    Wilper and colleagues' study (which we coauthored) used data from the
    1988-1994 NHANES, with mortality follow-up through 2000 (28). The study
    assessed mortality among uninsured and privately insured persons age 17
    to 64 years, controlling for demographic characteristics, smoking,
    alcohol consumption, body mass index, leisure time activity, self-rated
    health, and physician-rated health after the NHANES physician completed
    the medical examination. The study also included sensitivity analyses
    adjusting for the number of hospitalizations and physician visits
    within the past year, limitations in work or activities, job or
    housework changes due to health problems, and number of self-reported
    chronic diseases, which yielded results similar to those of the main
    model. In the main model, being uninsured was associated with a
    mortality hazard ratio of 1.40 (95% CI, 1.06 to 1.84).

    Quasi-Experimental Studies of State and Provincial Coverage Expansions

    In two similar studies (29, 30), Sommers and colleagues compared
    mortality trends in states that expanded coverage to low-income
    residents (before implementation of the Affordable Care Act) with
    trends in similar states without coverage expansions.

    Their analysis of Medicaid expansions in Maine, New York, and Arizona
    during the early 2000s found that adult mortality rates fell faster in
    those states than in neighboring ones (a relative reduction of 6.1%, or
    19.6 deaths per 100,000), coincident with a decline in the uninsurance
    rate of 3.2 percentage points (29). Mortality reductions were largest
    among nonwhites, adults age 35 to 64 years, and poorer counties.
    Sommers and colleagues' subsequent reanalysis using data that allowed
    better matching to control counties yielded a slightly lower estimate
    of the mortality effect (30). As the authors note, the large mortality
    effect from a relatively modest coverage expansion may reflect the fact
    that Medicaid enrollment often occurred ``at the point of care for
    patients with acute illnesses'' leading to the selective enrollment of
    those most likely to benefit from coverage.

    A study of the effect of Massachusetts' 2006 coverage expansion
    compared mortality trends in Massachusetts counties with those in
    propensity score-matched counties in other states. Mortality decreased
    by 2.9% in Massachusetts relative to the comparison counties, a
    difference of 8.2 deaths per 100,000 adults, with larger declines in
    poorer counties and those with lower coverage rates before the
    expansion (31).

    Other Quasi-Experimental Studies

    Several researchers have used data from the Health and Retirement Study
    (HRS)--a longitudinal study that has followed cohorts enrolled at age
    51 years or older--to assess the effect of insurance coverage on
    mortality. The HRS periodically survey respondents and their families
    and has been linked to Medicare and National Death Index data.

    McWilliams and colleagues found significantly higher mortality rates
    among uninsured compared with insured HRS respondents, even after
    propensity score adjustment for multiple predictors of insurance
    coverage (32). Baker and colleagues found that respondents who were
    uninsured (compared with those who had private insurance) had higher
    long-term but not short-term mortality (33). After adjustment for
    multiple base-line characteristics, including instrumental variables
    associated with coverage (such as a spouse's union membership), Hadley
    and Waidmann found a strong positive association between insurance
    coverage and survival before age 65 years (34). Black and colleagues
    suggested, on the basis of a ``battery of causal inference methods,''
    that others overestimated the survival benefits of insurance and that
    uninsured HRS respondents had only slightly higher (adjusted) mortality
    than those with private coverage (35). Finally, studies have reached
    conflicting conclusions as to whether the health of previously
    uninsured persons improves (relative to those who were previously
    insured) after they reach age 65 years and become eligible for Medicare
    (26, 36). Overall, the preponderance of evidence from the HRS suggests
    that being uninsured is associated with some increase in mortality.

    Some studies using other data sources suggest that death rates drop at
    age 65 years, coincident with the acquisition of Medicare eligibility
    (37, 38), whereas others do not (39).

    Finally, several studies have assessed the relationship between
    insurance coverage and hypertension control, a likely mediator of any
    relationship between coverage and all-cause mortality. Lurie and
    colleagues (40) followed a cohort of 186 patients who lost Medicaid
    coverage because of a statewide policy change and a control group of
    109 patients who remained eligible. Among those who lost coverage, five
    died within 6 months (compared with none in the control group; P =
    .16), and the average diastolic blood pressure of those with
    hypertension increased by 10 mm Hg (compared with a 5-mm Hg decrease in
    controls; P = 0.003) (40). At 1 year, seven patients who had lost
    Medicaid and one control had died; blood pressure differences were
    slightly less marked than seen at 6 months (41). A similar study of
    patients terminated from Veterans Affairs outpatient care because of a
    budget shortfall found marked deterioration in hypertension control
    among the terminated patients relative to controls who maintained
    access (42). These clinic-based findings accord with cross sectional
    population-based analyses of data from NHANES, which have found worse
    blood pressure control among uninsured than insured patients with
    hypertension (43-45).

    Evidence From Other Nations and From Cross-National Studies

    The United States lags behind most other wealthy nations in life
    expectancy and is the only one with substantial numbers of uninsured
    residents (46). Although many factors confound cross-national
    comparisons, a recent study suggests that worse access to good-quality
    health care contributes to our nation's higher mortality from medically
    preventable causes (so-called amenable mortality) (47). Similarly, a
    recent review of studies from many nations concluded that ``broader
    health coverage generally leads to better access to necessary care and
    improved population health.'' (48)

    Quasi-experimental studies assessing newly implemented universal
    coverage in wealthy nations have reached similar conclusions. For
    instance, Taiwan's roll-out of a single-payer system in 1995 was
    associated with an accelerated decline in amenable mortality,
    particularly in townships where coverage gains were larger (49, 50). In
    Canada, a study exploiting the different dates on which provinces
    implemented universal coverage estimated that coverage expansion
    reduced infant mortality by about 5% (P < 0.03) (51).

    Finally, a recent study of cystic fibrosis cohorts also suggests that
    coverage improves mortality. Such patients live, on average, 10 years
    longer in Canada than in the United States. Among U.S. patients, those
    without known coverage have the shortest survival; among the privately
    insured, life expectancy is similar to that among patients in Canada
    (52).

    Table 2. Why the Causal Relationship of Health Insurance to Mortality Is
                                  Hard to Study
    ------------------------------------------------------------------------

    -------------------------------------------------------------------------
    Deaths, especially from causes amenable to medical treatment, are rare
     among nonelderly adults, who account for most of the uninsured.
    Because insurance might prevent death by slowing the decline in health
     over several years, short-term studies may underestimate its effects.
    Many people cycle in and out of insurance, diluting differences between
     groups.
    Randomly assigning participants to no coverage is unethical in most
     circumstances.
    Observational studies must address reverse causality. Illness sometimes
     causes people to acquire public insurance by qualifying them for
     Medicaid, Medicare, or Department of Veterans Affairs disability
     coverage. Conversely, illness may cause job loss and resultant loss of
     private coverage.
    In cohort studies, adequate control for baseline health status is
     difficult, particularly in uninsured patients, whose lack of access
     lowers self-rated health and also causes less awareness of important
     risk factors, such as hypertension or hyperlipidemia.
    Quasi-experimental studies, which exploit factors associated with
     coverage (such as policy changes), rest on unverifiable assumptions
     (e.g., that without a coverage expansion, mortality trends in states
     expanding coverage would parallel those in a comparator state).
    ------------------------------------------------------------------------

    DISCUSSION

    The evidence accumulated since the publication of the IOM's report in
    2002 supports and strengthens its conclusion that health insurance
    reduces mortality. Several newer observational and quasi-experimental
    studies have found that uninsurance shortens survival, and a few with
    null results used confounded or questionable adjustments for baseline
    health. The results of the only recent RCT, although far from
    definitive, are consistent with the positive findings from cohort and
    quasi-experimental analyses.

    Several factors complicate efforts to determine whether uninsurance
    increases mortality (Table 2). Randomly assigning people to uninsurance
    is usually unethical, and quasi-experimental analyses rest on
    unverifiable assumptions. Deaths are rare and mortality effects may be
    delayed, mandating large studies with long follow-up. Many people cycle
    into and out of coverage, diluting the effects of insurance. And
    statistical adjustments for baseline health usually rely on
    participants' self-reports, which may be influenced by coverage. Hence,
    such adjustments may under- or overadjust for differences between
    insured and uninsured persons.

    Inferences about mechanisms through which insurance affects mortality
    are subject to even greater uncertainty. In some circumstances,
    coverage might raise mortality by increasing access to dangerous drugs
    (such as oral opioids) or procedures (such as morcellation
    hysterectomy). On the other hand, coverage clearly reduces mortality in
    several serious conditions, although few are common enough to have a
    detectable effect on population-level mortality. The exception is
    hypertension, which is prevalent among the uninsured and seems a likely
    contributor to their higher death rates. Although uncontrolled
    hyperlipidemia is also more common among the uninsured (44), the OHIE--
    the only RCT performed in the statin era-found no effect of coverage on
    cholesterol levels.

    Finally, our focus on mortality should not obscure other well-
    established benefits of health insurance: improved self-rated health,
    financial protection, and reduced likelihood of depression. Insurance
    is the gateway to medical care, whose aim is not just saving lives but
    also relieving human suffering.

    Overall, the case for coverage is strong. Even skeptics who suggest
    that insurance doesn't improve out comes seem to vote differently with
    their feet. As one prominent economist (53) recently asked, ``How many
    of the people who write such things . . . choose to just not bother
    getting their healthcare?''

    From The City University of New York School of Urban Public Health at
    Hunter College, New York, New York, and Harvard Medical School, Boston,
    Massachusetts.

    Disclosures: Drs. Woolhandler and Himmelstein report serving as unpaid
    advisors to Bernie Sanders' presidential campaign and were founders of
    and remain active in Physicians for a National Health Program, an
    organization that advocates for
    single-payer reform. Forms can be viewed at www.acponline.org/authors/
    icmje/ConflictOfInterestForms.do?msNum=M17-1403.

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                                     ______

                    From The New England Journal of Medicine

                                 Sounding Board

                     Health Insurance Coverage and Health--
                       What the Recent Evidence Tells Us

     Benjamin D. Sommers, M.D., Ph.D., Atul A. Gawande, M.D., M.P.H., and
                            Katherine Baicker, Ph.D.

    The national debate over the Affordable Care Act (ACA) has involved
    substantial discussion about what effects--if any--insurance coverage
    has on health and mortality. The prospect that the law's replacement
    might lead to millions of Americans losing coverage has brought this
    empirical question into sharp focus. For instance, politicians have
    recently argued that the number of people with health insurance is not
    a useful policy metric \1\ and that no one dies from a lack of access
    to health care.\2\ However, assessing the impact of insurance coverage
    on health is complex: health effects may take a long time to appear,
    can vary according to insurance benefit design, and are often clouded
    by confounding factors, since insurance changes usually correlate with
    other circumstances that also affect health care use and outcomes.

    Nonetheless, over the past decade, high quality studies have shed light
    on the effects of coverage on care and health. Here, we review and
    synthesize this evidence, focusing on the most rigorous studies from
    the past decade on the effects of coverage for nonelderly adults.
    Previous reviews have provided a thorough discussion of older
    studies.\3\ We concentrate on more recent experimental and quasi-
    experimental studies of the ACA and other expansions of public or
    private insurance. The effects of coverage probably vary among people,
    types of plans, and settings, and these studies may not all directly
    apply to the current policy debate. But as a whole, this body of
    research (Table 1) offers important insights into how coverage affects
    health care utilization, disease treatment and outcomes, self-reported
    health, and mortality.

                 FINANCIAL PROTECTION AND THE ROLE OF INSURANCE

    Before we assess these effects, it is worth recognizing the role of
    insurance as a tool for managing financial risk. There is abundant
    evidence that having health insurance improves financial security. The
    strongest evidence comes from the Oregon Health Insurance Experiment, a
    rare randomized, controlled trial of health insurance coverage.\31\ In
    that study, people selected by lottery from a Medicaid waiting list
    experienced major gains in financial well-being as compared with those
    who were not selected: a $390 average decrease in the amount of medical
    bills sent to collection and a virtual elimination of catastrophic out-
    of-pocket expenses.\4\, \8\ Studies of other insurance
    expansions, such as Massachusetts' 2006 health care reform,\7\ the
    ACA's 2010 ``dependent-coverage provision'' enabling young adults to
    stay on a parent's plan until age 26,\6\ and the ACA's 2014 Medicaid
    expansion,\5\ have all revealed similar changes, including reduced bill
    collections and bankruptcies, confirming that insurance coverage
    reduces the risk of large unpredictable medical costs.

    But from a policy perspective, health insurance is viewed differently
    from most other types of insurance: there is no push, for example, for
    universal homeowners' or renters' insurance subsidized by the federal
    government. We contend that there are two reasons for this difference.
    First, policymakers may value publicly subsidized health insurance as
    an important part of the social safety net that broadly redistributes
    resources to lower-income populations. Second, policymakers may view
    health insurance as a tool for achieving the specific policy priority
    of improved medical care and public health. Evaluating the impact of
    insurance coverage on health outcomes--and whether these benefits
    justify the costs of expanding coverage--is our focus.

     Table 1. Evidence on the Effects of Health Insurance on Health Care and
                           Health Outcomes, 2007-2017
    ------------------------------------------------------------------------
                               Insurance or Policy
       Domain and Findings          Examined *               Studies
    ------------------------------------------------------------------------
    Financial security
        Reduction in medical   Medicaid             Baicker et al. 2013;\4\
         bills sent to                               Hu et al. 2016 \5\
         collection and in
         catastrophic medical
         spending
        Reduced out-of-pocket  DCP, Medicaid        Chua and Sommers
         medical spending                            2014;\6\ Baicker et al.
                                                     2013 \4\
        Reduced personal       MA                   Mazumder and Miller 2016
         bankruptcies and                            \7\
         improved credit
         scores
    Access to care and
     utilization
        Increased outpatient   Medicaid, MA         Finkelstein et al.
         utilization and                             2012;\8\ Sommers et al.
         rates of having a                           2014;\9\ Simon et al.
         usual source of care/                       2017 \10\
         personal physician
        Increased preventive   Medicaid, MA         Baicker et al. 2013;\4\
         visits and some                             Sommers et al. 2014 and
         preventive services                         2016;\9\,\11\ Simon et
         including cancer                            al. 2017 \10\
         screening and lab
         tests
        Increased              Medicaid             Ghosh et al. 2017;\12\
         prescription drug                           Sommers et al. 2016
         utilization and                             \11\
         adherence
        Mixed evidence on      Medicaid, DCP, MA    Taubman et al. 2014;\13\
         emergency department                        Akosa Antwi et al.
         use, with some                              2015;\14\ Miller
         studies showing an                          2012;\15\ Sommers et
         increase and others                         al. 2016 \11\
         a decrease
        Improved access to     DCP, MA              Scott et al. 2016;\16\
         surgical care                               Loehrer et al. 2016
                                                     \17\
    Chronic disease care and
     outcomes
        Increased rates of     Medicaid             Baicker et al. 2013;\4\
         diagnosing chronic                          Wherry and Miller 2016
         conditions                                  \18\
        Increased treatment    Medicaid             Baicker et al. 2013;\4\
         for chronic                                 Sommers et al. 2017
         conditions                                  \19\
        Improved depression    Medicaid             Baicker et al. 2013 \4\
         outcomes
        No significant change  Medicaid             Baicker et al. 2013 \4\
         in blood pressure,
         cholesterol, or
         glycated hemoglobin
        Mixed evidence on      MA, DCP              Keating et al. 2013;\20\
         cancer stage at time                        Robbins et al.
         of diagnosis                                2015;\21\ Loehrer et
                                                     al. 2016 \17\
    Well-being and self-
     reported health
        Improved self-         Medicaid, MA, DCP,   Baicker et al. 2013;\4\
         reported health in     ACA                  Sommers et al.
         most studies                                2012;\22\ Van Der Wees
                                                     et al. 2013;\23\ Chua
                                                     and Sommers 2014;\6\
                                                     Sommers et al.
                                                     2015;\24\ Simon et al.
                                                     2017;\10\ Sommers et
                                                     al. 2017 \19\
        Some ACA-specific      Medicaid, ACA        Courtemanche et al.
         studies have shown                          2017;\25\ Miller and
         limited or                                  Wherry 2017 \26\
         nonsignificant
         changes
    Mortality
        Conflicting            Private insurance    Kronick 2009;\27\ Wilper
         observational                               et al. 2009 \28\
         studies on whether
         lack of insurance is
         an independent
         predictor of
         mortality
        Highly imprecise       Medicaid             Finkelstein et al. 2012
         estimates in                                \8\
         randomized trial,
         unable to rule out
         large mortality
         increases or
         decreases
        Significant            Medicaid, MA         Sommers et al. 2012;\22\
         reductions in                               Sommers et al. 2014;\9\
         mortality in quasi-                         Sommers 2017 \29\
         experimental
         analyses,
         particularly for
         health care-amenable
         causes of death
    ------------------------------------------------------------------------
    * ``Medicaid'' includes pre-ACA expansions of Medicaid in selected
      states and the ACA's 2014 Medicaid expansion. ACA denotes Affordable
      Care Act (specifically applies here to the 2014 coverage expansions
      including Medicaid and subsidized market place coverage), DCP
      dependent-coverage provision (the ACA policy enacted in 2010 that
      allows young adults to remain on their parents' plan until the age of
      26 years), and MA Massachusetts statewide health care reform (enacted
      2006).

                         ACCESS TO CARE AND UTILIZATION

    For coverage to improve health, insurance must improve people's care,
    not just change how it's paid for. Several observational studies have
    found that the ACA's coverage expansion was associated with higher
    rates of having a usual source of care and being able to afford needed
    care,\32\, \33\ factors typically associated with better
    health outcomes.\34\ Stronger experimental and quasi-experimental
    evidence shows that coverage expansions similarly lead to greater
    access to primary care,\11\, \24\ more ambulatory care
    visits,\8\ increased use of prescription medications,\4\,
    \12\ and better medication adherence.\11\

    There is also strong evidence that coverage expansion increases access
    to preventive services, which can directly maintain or improve health.
    Studies of Massachusetts' health care reform \9\ and the ACA's Medicaid
    expansion found higher rates of preventive health care visits,\1\ and
    although the utility of the ``annual exam'' is uncertain, such visits
    may facilitate more specific evidence-based screening. For instance,
    the ACA Medicaid expansion has led to significant increases in testing
    for diabetes,\11\ hypercholesterolemia,\18\ and HIV,\10\ and the Oregon
    study revealed a 15-
    percentage-point increase in the rate of cholesterol screening and 15-
    to 30-percentage-point increases in rates of screening for cervical,
    prostate, and breast cancer.\4\

    The connection between health outcomes and use of other services, such
    as surgery, emergency-department (ED) care, and hospitalizations, tends
    to be more complicated. Much of this utilization serves critical health
    needs, though some may represent low-value care or reflect poor
    outpatient care. Thus, it is perhaps not surprising that the evidence
    on the effects of coverage on ED use and hospitalizations is mixed.\35\
    Both types of utilization went up in the Oregon study,\8\,
    \13\ whereas studies of other coverage expansions found reductions in
    ED use,\11\, \14\, \15\ and changes in hospital
    use have not been significant in several ACA studies\11\,
    \26\--though these studies may not have had an adequate sample size to
    examine this less common outcome. Meanwhile, studies of Massachusetts'
    reform and the ACA's dependent-coverage provision indicate that
    insurance improves access to some high-value types of surgical
    care.\16\, \17\

                       CHRONIC DISEASE CARE AND OUTCOMES

    The effects of coverage are particularly important for people with
    chronic conditions, a vulnerable high-cost population. Here, the Oregon
    experiment found nuanced effects. After 2 years of coverage, there were
    no statistically significant changes in glycated hemoglobin, blood
    pressure, or cholesterol levels.\4\ On the basis of these results, some
    observers have argued that expanding Medicaid does not improve health
    and is thus inadvisable.\36\ However, the study revealed significant
    increases in the rate of diagnosis of diabetes that were consistent
    with findings in two recent post-ACA studies \18\, \37\
    along with a near-doubling of use of diabetes medications,\4\ again
    consistent with more recent data on the ACA's Medicaid expansion.\12\
    Glycated hemoglobin levels did not improve, but, as the authors note,
    the confidence intervals are potentially consistent with these
    medications' working as expected.\4\ The investigators did not detect
    significant changes in diagnosis of or treatment for high cholesterol
    or hypertension. One recent quasi-experimental study, however, showed
    that the ACA's Medicaid expansion was associated with better blood-
    pressure control among community health center patients.\38\

    Meanwhile, the Oregon study found substantial improvements in
    depression, one of the leading causes of disability in the United
    States.\39\ It also found an increased rate of diagnosis, a borderline-
    significant increase in the rate of treatment with antidepressant
    medication, and a 30% relative reduction in rates of depressive
    symptoms.\4\

    Other studies have assessed the effects of insurance coverage on
    cancer, the leading cause of death among nonelderly adults in the
    United States.\40\ Though not all cancer results in chronic illness,
    most cancer diagnoses necessitate a period of ongoing care, and
    approximately 8 million U.S. adults under age 70 are currently living
    with cancer.\41\ Beyond increases in cancer screening, health insurance
    may also facilitate more timely or effective cancer care. However,
    evidence on this front is mixed. A study of Massachusetts' reform did
    not find any changes in breast-cancer stage at diagnosis,\20\ whereas
    the ACNs dependent-coverage provision was associated with earlier-stage
    diagnosis and treatment of cervical cancer among young women.\21\
    Another Massachusetts study revealed an increase in rates of
    potentially curative surgery for colon cancer among low-income patients
    after coverage expansion, with fewer patients waiting until the
    emergency stage for treatment.\17\

    Coverage implications for many other illnesses such as asthma, kidney
    disease, and heart failure require additional research. Studies do show
    that for persons reporting any chronic condition, gaining coverage
    increases access to regular care for those conditions.\19\,
    \30\ Overall, the picture for managing chronic physical conditions is
    thus not straightforward, with coverage effects potentially varying
    among diseases, populations, and delivery systems.

                      WELL-BEING AND SELF-REPORTED HEALTH

    Although the evidence on outcomes for some conditions varies, evidence
    from multiple studies indicates that coverage substantially improves
    patients' perceptions of their health. At 1 year, the Oregon study
    found a 25% increase in the likelihood of patients reporting ``good,
    very good, or excellent'' health, and more days in good physical and
    mental health.\8\ Evidence from quasi-experimental studies indicates
    that self-reported health and functional status improved after
    Massachusetts' reform \23\ and after several pre-ACA state Medicaid
    expansions,\22\ and that self-
    reported physical and mental health improved after the ACA's dependent-
    coverage provision went into effect.\6\

    Recent studies of the ACA's 2014 coverage expansion provide more mixed
    evidence. Multiple analyses have found improved self-reported health
    after the ACA's coverage expansion, either in broad national trends
    \24\ or Medicaid expansion studies,\10\, \11\ whereas one
    found significant changes only for select subpopulations \25\ and
    another not at all.\26\ Larger coverage gains have generally been
    associated with more consistent findings of improved self-reported
    health.\19\

    Does self-reported health even matter? It squarely fits within the
    World Health Organization's definition of health as ``a state of
    complete physical, mental, and social well-being,'' and improved
    subjective well-being (i.e., feeling better) is also a primary goal for
    much of the medical care delivered by health care professionals. In
    addition, self-reported health is a validated measure of the risk of
    death. People who describe their health as poor have mortality rates 2
    to 10 times as high as those who report being in the healthiest
    category.\42\, \43\

                                   MORTALITY

    Perhaps no research question better encapsulates this policy debate
    than, ``Does coverage save lives?'' Beginning with the Institute of
    Medicine's 2002 report Care Without Coverage, some analyses have
    suggested that lack of insurance causes tens of thousands of deaths
    each year in the United States.\44\ Subsequent observational studies
    had conflicting findings. One concluded that lacking coverage was a
    strong independent risk factor for death,\28\ whereas another found
    that coverage was only a proxy for risk factors such as socioeconomic
    status and health-related behaviors.\27\ More recently, several studies
    have been conducted with stronger research designs better suited to
    answering this question.

    The Oregon study assessed mortality but was limited by the infrequency
    of deaths in the sample. The estimated 1-year mortality change was a
    nonsignificant 16% reduction, but with a confidence interval of -82% to
    +50%, meaning that the study could not rule out large reductions--or
    increases--in mortality. As the authors note, the study sample and
    duration were not well suited to evaluating mortality.

    Several quasi-experimental studies using population-level data and
    longer follow-up offer more precise estimates of coverage's effect on
    mortality. One study compared three states implementing large Medicaid
    expansions in the early 2000s to neighboring states that didn't expand
    Medicaid, finding a significant 6% decrease in mortality over 5 years
    of follow-up.\22\ A subsequent analysis showed the largest decreases
    were for deaths from ``health-care-amenable'' conditions such as heart
    disease, infections, and cancer, which are more plausibly affected by
    access to medical care.\29\ Meanwhile, a study of Massachusetts' 2006
    reform found significant reductions in all-cause mortality and health-
    care-amenable mortality as compared with mortality in demographically
    similar counties nationally, particularly those with lower pre-
    expansion rates of insurance coverage.\9\ Overall, the study identified
    a ``number needed to treat'' of 830 adults gaining coverage to prevent
    one death a year. The comparable estimate in a more recent analysis of
    Medicaid's mortality effects was one life saved for every 239 to 316
    adults gaining coverage.\29\

    How can one reconcile these mortality findings with the nonsignificant
    cardiovascular and diabetes findings in the Oregon study? Research
    design could account for the difference: the Oregon experiment was a
    randomized trial and the quasi-
    experimental studies were not, so the latter are susceptible to
    unmeasured confounding despite attempts to rule out alternative
    explanations, such as economic factors, demographic shifts, and secular
    trends in medical technology. But--as coauthors of several of these
    articles--we believe that other explanations better account for this
    pattern of results.

    First, mortality is a composite outcome of many conditions and factors.
    Hypertension, dyslipidemia, and elevated glycated hemoglobin levels are
    important clinical measures but do not capture numerous other causes of
    increased risk of death. Second, the studies vary substantially in
    their timing and sample sizes. The Massachusetts and Medicaid mortality
    studies examined hundreds of thousands of people gaining coverage over
    4 to 5 years of follow-up, as compared with roughly 10,000 Oregonians
    gaining coverage and being assessed after less than 2 years. It may
    take years for important effects of insurance coverage--such as
    increased use of primary and preventive care, or treatment for life-
    threatening conditions such as cancer, HIV-AIDS, or liver or kidney
    disease--to manifest in reduced mortality, given that mortality changes
    in the other studies increased over time.\9\, \22\

    Third, the effects on self-reported health--so clearly seen in the
    Oregon study and other research--are themselves predictive of reduced
    mortality over a 5- to 10-year period.\42\, \43\ Studies
    suggest that a 25% reduction in self-reported poor health could
    plausibly cut mortality rates in half (or further) for the sickest
    members of society, who have disproportionately high rates of death.
    Finally, the links among mental health, financial stress, and physical
    health are numerous,\45\ suggesting additional pathways for coverage to
    produce long-term health effects.

                          DIFFERENT TYPES OF COVERAGE

    In light of recent evidence on the benefits of health insurance
    coverage, some ACA critics have argued that private insurance is
    beneficial but Medicaid is ineffective or even harmful.\46\ Is there
    evidence for this view? There is a greater body of rigorous evidence on
    Medicaid's effects--from studies of pre-ACA expansions, from the Oregon
    study, and from analyses of the ACA itself--than there is on the
    effects of private coverage. The latter includes studies of the ACA's
    dependent-coverage provision, which expanded only private insurance,
    and of Massachusetts' reform, which featured a combination of Medicaid
    expansion, subsidies for private insurance through Medicaid managed
    care insurers, and some in crease in employer coverage. But there is no
    large quasi-experimental or randomized trial demonstrating unique
    health benefits of private insurance. One head-to-head quasi-
    experimental study of Medicaid versus private insurance, based on
    Arkansas's decision to use ACA dollars to buy private coverage for low-
    income adults, found minimal differences.\11\, \19\ Overall,
    the evidence indicates that having health insurance is quite
    beneficial, but from patients' perspectives it does not seem to matter
    much whether it is public or private.\47\ Further research is needed to
    assess the relative effects of various insurance providers and plan
    designs.

    Finally, though it is outside the focus of our discussion, there is
    also quasi-experimental evidence that Medicare improves self-reported
    health \48\ and reduces in-
    hospital mortality among the elderly,\49\ though a study of older data
    from Medicare's 1965 implementation did not find a survival
    benefit.\50\ However, since universal coverage by Medicare for elderly
    Americans is well entrenched, both the policy debate and opportunities
    for future research on this front are much more limited.

                          IMPLICATIONS AND CONCLUSIONS

    One question experts are commonly asked is how the ACA--or its repeal--
    will affect health and mortality. The body of evidence summarized here
    indicates that coverage expansions significantly increase patients'
    access to care and use of preventive care, primary care, chronic
    illness treatment, medications, and surgery. These increases appear to
    produce significant, multi-faceted, and nuanced benefits to health.
    Some benefits may manifest in earlier detection of disease, some in
    better medication adherence and management of chronic conditions, and
    some in the psychological well-being born of knowing one can afford
    care when one gets sick. Such modest but cumulative changes--which one
    of us has called ``the heroism of incremental care'' \51\--may not
    occur for everyone and may not happen quickly. But the evidence
    suggests that they do occur, and that some of these changes will
    ultimately help tens of thousands of people live longer lives.
    Conversely, the data suggest that policies that reduce coverage will
    produce significant harms to health, particularly among people with
    lower incomes and chronic conditions.

    Do these findings apply to the ACA? Drawing on evidence from recent
    coverage expansions is, in our view, the most reasonable way to
    estimate future effects of policy, but this sort of extrapolation is
    not an exact science. The ACA shares many features with prior
    expansions, in particular the Massachusetts reform on which it was
    modeled. But it is a complex law implemented in a highly contentious
    and uncertain policy environment, and its effects may have been limited
    by policies in some states that reduced take-up.\52\ Congress's partial
    defunding of the provisions for stabilizing the ACA's insurance
    marketplaces,\53\ and plan offerings with high patient cost sharing.
    Furthermore, every state's Medicaid program has unique features, which
    makes direct comparisons difficult. Finally, coverage expansions and
    contractions will not necessarily produce mirror-image effects. For
    these reasons, no study can offer a precise prediction for the current
    policy debate. But our assessment, in short, is that these studies
    provide the best evidence we have for projecting the impact of the ACA
    or its repeal.

    The many benefits of coverage, though, come at a real cost. Given the
    increases in most types of utilization, expanding coverage leads to an
    increase in societal resources devoted to health care.\8\ There are key
    policy questions about how to control costs, how much redistribution
    across socioeconomic groups is optimal, and how trade-offs among
    federal, state, local, and private spending should be managed. In none
    of these scenarios, however, is there evidence that covering more
    people in the United States will ultimately save society money.

    Are the benefits of publicly subsidized coverage worth the cost? An
    analysis of mortality changes after Medicaid expansion suggests that
    expanding Medicaid saves lives at a societal cost of $327,000 to
    $867,000 per life saved.\29\ By comparison, other public policies that
    reduce mortality have been found to average $7.6 million per life
    saved, suggesting that expanding health insurance is a more cost-
    effective investment than many others we currently make in areas such
    as workplace safety and environmental protections.\29\, \54\
    Factoring in enhanced well-being, mental health, and other outcomes
    would only further improve the cost-benefit ratio. But ultimately,
    policymakers and other stakeholders must decide how much they value
    these improvements in health, relative to other uses of public
    resources--from spending them on education and other social services to
    reducing taxes.

    There remain many unanswered questions about U.S. health insurance
    policy, including how to best structure coverage to maximize health and
    value and how much public spending we want to devote to subsidizing
    coverage for people who cannot afford it. But whether enrollees benefit
    from that coverage is not one of the unanswered questions. Insurance
    coverage increases access to care and improves a wide range of health
    outcomes. Arguing that health insurance coverage doesn't improve health
    is simply inconsistent with the evidence.

    Disclosure forms provided by the authors are available at https://
    www.nejm.
    org/.

    From the Department of Health Policy and Management, Harvard T.H. Chan
    School of Public Health (B.D.S., A.A.G., K.B.), and the Departments of
    Medicine (B.D.S.) and Surgery (A.A.G.), Harvard Medical School and
    Brigham and Women's Hospital-all in Boston.

    This article was published on June 21, 2017, at https://www.nejm.org/.

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                                     ______

                                 Family Voices

                                 P.O. Box 37188

                             Albuquerque, NM 87176

                                  202-669-5233

    As a nonpartisan organization of and for families of children and youth
    with special health care needs, Family Voices strongly urges Congress
    to reject the Graham-
    Cassidy bill. Children and youth with special health care needs include
    children with physical and developmental disabilities, chronic
    illnesses, brain injury, cancer, and rare diseases. Over 40 percent of
    children and youth with special health care needs--over 6 million
    children--rely on the Medicaid program to get the health care they
    need. Often this care includes life-sustaining equipment or medications
    that virtually no family could afford without help, even if they have
    private insurance coverage.

    By severely capping the federal contribution to Medicaid, this
    legislation will significantly compromise the nation's health care
    system for children in general and children with special health care
    needs in particular. With much less funding for Medicaid, states will
    be compelled to restrict eligibility, cut critical benefits, and/or
    reduce reimbursement to providers, thus reducing access to care,
    especially in rural areas. Senators wisely rejected earlier legislation
    that would have capped the Medicaid program. The Graham-Cassidy bill
    would be even worse than those other bills for the children (and
    others) who rely on Medicaid for their health care.

    This bill is also worse for those relying on private insurance. If they
    vote for this bill, Senators will be doing what almost every one of
    them said they would not do--end the guarantee that people with pre-
    existing conditions will not face discrimination and prohibitively high
    premiums. If this bill is enacted, people with the greatest need for
    health care may not be able to afford the insurance to pay for it. And
    if they cannot afford the insurance, they will not have access to care.
    They will do without treatment they need or will incur great medical
    debt trying to pay for it.

    Moreover, this legislation also allow states to let insurers offer
    polices that do not cover important health benefits, such as maternity
    care, substance abuse treatment, and pediatric oral and vision care.

    We recognize that policy makers have different philosophies about the
    federal government's role in the health care system. But this system is
    vast and complex; any legislation that would make extensive changes to
    it, as would the Graham-Cassidy bill, should be very carefully
    considered. Such legislation should be subject to multiple hearings,
    analyzed by experts--including the Congressional Budget Office--
    available for public comment, and debated rationally by lawmakers who
    are fully informed about its impact on their constituents. This
    ``regular order'' has been completely bypassed with respect to the
    Graham-Cassidy bill--another reason that Senators should reject it next
    week.

    We respectfully ask each Senator to pay heed to the scores of patient
    groups, health care providers and health care experts who have warned
    that this legislation will hurt millions of Americans. Most important,
    we ask each Senator to listen to the pleas of their constituents whose
    children have significant health care needs.

    Our children are our greatest responsibility and the future of our
    country. Family voices are united in their message: This legislation
    will jeopardize the health of our children and the wel-being of our
    families. Senators should reject the Graham-
    Cassidy bill.

                              About Family Voices

    Family Voices is a national, nonprofit, family-led organization
    promoting quality health care for all children and youth, particularly
    those with special health care needs. Working with family leaders and
    professional partners at the local, state, regional, and national
    levels since 1992, Family Voices has brought a respected family
    perspective to improving health care programs and policies and ensuring
    that health care systems include, listen to, and honor the voices of
    families.

                                     ______

                               Feminist Majority

                        1600 Wilson Boulevard, Suite 801

                              Arlington, VA 22209

                                  703-522-2214

                                703-522-2219 fax

    Chairman Orrin Hatch
    Ranking Member Ron Wyden
    U.S. Senate
    Committee on Finance

    RE:  Hearing to consider the Graham-Cassidy-Heller-Johnson proposal

    Dear Chairman Hatch, Ranking Member Wyden, and Members of the
    Committee:

    On behalf of the Feminist Majority, a national women's rights
    organization dedicated to women's equality, reproductive health, and
    the empowerment of women in girls in all sectors of society, we write
    in strong opposition to the Graham-Cassidy-Heller-Johnson (``Graham-
    Cassidy'') proposal to repeal the Affordable Care Act (ACA), severely
    cut federal funding for the Medicaid program, and change the financing
    structure of Medicaid to a per capita cap or block grant system.

    This plan would have a devastating impact on women's health. Not only
    would it cut off access to health insurance coverage for an estimated
    32 million people, the Graham-Cassidy bill would make it more
    difficult, if not impossible, for many to access care, including women,
    people with disabilities, seniors, and anyone with a prior medical
    condition.

    Medicaid

    The Medicaid program provides a lifeline for millions of people,
    including middle-class people who rely on Medicaid to fill healthcare
    gaps, and gives families and individuals a chance to lead healthy
    lives. The Graham-Cassidy bill, however, would fundamentally dismantle
    this lifesaving program. The deep funding cuts to Medicaid contained in
    the Graham-Cassidy proposal together with its proposed block grants and
    per capita caps on federal Medicaid funds shifts enormous costs to the
    states, threatens state budgets, and jeopardizes access to care.
    Without the guarantee of federal funds for all Medicaid enrollees,
    states will be forced to cut benefits, either by limiting covered
    services, increasing cost-sharing on low-income people, or restricting
    enrollment. States will also be hampered in their responses to public
    health emergencies, such as the opioid crisis or an outbreak of Zika,
    or to increased demand on healthcare services.

    By limiting federal support for Medicaid, including by cutting the
    growth rate, the Graham-Cassidy proposal puts the health and lives of
    women, the elderly, and people with disabilities at risk. Two-thirds of
    adult Medicaid beneficiaries are women,\1\ and Medicaid provides health
    coverage to one in five women of reproductive age.\2\ Nearly one-third
    of Black women, over one-quarter of Latinas, and about 20 percent of
    Asian American and Pacific Islander women of reproductive age are
    enrolled in the program.\3\ Medicaid covers the cost of over half of
    all births in the U.S. and provides nearly 75 percent of all public
    family planning funds.\4\ It also pays for more than half of all long-
    term care expenditures, including nursing homes.\5\ Two-thirds of
    nursing home patients are women.\6\ Medicaid allows these women, many
    of whom have gone through their savings and assets, to receive the
    long-term care they need. Medicaid cuts and caps, however, will
    restrict access to care at all stages of women's lives, leading to
    poorer health outcomes that can impact not just individual well-being
    but also destabilize families and communities.
    ---------------------------------------------------------------------------
        \1\ Julia Paradise, et al., Kaiser Family Foundation, ``Medicaid at
    50,'' http://www.kff.org/report-section/medicaid-at-50-low-income-
    pregnant-women-children-and-families-and-childless-adults/.
        \2\ Kaiser Family Foundation, ``Medicaid's Role for Women'' (June
    22, 2017), http://www.
    kff.org/womens-health-policy/fact-sheet/medicaids-role-for-women/.
        \3\ In Our Own Voice: National Black Women's Reproductive Justice
    Agenda, et al., Fact Sheet, ``Attacks on the Affordable Care Act,
    Planned Parenthood and Medicaid Are Attacks on Reproductive Justice for
    Women of Color'' (September 2017), available at http://www.national
    partnership.org/research-library/repro/the-house-republican-repeal-
    bill-threatens-reproductive-justice-for-women-of-color.pdf.
        \4\ Kaiser Family Foundation, supra note 2.
        \5\ Id.
        \6\ Id.

    Although the proposed changes to Medicaid would have a devastating
    impact on all aspects of women's health, the proposed funding ban to
    Planned Parenthood is particularly harmful. The Graham-Cassidy plan
    would prohibit Planned Parenthood from receiving any Medicaid funding
    for one year for any service, including family planning, cancer
    screenings, and testing for sexually transmitted infections. Barring
    Planned Parenthood from receiving federal Medicaid reimbursements
    jeopardizes access to these basic healthcare services for millions of
    low income women and young people. More than half of Planned
    Parenthood's patients rely on Medicaid for care, and 56 percent of
    Planned Parenthood health centers are in rural or medically underserved
    ---------------------------------------------------------------------------
    areas.

    Medicaid also allows people with disabilities to receive critically
    needed care, whether medications, therapy, or community-based or in-
    home services. This care frees people to pursue jobs or an education,
    or simply allows them to live with their families instead of inside
    institutions. Roughly 40 percent of Medicaid spending benefits people
    with disabilities. \7\ Medicaid covers 60 percent of children with
    disabilities, and 40 percent of non-elderly adults with
    disabilities.\8\ Medicaid also provides some economic security for
    caregivers, many of whom are women, who would otherwise be unable to
    meet the needs of their loved ones while also meeting basic needs for
    themselves or other family members.
    ---------------------------------------------------------------------------
        \7\ Kaiser Family Foundation, ``Medicaid Pocket Primer'' (June 9,
    2017), http://www.kff.org/medicaid/fact-sheet/medicaid-pocket-primer/.
        \8\ Id.

    The Graham-Cassidy proposal would also eliminate both federal funding
    for the Medicaid expansion--which has allowed over 10 million people to
    gain coverage \9\ including an estimated 3.9 million women \10\--as
    well as federal premium tax credits and cost-sharing subsidies.
    Instead, starting in 2020, the federal government would create new,
    temporary federal block grants to the states, which are estimated to
    amount to over $215 billion in revenue loss.\11\ In addition, the
    Medicaid Directors of all 50 states have expressed deep concern about
    these block grants, warning that the vast majority of states would not
    be prepared to operationalize them in 2020, leaving the fate of
    millions of people uncertain.\12\ Even more alarming, the block grants
    would expire in 2026, without any guarantee of renewal, inserting even
    more uncertainty into state budgets and forcing millions of people to
    lose access to care.
    ---------------------------------------------------------------------------
        \9\ Kaiser Family Foundation, ``Medicaid Expansion Enrollment FY
    2016,'' http://kaiserf.am/2sPNGq6.
        \10\ National Women's Law Center, ``ACA Repeal: What's at Stake for
    Women's Medicaid Coverage'' (February 13, 2017), https://nwlc.org/
    resources/aca-repeal-whats-at-stake-for-womens-medicaid-coverage/.
        \11\ Avalere, Press Release, ``Graham-Cassidy-Heller-Johnson Bill
    Would Reduce Federal Funding to States by $215 Billion'' (September 20,
    2017), http://avalere.com/expertise/life-sciences/insights/graham-
    cassidy-heller-johnson-bill-would-reduce-federal-funding-to-sta.
        \12\ National Association of Medicaid Directors, Press Release,
    ``NAMD Statement on Graham-Cassidy'' (September 22, 2017), http://
    medicaiddirectors.org/wp-content/uploads/2017/09/NAMD-Statement-on-
    Graham-Cassidy9_22_17.pdf/.

    Medicaid is the largest insurer in the nation, serving around 70
    million people each year.\13\ The Graham-Cassidy proposal seeks to
    dramatically cut and fundamentally change the program without a full
    score from the Congressional Budget Office, without adequate hearings,
    and without full and robust deliberation that includes a wide variety
    of stakeholders examining the effect of program changes on the
    healthcare system, on U.S. workers, and on state economies.\14\
    Medicaid creates and supports millions of jobs in the U.S. and is
    critical to state economies. Cutting Medicaid will undoubtedly lead to
    a loss of jobs and may disproportionately impact women workers who make
    up the majority of certain healthcare workers, including 80 percent of
    ambulatory health care employees, 76 percent of hospital employees, and
    80 percent of nursing home and residential care facility employees,
    among other jobs.\15\
    ---------------------------------------------------------------------------
        \13\ Kaiser Family Foundation, supra note 7.
        \14\ The Commonwealth Fund, ``Repealing Federal Health Reform:
    Economic and Employment Consequences for States'' (January 2017),
    http://www.commonwealthfund.org/publications/issue-briefs/2017/jan/
    repealing-federal-health-reform.
        \15\ National Women's Law Center, ``Medicaid Is Vital for Women's
    Jobs in Every Community'' (June 26, 2017), https://nwlc.org/resources/
    medicaid-is-vital-for-womens-jobs-in-every-community/.

    Time and time again, including during the previous attempts to pass ACA
    repeal bills this summer, the public has rejected efforts to decimate
    the Medicaid program. The Senate should abandon this effort and instead
    work to protect the coverage gains made by the Affordable Care Act.

    Other Aspects of ACA Repeal

    In addition to the proposed changes to Medicaid, the Graham-Cassidy
    bill proposes to repeal the ACA premium tax credits and cost-sharing
    subsidies as well as the individual mandate. The bill would also allow
    states to waive important consumer protections, such as the prohibition
    on charging people with pre-existing conditions more for coverage and
    the guarantee of coverage for ten categories of essential health
    benefits. These provisions would put health insurance coverage out of
    reach for millions, cause premiums and other costs to sky rocket, and
    deny care to those in need.

    By eliminating the premium tax credits and cost-sharing subsidies, the
    Graham-Cassidy plan would jeopardize coverage for the over 12 million
    people who enrolled in marketplace plans during the 2017 open
    enrollment period.\16\ Of those who enrolled through HealthCare.gov, 54
    percent were women and girls.\17\ Nationwide, 83 percent of those who
    enrolled in a marketplace plan received a premium tax credit, and more
    than half qualified for cost-sharing reductions.\18\ As discussed
    above, the block granting of ACA federal financial assistance to the
    states would be inadequate to meet the need. Further, there is no
    requirement that states spend the block grant funds to help low- and
    middle-income people obtain coverage, and the block grants themselves
    would expire in 2026. As a result, millions of people, many of whom
    accessed coverage for the first time, would lose coverage.
    ---------------------------------------------------------------------------
        \16\ Centers for Medicare and Medicaid Services, ``Health Insurance
    Marketplaces 2017 Open Enrollment Period Final Enrollment Report:
    November 1, 2016-January 31, 2017'' (March 15, 2017), https://
    www.ems.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-
    items/2017-03-15.html.
        \17\ Id.
        \18\ Id.

    Even as the Graham-Cassidy bill would eliminate financial assistance
    for marketplace enrollees, it would also cause the cost of those plans
    to rise. By ending the premium tax credits and cost sharing reductions,
    the Graham-Cassidy proposal would introduce a new layer of government-
    created uncertainty into the private insurance market, destabilizing
    the market and causing insurers to raise their rates. In addition, like
    all of the ACA repeal bills that preceded it and failed, the Graham-
    Cassidy plan ends the individual mandate, which could cause younger and
    healthier people to leave the marketplace, raising the cost of
    insurance for older adults and those with medical conditions. According
    to estimates, under the Graham-Cassidy plan, premiums would rise by 20
    percent in the first year alone.\19\
    ---------------------------------------------------------------------------
        \19\ Center on Budget and Policy Priorities, ``Like Other ACA
    Repeal Bills, Cassidy-Graham Plan Would Add Millions to Uninsured,
    Destabilize Individual Market'' (September 20, 2017), https://
    www.cbpp.org/research/health/like-other-aca-repeaI-bills-cassidy-
    graham-plan-would-add-millions-to-uninsured.

    Individuals with pre-existing conditions, however, would experience the
    greatest cost increases because the Graham-Cassidy proposal would also
    allow states to waive the protections that prohibit insurance companies
    from charging individuals with pre-existing conditions more than so-
    called ``healthier'' people. For women, this may mean being charged
    more for having experienced a pregnancy, childbirth, an eating
    disorder, depression, lupus, or breast cancer, or having received
    medical treatment related to sexual or intimate partner violence.
    Premium surcharges could range from $142,650 per year for metastatic
    cancer to $17,320 for a pregnancy.\20\ These surcharges would price
    many families and individuals out of the market. By definition, these
    are people--new mothers, cancer survivors, children with medical
    conditions, etc.--who most need access to healthcare.
    ---------------------------------------------------------------------------
        \20\ Sam Berger and Emily Gee, Center for American Progress,
    ``Latest ACA Repeal Plan Would Explode Premiums for People With Pre-
    Existing Conditions'' (April 20, 2017), https://
    www.americanprogress.org/issues/healthcare/news/2017/04/20/430858/
    latest-aca-repeal-plan-explode-premiums-people-pre-existing-
    conditions/.

    For those who can pay increasing costs, the Graham-Cassidy bill may
    force them to pay more for less. Currently, insurance companies are
    required to cover 10 categories of essential health benefits (EHBs),
    such as emergency care, hospitalization, laboratory services, pediatric
    care, and more. The Graham-Cassidy proposal, however, would allow
    states to waive coverage of EHBs. States could eliminate any or all of
    these benefits, including maternity care, or allow insurers to
    determine the scope of coverage. As a result, people who are able to
    purchase health insurance would face substantial increases in their
    out-of-pocket costs for care because their insurance plan would no
    longer cover the care they need. In particular, people who rely on
    expensive prescription drugs, mental health services, or substance
    abuse treatment could see large increases in their healthcare spending
    ---------------------------------------------------------------------------
    or would be forced to stop receiving those services all together.

    The loss of maternity care as a covered essential health benefit would
    be particularly burdensome for women and their families. Prior to the
    ACA, only 18 states required nongroup health insurance plans to cover
    maternity care.\21\ As a result, only 12 percent of individual
    insurance plans nationwide offered maternity coverage.\22\ It is
    expected that states that did not previously require maternity benefits
    would stop guaranteeing coverage for those services. In these states,
    women who want maternity coverage would have to purchase a rider at a
    cost of more than $1,000 per month, a cost that many women simply
    cannot afford.\23\ Under these circumstances, having a baby could mean
    financial ruin. The average cost of childbirth in the United States
    ranges from around $32,000 for a vaginal birth and $51,000 for a
    cesarean birth.\24\
    ---------------------------------------------------------------------------
        \21\ Kaiser Family Foundation, ``Pre-ACA State Maternity Coverage
    Mandates: Individual and Small Group Markets,'' https://www.kff.org/
    state-category/health-insurance-managed-care/pre-aca-state-mandated-
    health-insurance-benefits/.
        \22\ National Women's Law Center, ``The Many Ways the American
    Health Care Act Would Jeopardize Women's Health and Economic Security''
    (May 24, 2017), https://nwlc.org/resources/the-many-ways-the-american-
    health-care-act-would-jeopardize-womens-health-and-economic-security/.
        \23\ Congressional Budget Office, ``Cost Estimate: H.R. 1628, the
    American Health Care Act of 2017 as passed by the House of
    Representatives on May 4, 2017'' at 26 (May 24, 2017), https://
    www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/
    hr1628aspassed.pdf.
        \24\ Truven Health Analytics, ``The Cost of Having a Baby in the
    United States'' 6 (January 2013), http://
    transform.childbirthconnection.org/wp-content/uploads/2013/01/Cost-of-
    Having-a-Baby1.pdf.

    Denial of maternity coverage is also dangerous and endangers women's
    lives. Pregnancy carries considerable health risks, including anemia,
    gestational diabetes, depression, infection, and high blood pressure,
    which can lead to hypertension or preeclampsia. These conditions, if
    untreated, can lead to serious complications, including preterm
    delivery, low- or high-birth weight babies, and infant or maternal
    ---------------------------------------------------------------------------
    death.

    Coupling the denial of maternity coverage with the elimination of other
    essential health benefits--like coverage for mental health and
    substance abuse services or chronic disease management--increases the
    likelihood of maternal and child death. Many maternal deaths are the
    result of pre-existing health conditions like cardiovascular disease,
    obesity, and substance use. If coverage for treating those underlying
    conditions were cut, fewer women would be able to access care to keep
    themselves and their children healthy. This is especially concerning
    since the United States has the highest level of maternal death in the
    developed world.\25\ Maternal death rates are particularly high among
    Black women who are more likely, as a group, to experience additional
    health disparities.\26\ In addition, the Graham-
    Cassidy proposal would increase restrictions on abortion coverage, a
    policy that undermines healthy motherhood and endangers women's health
    by putting healthcare out of reach.
    ---------------------------------------------------------------------------
        \25\ Nina Martin and Renee Montagne, ``U.S. Has the Worst Rate of
    Maternal Deaths in the Developed World,'' NPR (May 12, 2017), http://
    www.npr.org/2017/O5/12/528098789/u-s-has-the-worst-rate-of-maternal-
    deaths-in-the-developed-world.
        \26\ Centers for Disease Control and Prevention, ``Pregnancy
    Mortality Surveillance System'' (June 29, 2017), https://www.cdc.gov/
    reproductivehealth/maternalinfanthealth/pmss.html.

    The Graham-Cassidy bill would also allow states to re-impose annual and
    lifetime caps on coverage, a practice that the ACA had curbed.
    Prohibiting caps on coverage ensures that families and individuals with
    serious health concerns can access benefits when they need them the
    most. Imposing caps is tantamount to imposing a cutoff date on
    ---------------------------------------------------------------------------
    critically-needed care, threatening the lives of the most vulnerable.

    Increasing healthcare costs would mean less financial stability for
    families, too many of whom are already struggling to get by. The family
    forced to pay higher premiums because of a pre-existing condition may
    be forced to choose between healthcare or food, healthcare or their
    child's education, healthcare or the rent. Adult children may find
    themselves financially stretched to pay for an elderly parent's care
    when they can no longer rely on Medicaid to help pay the cost of
    nursing home care. Skyrocketing out-of-pocket costs as well as the loss
    of coverage all together could lead families into bankruptcy. In fact,
    a recent study of bankruptcy filings found that expanded access to
    insurance coverage under the ACA helped drive down personal bankruptcy
    filings.\27\ The Senate should not lead the country backward.
    ---------------------------------------------------------------------------
        \27\ Allen St. John, ``How the Affordable Care Act Drove Down
    Personal Bankruptcy,'' Consumer Reports (May 2, 2017), https://
    www.consumerreports.org/personal-bankruptcy/how-the-aca-drove-down-
    personal-bankruptcy/.

    For the reasons discussed above, the Feminist Majority strongly opposes
    the
    Graham-Cassidy bill, and we urge the Senate to abandon this effort, as
    well as all efforts to repeal the ACA and dismantle or defund the
    Medicaid program. In addition, the Feminist Majority has grave grave
    concerns about the lack of transparency surrounding the development of
    this legislation, as well as previous legislation to repeal the ACA and
    restructure Medicaid. It should be noted that this one hearing, with
    its cursory attempt to gather public input without reasonable notice,
    is not an adequate replacement for rigorous debate and deliberation of
    a proposal to reshape the U.S. healthcare system. We encourage the
    Senate to return to regular order and work in a bipartisan fashion to
    ---------------------------------------------------------------------------
    strengthen the ACA and increase access to healthcare for all.

    Sincerely,

    Eleanor Smeal                       Gaylynn Burroughs
    President                           Policy Director

                                     ______

                      Letter Submitted by Sarah Fox, Ph.D.

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
    Monday, September 25, 2017

    Senator Hatch, Republican members of the Senate Finance Committee, and
    future historians:

    I am writing to share my perspectives with regard to the Graham-
    Cassidy-Heller-Johnson bill, as well as all the other Republican
    repeal-and-replace bills to date. Although I am addressing this letter
    to the entire Finance Committee, I am really addressing just the
    Republican members. I have no quarrel with the Democrats, who have
    fought valiantly for access to affordable healthcare for all Americans.
    They, and Senator McCain, are apparently the heroes of the day.

    I also write this letter to future historians, in the hope that they
    find this letter buried among thousands in the records of this Senate
    hearing. Our government is in crisis, and many of us fear it cannot
    survive until January 2021. We hope it does. But if it does not, we
    want historians to have good records for our nation's post-mortem, so
    perhaps history will not repeat itself.

    My life partner has cancer--Stage IIIb melanoma. Her Obamacare
    insurance (through the individual marketplace) has been indispensable
    in her fight, and you want to take this all-important safety net away
    from her to please the billionaire oligarchs who fund your campaigns.
    As you can well imagine, we have both become highly involved in the
    fight to save the ACA, because her life potentially depends on it.
    Unlike you wealthy politicians, we cannot afford to pay, out of pocket,
    for the sorts of drugs necessary to treat a Stage IV recurrence--like
    Keytruda or Opdivo, at $150,000 for a round of treatment. So in
    addition to fighting the cancer, we now have to fight the government.

    Under Graham-Cassidy, the insurance available to us would be junk.
    Either it would not cover cancer in any meaningful way, or it would
    have an unaffordable price (or both?). So let me be crystal clear,
    senators: You have tightened a noose around my life-partner's neck, and
    you are threatening to kick the chair out from under her feet. You
    clearly have the power to kill her, and we are helpless to stop you.
    Our annoying story is but one out of the millions you've heard over and
    over.

    We have spent months begging for you to spare her life, but our story
    clearly does not matter to you. Her life clearly has no importance in
    your universe.

    This has become our full-time job--fighting you. Your ignorant
    supporters call us ``snowflakes,'' ``libtards,'' and ``demwits.'' They,
    and you too, accuse us of being paid activists, funded apparently by
    George Soros. We receive no funding from anyone. We are backed into a
    corner and fighting literally for our lives! Nobody has to PAY us for
    that! Perhaps doing something without pay does not compute in the minds
    of the wealthy. We know many, many equally impassioned activists with
    similarly compelling stories. I have not yet met anyone funded in any
    way by George Soros or anyone else. Your mockery of our movement is
    insulting. But with time, you will learn to respect us.

    I came into this movement with the conviction of any academic, that
    knowledge and truth are power. I turned a great bulk of my time towards
    researching your harmful bills, and I quickly became astonished at the
    level of ignorance you and your staffers have about the legislation you
    write and vote to pass. So I, along with several other ad-hoc analysts,
    professional analysts and journalists, sought to educate you and inform
    every-day Americans. We were quite successful in doing that. You
    clearly underestimated the determination of our movement.

    You are now fully aware what a horrible bill you seek to pass this
    week, because we have found all your tricks. Even Jimmy Kimmel is aware
    of them. You are fully aware this bill would strip at least 32 million
    Americans of their healthcare insurance (and in too many cases, their
    very access to health care). This is irrelevant to you. You know the
    personal stories of many of those who stand to die under this
    legislation, and you lie to them and insult them to their faces. And
    you do not care.

    You understand that we would have junk insurance under Graham-Cassidy-
    Heller-Johnson, and you do not care. You understand the junk insurance
    would be unaffordable for many, including the poor and the elderly. And
    you do not care. You know how many people you would be kicking off of
    Medicaid, including the disabled and elderly. And you do not care. You
    understand that hard-working families would increasingly face medical
    bankruptcy, and you do not care. You understand that crippling tax
    burdens would be shifted to the states, and you don't care. Governors,
    insurance commissioners, medical associations, patient advocacy
    associations, and our nation's top analysts, hailing from all political
    ideologies, have overwhelmingly opposed this bill. And again, you do
    not care. Most of all, your supposed bosses, The People, have spoken
    with a rather loud, clear, and unified voice that WE DO NOT WANT THE
    LEGISLATION YOU ARE TRYING TO PASS. And you do not care.

    You care about nothing but being reelected, and you seem to think large
    contributions from wealthy contributors will make that possible. In
    your fantasy world, you believe slick TV ads are going to woo enough
    stupid voters to put you over the line. And yet again, you
    underestimate us. We are not stupid. We are ``woke.''

    Just like we have educated our fellow Americans about the innumerable
    faults with all of your repeal/replace bills, we will educate them
    about your callous disregard for their best interests--for their very
    lives. Whenever someone loses his or her insurance, we'll be there to
    let them know why it happened. Whenever someone goes broke because of a
    catastrophic illness in the family, we'll explain to them how it
    wouldn't have happened under the ACA. Whenever someone dies for lack of
    insurance, we'll let the grieving family know who to blame. We'll keep
    track of how many people lose insurance, we will estimate the excess
    death toll directly attributable to this bill in each and every state,
    and we will hold you accountable for it. We will make you care, because
    you will lose your jobs.

    These healthcare battles--the first major battles of the new
    administration--have plainly revealed all of you for the monsters you
    are. We know without ambiguity that you are willing to sacrifice our
    lives and well-being for the advancement of your careers. Shame on you
    all!

    I thank Senator McCain for standing up against what you are doing, even
    though he may inexplicably agree with the bill. You Republicans have
    abused your power. You have not approached Graham-Cassidy-Heller-
    Johnson through proper channels. Your hearing on Monday is a sham. As
    of Friday afternoon, you don't even know who your witnesses will be.
    I'm sure it doesn't matter, because you won't care what they have to
    say anyway. It says something very frightening that only one senator in
    your party is willing to stand up for Democracy and demand a fair
    process. Not even Senator Alexander is willing to do that, and I am
    disappointed.

    Aside from the election process, our government is no longer answerable
    to The People. We have learned that. Except for our precious vote, we
    no longer live in a viable Democracy. Our nation is in peril. We
    progressives cherish our system of government, and we will fight our
    hardest to win our country back. We will see you in the polls--in 2018,
    2020, and 2022.

    After we have taken back our country, the pendulum will swing rather
    hard. If you Republicans destroy our Medicaid and health insurance
    system, actually making it worse than it was before the ACA, you will
    have lost me as a strong voice of moderation. I have discouraged the
    Medicare-for-All movement because of the prudence of seeking the
    attainable in our current political climate. But if we have to rebuild
    from the very foundation of our healthcare system, I will be a
    proponent for straight-up socialized medicine. That is because I have
    learned one very important thing during all my work on this issue:
    Healthcare is a RIGHT, not a privilege.

    You have a lot to consider, senators. In all of your deliberations,
    please remember that The People, whom you belittle, defraud, and
    neglect, are your bosses. And we have run out of patience with you.

    Sincerely,

    Sarah Fox, Ph.D.

                                     ______

                              Friday Health Plans

                           700 Main Street, Suite 100

                               Alamosa, CO 81101

                                 (800) 475-8466

                       https://www.fridayhealthplans.com/

    September 22, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Re: Statement for the record submitted for September 25th hearing
    titled ``Graham-Cassidy-Heller-Johnson Proposal''

    Friday Health Plans is a small health insurer focused on ACA compliant
    health insurance for rural Colorado. Unlike many larger insurers who
    are running away from the ACA, we are investing to grow our
    participation in this market to additional parts of Colorado. We are
    also working proactively with additional states in need of offering
    new, innovative health insurance options to their residents.

    We support measures that will stabilize the individual marketplace,
    lower premiums for more Americans, and improve consumer choice.
    Unfortunately, the
    Graham-Cassidy bill would significantly increase the uncertainty and
    risk in this market. The ensuing confusion and volatility this bill
    would create would also make it essentially impossible for us to expand
    and invest in new markets.

    Despite our deep concerns about Graham-Cassidy, it is our goal to be
    constructive participants in the national dialogue on improving health
    care access and quality, while lowering costs. We have many policy
    recommendations that could help to achieve the goals of market
    stabilization, lower premiums, and increased choice--here are some we
    consider to be most important:

    1. Enforce the individual mandate. Without the mandate (or a functional
    equivalent), community rating and guaranteed issue are highly
    impractical.
    2. Commit to continued cost sharing reduction (CSR) subsidies. The
    uncertainty around this funding is hurting consumers and is driving
    higher premiums this year.
    3. Fix risk adjustment methodologies. While we agree in principle to
    compensating insurers who have higher risk populations, the current
    risk adjustment formula has structural flaws that disadvantage small
    carriers, rural carriers, and carriers that strive to offer affordable
    premiums.

    Thank you very much for affording us this opportunity to comment on the
    Graham-Cassidy proposal and provide additional input on your efforts to
    improve the health care system in the U.S. We stand ready to work with
    you and any other members of the Finance Committee who share this
    important goal.

    Sincerely,

    David Pinkert
    President, Friday Health Plans

                                     ______

                     Letter Submitted by Anne Morgan Giroux

    September 18, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal on
    September 25, 2017

    Dear Senators,

    My daughter is 22-years-old. She has epilepsy and a developmental
    disability and depends on Medicaid to live. What a drain she is to the
    system yes?

    Hell no. She works 35 hours a week at 2 jobs. She rents an apartment
    and lives mostly independently. She employs people to help her with the
    things she cannot do on her own. She volunteers. She spends money
    shopping at the mall near her apartment and eats out . . . a lot. Why
    does this matter?

    Because if you go through with this bill, she loses all of that. And we
    lose . . . all of us.

    She is able to keep her job because of her job coach, who helps train
    her, and helps her stay on track at work, and work through any issues
    and concerns. Medicaid pays for her job coach.

    No job coach, no job.
      No job, no rent money and no apartment
         No job, no money to spend in our community.
          No job, no employing staff to assist her.
            No job, no life.

    And the irony here is that she becomes MORE dependent on government
    assistance. She qualifies for Social Security Insurance but hardly ever
    receives this money because she is employed and makes enough money on
    her own. However, she will need to take the full amount if she cannot
    keep her job, thus relying more on taxpayer dollars.

    She relies on Medicaid for her job coach, for her supports in her
    apartment and for her prescription drugs. If you take that away, you
    are taking away her life.

    I know you all hate ObamaCare but for God's sake, would you please slow
    down and listen. Give your bill time to be examined, researched and
    testified on! This affects WAY too many people to ram it through.

    You owe that to the people who elected you, including my 22-year-old
    daughter, Lily, who by the way, also votes.

    Sincerely,

    Anne Morgan Giroux
    Madison, WI
    Mom to Lily

                                     ______

                              Guttmacher Institute

                     1301 Connecticut Avenue, NW, Suite 700

                              Washington, DC 20036

                                Tel 202-296-4012

                                Fax 202-223-5756

                          https://www.guttmacher.org/

    Heather Boonstra
    Director of Public Policy

    September 25, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Building
    Washington, DC 20510-6200

    Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
    September 25, 2017

    Dear Chairman Hatch and Ranking Member Wyden:

    Thank you for the opportunity to submit this statement on behalf of the
    Guttmacher Institute in opposition to H.R. 1628, the Graham-Cassidy-
    Heller-Johnson proposal to repeal the Affordable Care Act (ACA) and
    overhaul the Medicaid program, on which a hearing is being held before
    the Committee on Finance on September 25, 2017.

    Through its work as a nonprofit research and policy organization
    committed to advancing sexual and reproductive health and rights in the
    United States and globally, the Guttmacher Institute has developed and
    analyzed considerable evidence on the need for and benefits of
    affordable, comprehensive health insurance coverage that people can use
    to obtain high-quality reproductive health services at nearby, trusted
    providers.

    Many of the Institute's relevant research and policy analyses, along
    with those of other experts in the field, are addressed in a series of
    recent articles referenced below for your review:

          Why Protecting Medicaid Means Protecting Sexual and Reproductive
    Health.\1\
    ---------------------------------------------------------------------------
        \1\ Sonfield, A., ``Why Protecting Medicaid Means Protecting Sexual
    and Reproductive Health,'' Guttmacher Policy Review, 2017, 20: 39-43,
    https://www.guttmacher.org/gpr/2017/03/why-protecting-medicaid-means-
    protecting-sexual-and-reproductive-health.
    ---------------------------------------------------------------------------
          How Dismantling the ACA's Marketplace Coverage Would Impact
    Sexual and Reproductive Health.\2\
    ---------------------------------------------------------------------------
        \2\ Hasstedt, K., ``How Dismantling the ACA's Marketplace Coverage
    Would Impact Sexual and Reproductive Health,'' Guttmacher Policy
    Review, 2017, 20: 48-52, https://www.
    guttmacher.org/gpr/2017/04/how-dismantling-acas-marketplace-coverage-
    would-impact-sexual-and-reproductive-health.
    ---------------------------------------------------------------------------
          No One Benefits if Women Lose Coverage for Maternity Care.\3\
    ---------------------------------------------------------------------------
        \3\ Sonfield, A., ``No One Benefits if Women Lose Coverage for
    Maternity Care,'' Guttmacher Policy Review, 2017, 20: 78-81, https://
    www.guttmacher.org/gpr/2017/06/no-one-benefits-if-women-lose-coverage-
    maternity-care.
    ---------------------------------------------------------------------------
          What Is at Stake With the Federal Contraceptive Coverage
    Guarantee? \4\
    ---------------------------------------------------------------------------
        \4\ Sonfield, A., ``What Is at Stake With the Federal Contraceptive
    Coverage Guarantee?'', Guttmacher Policy Review, 2017, 20: 8-11,
    https://www.guttmacher.org/gpr/2017/01/what-stake-federal-
    contraceptive-coverage-guarantee.
    ---------------------------------------------------------------------------
          Conservatives Are Using the American Health Care Act to Restrict
    Private Insurance from Covering Abortion.\5\
    ---------------------------------------------------------------------------
        \5\ Sonfield, A., ``Conservatives Are Using the American Health
    Care Act to Restrict Private Insurance From Covering Abortion,'' Health
    Affairs blog, March 21, 2017, https://www.
    guttmacher.org/article/2017/03/conservatives-are-using-american-health-
    care-act-restrict-private-insurance-covering.
    ---------------------------------------------------------------------------
          Beyond the Rhetoric: The Real-World Impact of Attacks on Planned
    Parenthood and Title X.\6\
    ---------------------------------------------------------------------------
        \6\ Hasstedt, K., ``Beyond the Rhetoric: The Real-World Impact of
    Attacks on Planned Parenthood and Title X,'' Guttmacher Policy Review,
    2017, 20: 86-91, https://www.guttmacher.org/gpr/2017/08/beyond-
    rhetoric-real-world-impact-attacks-planned-parenthood-and-title-x.

    Collectively, this body of evidence demonstrates the severely negative
    consequences the Graham-Cassidy proposal would have for reproductive
    health. For these reasons, we oppose the Graham-Cassidy proposal and
    urge the Senate to do the same, just as it has rejected all other
    recent attempts to repeal the ACA and undermine Medicaid that would
    have resulted in similar harms.

    Benefits of the ACA for Reproductive Health

    The major coverage provisions of the ACA went into effect at the
    beginning of 2014, and have particularly benefitted the availability
    and quality of insurance coverage for women of reproductive age (15-
    44). Nationally, the proportion of these women who were uninsured
    dropped by 36% between 2013 and 2015, after the ACA's coverage
    expansions had been implemented.\7\ This change was driven by
    substantial gains in both Medicaid coverage and private insurance
    coverage via the ACA's marketplaces. It was especially pronounced in
    states that had expanded Medicaid under the ACA, where collectively,
    the proportion of women of reproductive age without coverage dropped by
    45%.
    ---------------------------------------------------------------------------
        \7\ Guttmacher Institute, ``Uninsured Rate Among Women of
    Reproductive Age Has Fallen More Than One-Third Under the Affordable
    Care Act,'' News in Context, November 17, 2016, https://
    www.guttmacher.org/article/2016/11/uninsured-rate-among-women-
    reproductive-age-has-fallen-more-one-third-under.

    Moreover, the ACA established important protections specifically for
    coverage of reproductive health services, and has done much to promote
    ---------------------------------------------------------------------------
    better access to this care:

          Contraception: An estimated 58 million women have benefitted
    from the contraceptive coverage guarantee.\8\ Privately insured women
    have experienced notable declines in out-of-pocket costs for
    contraception, an impact that has become more pronounced over time.\9\
    ---------------------------------------------------------------------------
        \8\ National Women's Law Center (NWLC), ``New Data Estimate 57.6
    Million Women Have Coverage of Birth Control Without Out-of-Pocket
    Costs,'' Washington, DC: NWLC, 2017, https://nwlc.org/resources/new-
    data-estimate-57-6-million-women-have-coverage-of-birth-control-
    without-out-of-pocket-costs/.
        \9\ Sonfield, A., et al., ``Impact of the federal contraceptive
    coverage guarantee on out-of-pocket payments for contraceptives: 2014
    update,'' Contraception, 2015, 91(1):44-48, http://www.
    contraceptionjournal.org/article/S0010-7824(14)00687-8/abstract.

          Maternity care: The ACA also closed major gaps in private
    insurance coverage of maternity care, by requiring plans in the small
    group and individual markets to cover those services.\10\ Prior to the
    ACA, 8 in 10 plans in the individual market failed to cover maternity
    care at all.
    ---------------------------------------------------------------------------
        \10\ NWLC, ``Nowhere to Turn: How the Individual Health Insurance
    Market Fails Women,'' Washington, DC: NWLC, 2008, https://nwlc.org/
    resources/nowhere-turn-how-individual-health-insurance-market-fails-
    women/.

          Access to providers: Safety-net health centers that provide
    family planning services have become an increasingly valued part of the
    health care system,\11\ delivering high-quality care to insured and
    uninsured individuals alike.\12\ The ACA has sparked this trend,
    including by requiring marketplace plans to contract with local safety-
    net providers.
    ---------------------------------------------------------------------------
        \11\ Hasstedt, K., and Rowan, A., ``Marketplace Plans' Provider
    Networks Are Just Not Adequate Without Family Planning Centers,''
    Guttmacher Policy Review, 2015, 18(2): 48-55, https://
    www.guttmacher.org/gpr/2015/07/marketplace-plans-provider-networks-are-
    just-not-adequate-without-family-planning.
        \12\ Hasstedt, K., ``Through ACA Implementation, Safety-Net Family
    Planning Providers Still Critical for Uninsured--and Insured--
    Clients,'' 2016, https://www.guttmacher.org/article/2016/08/through-
    aca-implementation-safety-net-family-planning-providers-still-critical.
    ---------------------------------------------------------------------------

    Threats of the Graham-Cassidy Proposal to Reproductive Health

    In contrast to the ACA, the Graham-Cassidy proposal would have a
    damaging impact on reproductive health in the United States.

    The broadest consequence of the Graham-Cassidy proposal would be the
    loss of comprehensive insurance coverage--including coverage for
    reproductive health care--for many millions of people in this country.
    The legislation would impose unprecedented and draconian caps on
    federal Medicaid spending and eliminate the ACA's Medicaid expansion.
    Together, these changes would fundamentally undermine a Medicaid
    program that is the source of coverage for 74 million U.S. residents,
    including 13 million women of reproductive age.\1\

    Moreover, the Graham-Cassidy proposal would eliminate the federal ACA
    marketplace, and the federal tax credits and subsidies that help make
    marketplace premiums and cost sharing affordable for low-income people.
    The ACA's marketplaces, tax credits and subsidies have been vital to
    expanding coverage for reproductive health services.\2\

    In place of the ACA's central coverage provisions, Graham-Cassidy
    includes a block grant provision that would allow states to redirect
    hundreds of billions of dollars in federal funding away from coverage
    and care for the low-income people who most need the financial help. It
    would also redistribute money in a way that is designed to punish the
    states that have worked the hardest to help their residents gain
    insurance coverage.\13\
    ---------------------------------------------------------------------------
        \13\ Leibenluft, J., et al., ``Like Other ACA Repeal Bills,
    Cassidy-Graham Plan Would Add Millions to Uninsured, Destabilize
    Individual Market,'' Washington, DC: Center on Budget and Policy
    Priorities, 2017, https://www.cbpp.org/research/health/like-other-aca-
    repeal-bills-cassidy-graham-plan-would-add-millions-to-uninsured.

    The Congressional Budget Office (CBO) has not been given the time it
    needs to analyze how the Graham Cassidy proposal would impact coverage,
    premiums or out-of-pocket spending, something that should be a
    prerequisite before voting on such a sweeping piece of legislation.
    However, it is clear that Graham-Cassidy would devastate both Medicaid
    and the individual insurance market. Previous CBO estimates of similar
    legislative proposals suggest the Graham-Cassidy proposal would result
    in at least 20 million people losing coverage within 10 years.\14\
    Recent estimates from the Commonwealth Fund put the number of people
    who stand to lose coverage at a minimum of 32 million after 2026.\15\
    ---------------------------------------------------------------------------
        \14\ Hall, K., Congressional Budget Office, letter to Senator Mike
    Enzi Re: H.R. 1628, the Better Care Reconciliation Act of 2017: An
    Amendment in the Nature of a Substitute [ERN17500], as posted on the
    website of the Senate Committee on the Budget on July 20, 2017, https:/
    /www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/52941-
    hr1628bcra.pdf.
        \15\ Collins, S.R., ``What Are the Potential Effects of the Graham-
    Cassidy ACA Repeal-and-
    Replace Bill? Past Estimates Provide Some Clues,'' To The Point, The
    Commonwealth Fund, http://www.commonwealthfund.org/publications/blog/
    2017/sep/potential-effects-of-graham-cassidy.

    In addition to resulting in extensive coverage losses, the Graham-
    Cassidy proposal includes many provisions that promise to undermine
    ---------------------------------------------------------------------------
    reproductive health specifically:

          Excluding Planned Parenthood from federal programs: Excluding
    Planned Parenthood health centers nationwide from Medicaid would
    jeopardize women's access to high-quality contraceptive and related
    care, and place an incredible burden on other types of safety-net
    family planning providers.\6\,}\16\
    ---------------------------------------------------------------------------
        \16\ Hasstedt, K., ``Understanding Planned Parenthood's Critical
    Role in the Nation's Family Planning Safety Net,'' Guttmacher Policy
    Review, 2017, 20:12-14, https://www.guttmacher.org/gpr/2017/01/
    understanding-planned-parenthoods-critical-role-nations-family-
    planning-safetv-net.

          Undermining contraceptive coverage: The Graham-Cassidy proposal
    would allow states to eliminate the protections of the ACA's preventive
    services benefit for some private insurance plans. That would endanger
    coverage of the full range of contraceptive methods and counseling
    without additional cost-sharing, potentially forcing people to use less
    ---------------------------------------------------------------------------
    effective or desirable methods, or no method at all.\4\

          Rolling back maternity coverage: The Graham-Cassidy proposal
    would allow states to eliminate the requirement that marketplace and
    other private health plans must cover 10 essential health benefits,
    including maternity care.\3\ The proposal could also undermine other
    important protections for patients, including those with preexisting
    medical conditions.

          Eliminating private insurance coverage of abortion: The Graham-
    Cassidy proposal includes multiple provisions designed to eliminate
    abortion coverage in many parts of the private insurance market.
    Abortion coverage is already difficult for many women to obtain and
    should be much more readily available, not restricted.\5\

    In conclusion, rather than thoughtfully addressing the gaps in our
    nation's systems of health insurance coverage and care, the Graham-
    Cassidy proposal would wreak havoc on the nation's health coverage
    programs, and most importantly, on the health and well-being of U.S.
    women and their families.

    Thank you for the opportunity to provide these comments.

    Sincerely,

    Heather Boonstra
    Director of Public Policy

                                     ______

                  Letter Submitted by Sue Matthes Hadden, R.N.

    Dear Senate Finance Committee,

    The Graham-Cassidy health care bill needs a CBO score before it is
    voted on. Since health care takes up over 30% of our GNP, this is
    nothing to rush or take lightly.

    I am a nurse who works with pediatric patients who have urology
    problems. Michigan has no pediatric urologists in the upper northern
    lower peninsula or upper peninsula.

    For people with no insurance or who are underinsured, it is expensive
    for them to bring their children to see us. But following up with us is
    what is needed to ensure their kidneys are healthy and so that we can
    intervene should they have decreasing kidney function. I have seen a
    huge change in parents being able to keep their appointments since the
    Medicaid expansion and ACA have been instituted. The
    Graham-Cassidy bill will create a tragedy for our patients. This week
    we had a patient who was lost to follow up for 2 years. We will now
    have to remove his kidney due to this lack of follow up. This kind of
    thing will sky rocket without Medicaid and adequate insurance for my
    patients.

    I am also very worried about my daughter who is in school getting a
    degree in occupational therapy. If she is not able to get insurance
    through the exchange, she will have to decrease her hours in school to
    work more to afford crappy catastrophic insurance. Then if she has any
    significant illness, she will have to drop out of school or declare
    bankruptcy. And we know that 60% of people who declare bankruptcy do so
    due to health care issues.

    Please demand a CBO score of the bill before allowing a Senate vote.
    This bill is a lemon.

    Best regards,
    Sue Hadden R.N.

                                     ______

                      Letter Submitted by Carolyn Holland

    September 24, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
    September 25, 2017

    Senator Hatch and members of the Senate Finance Committee:

    I am writing to give my perspective on the Graham-Cassidy-Heller-
    Johnson bill.

    It is a pretense for anyone in Congress to pretend that Graham-Cassidy-
    Heller-Johnson is the benign repeal of an unpopular program when it
    destabilizes not only the Affordable Care Act but also Medicaid.

    My father was a high school teacher who served in the Army Air Force in
    WWII. On September 8th we celebrated his 94th birthday in the nursing
    home that he moved into about a year and a half ago. Dad outlived his
    income in that when he was 93, the unregulated escalation in medical
    costs finally exceeded the meager increases in his teacher's pension
    and he went on Medicaid.

    My dad served his country and he served his community and he maintained
    his independence for as long as he could, even well into the age-
    related decline of his cognitive functioning. Needless to say, this was
    preceded by a series of excruciating decisions for our family. We
    simply could not provide the level of care that he gets through
    Medicaid.

    It is an embarrassment to this country and those like my father who
    have served it that our elected representatives would consider
    replacing essential federal health care programs with block grants that
    leave the states with fractions of pennies on the dollar to dole out
    for health care needs. Cutting programs that help citizens to obtain
    medical care is just mean. You cannot make this nation greater by
    impoverishing its citizens through unregulated costs, stripping them of
    care, and leaving them to die.

    Sincerely,

    Carolyn Holland

                                     ______

                      Letter Submitted by Marion Holmberg

    Dear Senators,

    My name is Marion Holmberg, and I live in Waukesha, Wisconsin. I am the
    mother of three young adults with intellectual disabilities. I am
    concerned about the cuts to Medicaid that are included in this bill;
    cuts to Medicaid are a direct threat to the lives and independence of
    people with disabilities. All three of my children use some form of
    Medicaid to help them live and work in the community.

    My daughter Meara, who is 21, is a graduate of Project SEARCH and works
    in one of the local schools in the kitchen. She requires regular job
    coaching in order to be successful on her job. Her job coach is paid
    through Wisconsin's IRIS (Include, Respect, I Self-direct), a long-term
    care program funded by Medicaid dollars. She spends her afternoons
    volunteering in the community supported by staff paid through IRIS.

    What will happen to her life when Medicaid funding is cut? Without this
    support, she sits home or worse will need to live in some type of
    institutional setting.

    For the sake of my children and so many others like them, I am begging
    you to:

          Please oppose the Graham-Cassidy bill and do not vote to move
    this bill out of the Finance Committee;
          Please oppose ANY cuts to Medicaid; and
          Please work in a bipartisan fashion to increase access to
    affordable, accessible health care and long term services and supports.

    Thank you!

    Marion Holmberg

                                     ______

                       Letter Submitted by Samir S. Jaber

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Dear Senators,

    When our nation's forefathers, in the midst of their struggle to repel
    their colonial masters, audaciously joined together to state that their
    Independence was based on those unalienable rights that have been given
    to all human beings by their Creator, they chose to highlight three of
    those rights: Life, Liberty, and the pursuit of Happiness. When their
    dreams were realized and codified in the Constitution of the United
    States, it was no accident that the preamble stated that its purpose
    was to promote the ``general welfare'' of the People.

    This notion--that humanity is endowed with those unalienable rights--is
    not unique to our nation. Indeed, it is a human right recognized
    throughout the world. Article 3 of the Universal Declaration of Human
    Rights reads that ``everyone has the right to life, liberty, and
    security of person.'' Governments throughout the world recognize these
    rights as an essential element of a free and prosperous society. The
    world's great religions share many commonalities, but the one most
    fundamental to their shared morality is their emphasis on the sanctity
    of human life, and the responsibility of all people to preserve and
    protect that life by any means necessary.

    It is with that in mind that I write to you regarding the Graham-
    Cassidy-Heller-Johnson Proposal. While I recognize that this proposal
    seeks to repair a system that leaves too many of our fellow Americans
    without access to healthcare, I believe its implementation will be of
    disastrous consequence to millions of people in this country, and I
    hope you choose to reject it.

    At this point, I believe that many of you are familiar with the crisis
    in our healthcare system. Millions of people in this country lack
    access to affordable healthcare. Whether it is because of the rising
    costs of health insurance, the lack of coverage, limited provider
    options, or discriminatory insurance practices, too many people in this
    country are suffering.

    The Affordable Care Act (ACA), while incomplete in some respects and
    flawed in others, sought to offer a remedy for those in need. Through
    subsidies on the private insurance market, an increase in Medicaid
    coverage, protections for young adults and people with preexisting
    conditions, and requirements that health insurance policies cover
    essential health benefits, the ACA presented more options for consumers
    to find insurance that met their medical and financial needs.

    I benefited from the ACA. While serving as a full-time student at the
    University of Wisconsin Madison, I maintained a series of part-time
    jobs to help pay for my housing and other costs of attendance. None of
    these positions offered health insurance. Thankfully, because of the
    ACA, I was able to be covered by my mother's employer-sponsored health
    insurance policy until I turned 26. Thus, when I suffered a significant
    knee injury a few months before my graduation, I was able to receive
    treatment to repair the injury and receive physical therapy, enabling
    me to walk across the stage with my peers and receive my diploma.

    While I have a personal investment in the ACA, my primary reason for
    writing to you is to express the fear I have for the millions of people
    who will suffer if the Graham-Cassidy-Heller-Johnson proposal is signed
    into law. This bill eliminates subsidies that help our fellow citizens
    afford private health insurance policies. This bill will increase
    health insurance premiums for the elderly and people with disabilities.
    This bill will dramatically reduce the amount of money allocated for
    Medicaid in the short-term--by eliminating the Medicaid Expansion--and
    in the long-run--through a per capita cap--which will have a
    catastrophic impact on millions of people in poverty who are dependent
    on the program to keep them alive and healthy. This bill will also
    enable states to eliminate protections for people with pre-existing
    conditions and coverage for essential health benefits, which could
    raise costs for the people most in need of medical care.

    While there is a consensus from all Americans that the ACA could be
    more robust--that it does not do enough to ensure that all people have
    access to affordable and complete healthcare--this bill does nothing to
    move the ACA towards that goal. Rather, it unravels those aspects of
    the ACA that millions of Americans value and rely upon. It represents a
    failure of our government to use its immense resources to help the
    people it was created to serve. It represents the failure of our
    representatives to uphold those principles that were the foundation of
    this great nation. It represents a commitment not to the sanctity of
    life, but to the desire to score a political victory, no matter the
    costs to the people in need.

    Healthcare should not be treated like a luxury--something that can only
    be accessed by those blessed with wealth and financial stability.
    Rather, healthcare is an unalienable human right. Every person will
    require healthcare at one point or another in their lives. Our
    government should be motivated to ensure that no one will be denied
    that right because of their economic status. That should be the number
    one priority of any civilized society.

    By prioritizing access to affordable healthcare, you can demonstrate
    fidelity to that unassailable principle that all people have the right
    to life. That its sanctity is paramount. This bill stands in opposition
    to this principle, and for that reason, I hope you vote against it.

    Sincerely,
    Sarnir S. Jaber

                                     ______

                 The Jewish Federations of North America (JFNA)

                               1720 I Street, NW

                           Washington, DC 20006-3736

                               Phone 202-785-5900

                                Fax 202-785-4937

             https://jewishfederations.org/about-jfna/washington-dc

    Mr. Chairman, Ranking Member Wyden, and Members of the Committee, the
    Jewish Federations of North America (JFNA) continue to firmly oppose
    Senate efforts to cap Medicaid and end the state Medicaid expansion. We
    are greatly disappointed that the Graham-Cassidy amendment to H.R.
    1628, the most recent effort to repeal the Affordable Care Act,
    includes devastating cuts to Medicaid similar to those proposed in the
    Better Care Reconciliation Act (BCRA). These cuts are the result of the
    legislation's proposal to fundamentally restructure Medicaid's federal
    financing commitment and roll back coverage for millions of people
    covered by this vital social safety net program.

    Medicaid is a lifeline for more than 70 million people, including low
    income children, pregnant women, older adults, people with
    disabilities, and those receiving treatment for opioid addiction
    nationwide. Converting Medicaid to per capita caps ends the federal
    government's long-standing commitment since Medicaid's inception to
    match states' Medicaid costs. Taking this step reneges on the federal
    government's promise to states and to beneficiaries that the program
    will remain sufficiently flexible to adjust for economic downturns,
    unexpected health care cost increases, and emergencies. We urge the
    Senate not to send this legislation to the floor without first
    considering it--or similar proposals in the future--through regular
    order in a bipartisan process, and without thorough non-partisan
    analysis of the short and long-term consequences for the nation as a
    whole and for every state.

    JFNA represents 148 Jewish federations and 300 network communities that
    together support 15 leading academic medical centers/health systems,
    100 Jewish nursing homes, 125 Jewish family and children's agencies,
    and 14 group homes, providing health care for more than 1 million
    Jewish and non-Jewish clients. Medicaid is a critical program for
    Jewish federations throughout the country and particularly for our
    communal health and long-term care partners that care for the most
    vulnerable in our communities.

    Restructuring and Cutting Medicaid Would Have Severe Consequences for
    Vulnerable Populations and Our Network of Providers Who Care for Them

    JFNA is deeply troubled by the Congressional Budget Office's (CBO)
    recently announced preliminary findings that, as with BCRA, the federal
    share of Medicaid would not keep pace with the real cost of health care
    under the Graham-Cassidy approach.\1\ Specifically, CBO found that
    federal Medicaid spending would be cut by about $1 trillion by 2026,
    relative to current law, and as a result, Medicaid ``would cover
    millions fewer enrollees.'' CBO attributed these spending and
    enrollment cuts to the legislation's elimination of the Medicaid
    expansion, its adoption of Medicaid per capita caps, and its option for
    states to impose work requirements on eligible individuals.
    ---------------------------------------------------------------------------
        \1\ Congressional Budget Office, ``Preliminary Analysis of
    Legislation That Would Replace Subsidies for Health Care with Block
    Grants,'' September 25, 2017, https://www.cbo.gov/system/files/ll5th-
    congress-2017-2018/costestimate/53126-health.pdf.

    Mirroring CBO's findings about BCRA's consequences, CBO concluded that
    the cuts resulting from the Graham-Cassidy per capita cap would require
    states to either increase their own spending or cut their Medicaid
    programs ``by cutting payments to health care providers and health
    plans, eliminating optional services, restricting eligibility for
    enrollment through work requirements and other changes, or (to the
    extent feasible) finding more efficient methods for delivering
    services.'' CBO determined that some Medicaid beneficiaries could see
    ---------------------------------------------------------------------------
    reduced access to care or lose their Medicaid coverage entirely.

    Restructuring and Cutting Medicaid Would Have Even More Serious Effects
    in the Long Term

    JFNA also remains gravely concerned that the Graham-Cassidy legislation
    would result in even deeper cuts to Medicaid over the long term.
    Particularly disturbing is the bill's provision to reduce the Medicaid
    per capita cap growth rate even further in 2025, just as the baby
    boomers begin to turn 80 years old--an age when they are far more
    likely to need expensive and long-term care. JFNA believes that taking
    this step will lead to even more significant cuts to Medicaid in 2025
    and beyond, and will greatly impair Medicaid's ability to adjust for
    this impending major demographic change. JFNA's concern about the
    legislation's long-term effects is supported by CBO's conclusion that
    BCRA, which would have reduced federal Medicaid spending through 2026
    by approximately 26%, actually would have resulted in cuts of as much
    as 35% in the years after 2026.

    Capping Medicaid Will Not Improve Care and Will Roll Back Years of
    Progress

    Notably, the Graham-Cassidy legislation's effort to limit federal
    spending on Medicaid by imposing per capita caps does nothing to lower
    the cost of caring for Medicaid beneficiaries. Nor does it improve the
    care being provided. It simply passes costs and fiscal risks to states.
    The end result will be millions more without health insurance, fewer
    benefits and services, and lower provider payments. These cuts will
    hurt low income and vulnerable children, older adults, and people with
    disabilities who have nowhere else to turn when health care providers--
    such as Jewish hospitals, nursing homes, group homes, and family and
    children's agencies--cannot maintain the necessary level of staffing to
    provide quality care, or are forced to turn Medicaid recipients away or
    even to close their doors. We believe that converting Medicaid to the
    proposed per capita cap will cause irreparable harm not only to the
    millions who depend on the program, but also to our large network of
    providers who care for them.

    JFNA believes that this legislation would roll back years of progress
    in caring for vulnerable populations and promote perverse consequences,
    such as:

          People who desperately need Medicaid and who are currently
    eligible will become uninsured and will turn increasingly to more
    expensive emergency rooms for care;
          States will be forced to cut back on crucial Medicaid services,
    such as home and community-based services, effectively forcing people
    with disabilities and older adults who are capable of living in the
    community with proper home and
    community-based services into nursing homes;
          States will be forced to curtail their mental health and
    substance use treatment services, which we know from the raging opioid
    crisis are needed now more than ever;
          States will be forced to reduce already low provider payment
    rates, thus further decreasing the pool of providers serving Medicaid
    beneficiaries and increasing waiting times for critical services; and
          Health care providers and entities that care for vulnerable
    populations will suffer significant financial losses. As a result,
    these agencies will be forced to lay off staff or close their doors
    altogether, resulting in significant job losses and further straining
    state economies.

    JFNA Recommends the Following Measures to Improve Care and Realize Cost
    Savings in Medicaid

    Although the Jewish Federations of North America must oppose the
    Graham-
    Cassidy amendment, we continue to stand ready to work with you, in
    tandem with our Jewish communal health and long-term care providers, to
    develop a new framework of policies to improve Medicaid quality,
    efficiency, and sustainability. To this end, we offer the following
    recommendations:

          Rebalancing: The concept of rebalancing refers to shifting
    Medicaid spending and resources from primarily financing long-term
    services and supports in institutional settings to community-based
    environments. Although skilled nursing facilities will remain vital
    providers, rebalancing Medicaid reimbursement for community-based long-
    term services and supports is both cost-effective and enhances quality
    of life for many Medicaid enrollees. The Balancing Incentive Program
    and the Money Follows the Person program are both designed to help
    states shift Medicaid spending on long-term services and supports from
    institutional settings to the community. Through these programs, states
    have successfully expanded these services and transferred individuals
    from institutional settings to their communities. Expanding rebalancing
    within the Medicaid program so that Medicaid funding can be made
    available for community-based long-term services and supports without a
    waiver is both cost-effective and assures enhanced quality of life.

          Promoting Telemedicine: Although expanding the use of
    telemedicine and health information technology through long-term care
    and behavioral health delivery systems will require an initial
    investment in technology, it offers the promise of greater efficiency,
    better and coordinated care, and significant cost savings.

          Improving the Coordination between Medicare and Medicaid:
    Medicaid and Medicare together provide health coverage for
    approximately 10 million low-income seniors and people with
    disabilities who are dually eligible for both programs. However,
    Medicaid and Medicare generally operate as separate programs.
    Beneficiaries have to navigate multiple sets of requirements, benefits,
    and plans. Different coverage and payment policies can create
    incentives to shift costs back and forth between the states and the
    federal government, leading to underutilization of services in some
    cases and overutilization in others. This lack of coordination between
    the programs may also result in fragmented care, which can lead to high
    costs and poor outcomes. The Dual-Eligible Special Needs Plans and the
    Financial Alignment Demonstration Imitative are two programs working to
    coordinate the financing structures and rationalize the administration
    between the two programs to improve care and reduce costs. These two
    programs should be explored further for their ability to improve care
    while also reducing costs.

          Increasing Value-Based Purchasing Initiatives: Value-based
    purchasing models, such as Accountable Care Organizations increasingly
    are being adopted in both Medicare and Medicaid. These models move away
    from the traditional fee-for-service system and towards payment based
    on quality and cost savings. Implementing these models more widely for
    high-cost, high-need populations in need of long-term services and
    supports could be a method to reduce costs while improving care for
    beneficiaries and should be analyzed further.

          Reducing Hospitalizations for Nursing Facility Residents: In
    2011, the CMS Medicare-Medicaid Coordination Office implemented an
    initiative to reduce avoidable hospitalizations of dually eligible
    beneficiaries living in nursing facilities. Long-term care facilities
    participating in the initiative have reported declines in all-cause
    hospitalizations and potentially avoidable hospitalizations, as well as
    reductions in Medicare expenditures. The second phase of this
    initiative is underway and will test whether a new payment model for
    long-term care facilities can improve quality of care by reducing
    avoidable hospitalizations lower combined Medicare and Medicaid
    spending. As the new results become available, if successful, this new
    payment model could be expanded.

          Promoting Prevention: Implementing preventive measures, such as
    chronic disease management, health education, and other services
    targeting high-risk groups, also may be able to lower Medicaid costs in
    the long term. Wellness programs, such as diabetic education, prenatal
    care, depression screening, and nutritional counseling, will improve
    the health of patients and save scarce funds.

          Expanding the Hospice Benefit: Expanding hospice education and
    care in Medicaid, a strategy which has already realized cost savings in
    Medicare, can reduce unnecessary treatment costs while enhancing the
    quality of life for patients and their families.

    In conclusion, JFNA opposes the Graham-Cassidy proposal because we
    believe that it will have devastating consequences for vulnerable
    populations and the providers who care for them. However, we stand
    ready to work with you, in tandem with our Jewish communal health and
    long-term care providers, to develop a new framework of policies to
    improve Medicaid quality, efficiency, and sustainability.

    Sincerely,

    William C. Daroff,
    Senior Vice President for Public Policy and Director of the Washington
    Office

                                     ______

                                   LeadingAge

                          2519 Connecticut Avenue, NW

                           Washington, DC 20008-1520

                                 P 202-783-2242

                                 F 202-783-2255

                             http://leadingage.org/

    LeadingAge appreciates this opportunity to comment on the impact of the
    Graham-Cassidy-Heller-Johnson Proposal on older Americans and the
    nonprofit organizations that provide essential long-term services and
    supports to them. We appreciate the Committee's efforts to ensure that
    all Americans have access to quality, affordable health care.

    The mission of LeadingAge is to be the trusted voice of aging. Our
    6,000+ members and partners include nonprofit organizations
    representing the entire field of aging services, 38 state associations,
    hundreds of businesses, consumer groups, foundations and research
    centers. LeadingAge is also a part of the Global Ageing Network, whose
    membership spans 30 countries. LeadingAge is a tax-exempt charitable
    organization focused on education, advocacy and applied research.

    Our comments focus on the devastating impact that eliminating the
    federal commitment to Medicaid will have on older persons and on
    persons with disabilities.

              CHANGING THE FINANCING STRUCTURE TO PER CAPITA CAPS
                          WOULD DEVASTATE THE PROGRAM

    We oppose efforts to convert Medicaid to a per capita or block grant
    allocation to the states because this would threaten the security of
    millions of people who count on the program in their later years. They
    would no longer have the certainty that the long-term services and
    supports they need would be covered because Medicaid funding would no
    longer be assured.

    Medicaid has become the default payer for long-term services and
    supports because there are no significant alternative sources of
    payment other than out-of-pocket. As of 2013, over one-third of all
    Medicaid expenditures went towards paying for long-term services and
    supports. People in need of long-term care are often the oldest and
    frailest Americans, many with complex health conditions. They have few
    options and very few can pay for these services on their own. Medicaid
    is essential to enabling them to live out their later years with
    dignity and support.

    Per capita caps and block grants would radically restructure Medicaid's
    financing so much that the program would be simply unrecognizable from
    its current form. When the specified federal match is no longer
    guaranteed, the per capita caps could be subject to change during every
    budget crisis or need for a pay-for. Funding could be reduced, the
    inflationary adjustor decreased, and so forth.

    Per capita caps and block grants would also cut Medicaid deepest
    precisely when the need is greatest because funding would no longer
    increase automatically during public health emergencies or in response
    to the emergence of new treatments. The aging of the baby boomers would
    make the federal Medicaid cuts worse over the long run because per
    capita caps would make no distinction between the ``young-old,'' and
    the ``old-old'' (85 and older). This is in stark contrast to the
    federal/state partnership that exists today.

    States already have substantial flexibility and can request waivers to
    make Medicaid meet their unique needs. The Administration has already
    committed to making state flexibility in Medicaid a cornerstone of its
    plans. There is no need to cap the federal contribution to the program
    to do this.

    To compensate for substantial cuts to Medicaid, states would have to
    raise taxes, make drastic cuts in other budget areas, restrict
    eligibility, or otherwise cut Medicaid spending--seriously harming
    beneficiaries. The draconian cuts under per capita caps or block grants
    would shift more costs to states, causing millions to be uninsured or
    reducing access to care.

    In June of this year, LeadingAge and the Center for Consumer Engagement
    in Health Innovation published the report ``Capping Medicaid: How Per
    Capita Caps Would Affect Long-Term Services and Supports and Home Care
    Jobs'' which analyzed the impact of per capita caps (PCC) on states'
    ability to fund Medicaid long-term services and supports (LTSS). In
    summary, we found five significant challenges that states would
    confront, all of which are likely to influence the ability of each
    state to adapt to payment by per capita cap (Table 1, p. 4):

        1.  The rate of growth of the over 85 population between 2015 and
    2025 is not addressed by an inflation rate that is based on population
    growth. A rapidly growing ``older'' old population has significantly
    greater needs and will require more LTSS resources than the PCC rate
    will finance. The gap between cap and costs of addressing growing need
    will fall to the state.

        2.  The cap does not account for the increase in the expected
    growth of the population over 65 with four or more chronic conditions;
    again the states will be left to figure out how to pay for LTSS for
    this population.

        3.  States that currently rely on above-average federal Medicaid
    support will be hardest hit and least able to make up the difference,
    thus forcing cuts in services or increases in state spending.

        4.  The increase in an old-old population with significant chronic
    conditions that cannot be cared for at home will put significant
    pressure on states that have expanded their home and community based
    services to re-allocate funds to nursing homes. This will have a
    negative impact both on the individuals who deserve to be served at
    home, and the paid home-based workforce.

        5.  States with higher spending will be forced to cut back, thus
    impacting the level of services available and placing greater stress on
    families that already contribute significant support to their loved
    ones.

    Imposing per capita caps on Medicaid will not make the system more
    rational or more effective, and we urge the Committee to oppose
    shifting the Medicaid program to a per capita cap financing system.

                THE NEED FOR AN EFFECTIVE SYSTEM FOR PAYING FOR
                        LONG-TERM SERVICES AND SUPPORTS

    In 2015, over 6 million people had a serious condition that caused them
    to need help with their health and personal care; the Department of
    Health and Human Services estimates that that number will grow over the
    next 50 years to 16 million. Medicare does not cover LTSS, yet about
    70% of people over age 65 will require some type of LTSS at some point
    during their lifetime. As our population ages, the need for these
    services will only grow. In addition, about 40% of the individuals who
    need LTSS are under age 65, and obtaining assistance with services in
    their home can enable these individuals to work and be productive
    citizens.

    Regardless of when individuals need these services, there is a lack of
    financing options to help them plan and pay for the services they need
    to help them live independently in their homes and communities where
    they want to be. Family caregivers are on the frontlines. They provided
    care valued at $470 billion in 2013--more than the total spending on
    Medicaid that year.

    Only 11% of older adults had private long-term care insurance in 2014.
    While private insurance can help people pay for the cost of services,
    it is not affordable for most, and many people do not qualify for it.
    Too often, the cost of services wipes out personal and retirement
    savings and assets that are often already insufficient. As a result,
    formerly middle class individuals are forced to rely on Medicaid to pay
    for the costs of LTSS. There are few options for individuals to help
    them pay for the services they need that could help them delay or
    prevent their need to rely on Medicaid, the largest payer of LTSS.

    For close to 30 years policy makers, advocates and consumers have
    struggled to identify the most effective ways to finance long-term
    services and supports. LeadingAge strongly believes that a coherent
    financing mechanism for LTSS is essential to protecting families from
    economic peril and providing adequate funding for the LTSS system to
    support high-quality, community-based services that promote dignity and
    independence, as we noted in our 2017 report, ``A New Vision for Long-
    Term Services and Supports.'' We believe that we need to be having this
    debate--how to pay for LTSS--not how to cut the Medicaid program.

    In addition, the role of affordable housing in improving health care
    and reducing costs cannot be discounted. The evidence is undeniable
    that housing plus services models lead to smarter spending, increased
    access to care, and better outcomes. Our members are at the forefront
    of providing housing with coordinated services and can attest to the
    enormous value that this combination provides to low income seniors and
    people with disabilities.

                                   CONCLUSION

    LeadingAge urges the Committee to reject the Graham-Cassidy-Heller-
    Johnson proposal. We urge Congress to begin a serious conversation
    between lawmakers, consumers, and providers on LTSS.

    Medicaid continues to be the fundamental source of payment for LTSS,
    just as Medicare is the fundamental source of payment for post-acute
    care services. Protecting the Medicaid program from the devastating
    impact of reduced funding and elimination of the federal commitment by
    imposing a per capita cap financing structure is critical to the
    foundation for a more effective system.

    We are more than willing to work with the Committee and Congress to
    address these critical, challenging needs.

                                     ______

                                Little Lobbyists

                                 P.O. Box 2052

                            Silver Spring, MD 20915

                        https://www.littlelobbyists.com/

    September 25, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Building
    Washington, DC 20510-6200

    RE: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal

    Chairman Hatch, Ranking Member Wyden, and Members of the Senate Finance
    Committee:

    We are Little Lobbyists, an organization comprised of families from
    different states and from across the political spectrum, with one thing
    in common: we have children with complex medical needs who require
    significant medical care. Our mission is to advocate on behalf of the
    hundreds of thousands of such children across the country, the most
    vulnerable among us, to ensure that their stories are heard as part of
    the ongoing health care debate and that their access to quality,
    affordable health care is protected.

    We visited each of your offices over the summer--some multiple times--
    and hand-delivered stories of medically complex children living in your
    state. We did this to make sure that their voices were heard; to give
    you an appreciation for the issues these children and their families
    face and an understanding of how crucial certain protections under
    current law are to their livelihoods. Our hope was that you would think
    of these children when considering new legislation, and make efforts to
    protect their access to the quality, affordable health care they need
    to survive.

    We write now to speak out emphatically against the latest proposed
    legislation, the Graham Cassidy-Cassidy-Heller-Johnson bill (Graham-
    Cassidy), which in its hasty construction will jeopardize the health
    and future of medically complex children in this country and rob their
    families of the measure of security they have under current law. Our
    children require far better--both in policy and procedure--than this
    bill shows them.

    There is no debate that our nation's health care system can, and must,
    be improved. There is also no debate that taking funding and legal
    protections away from medically complex children does not improve our
    health care system. Unfortunately, that is what this bill does. The
    Graham-Cassidy bill undermines three protections in current law that
    are vital to the health and well-being of medically complex children
    and their families.

    1. Significantly decreased Medicaid funding

    Even for families, with medically complex children, fortunate enough to
    have good, private health insurance, this insurance frequently does not
    cover home/community-based care (such as private duty nursing) and
    therapeutic care that many medically complex children require. Medicaid
    often fills this gap, and allows these children the ability to live at
    home, attend school, and get the care they need to achieve their
    potential and live as independently as possible.

    Graham-Cassidy's radical upheaval of Medicaid will cut hundreds of
    billions of dollars nationally from the program relative to current
    law, with no guarantee that the funds must be spent on the same
    populations. Under such dramatic funding reductions, it is virtually
    impossible that the Medicaid services our children depend on will not
    be negatively affected.

    At even greater risk, and of utmost importance to our families, are
    optional Medicaid programs like the Katie Beckett Medicaid waiver
    program created by Ronald Reagan. This program allows families that
    normally would not qualify for Medicaid to do so on account of the
    significant medical care expenses their children incur. This allows
    these families to care for their children in the home/community
    setting, rather than forcing them into institutions. The funding
    reductions in Graham-
    Cassidy will force states to prioritize mandatory programs, placing
    optional Medicaid programs such as Katie Beckett waivers first in line
    on the chopping block. In short, under Graham-Cassidy, the vital safety
    net that Medicaid provides many of our families will be pulled away,
    leaving us to worry constantly whether it will be there when we need
    it.

    2. Elimination of the Affordable Care Act's prohibition on annual/
    lifetime limits

    Many of our children accumulated millions of dollars in medical bills
    before they took their first breath outside of a hospital. Thankfully,
    under the Affordable Care Act (ACA). Insurance companies are prohibited
    from taking insurance coverage away from our kids if their care reaches
    a certain dollar amount. The emotional stress that comes with having a
    sick child in a hospital for weeks, months, or years is beyond
    description. Imagine adding to that the stress of constantly worrying
    whether it will be the next procedure, the next surgery, the next
    medication, that will take away your child's health insurance forever,
    and the guilt associated with rationing medical care for your child to
    avoid that possibility.

    Graham-Cassidy will make this a reality. Parents of medically complex
    children will no longer have the security in knowing, for certain, that
    their insurance company will not impose a cap on their child's health
    care. Graham-Cassidy would allow states the ability to waive ACA
    protections, including the ban on lifetime/annual caps on care. Whether
    or not the state ever does so, it will always be an ever-present source
    of anxiety for families with children who are medically complex. If
    this protection were eliminated, which many states stand ready to do,
    the financial impact on these families and the health impact on their
    children will be devastating.

    3. Elimination of the ACA's prohibition on pre-existing condition
    discrimination

    Medically complex children, by definition, have multiple pre-existing
    conditions, often since birth. Under the ACA, our families have
    certainty that our children will not face unaffordable increased
    premiums, or be unable to find health insurance altogether, because of
    conditions they have, through no fault of their own. We are able to
    focus on getting the right care for our children, not constantly
    engaging in a war with insurers over how much they will penalize us for
    our children's conditions.

    As with the issue of lifetime limits, Graham-Cassidy takes away from
    our families a bright-line protection we desperately rely on, and
    replaces it with a provision allowing states to waive it. We are given
    vague assurances that our children will be protected and that our
    insurance will continue to be ``affordable''--language in the bill
    that, without definition, is meaningless and subject to any
    interpretation. Indeed, the virtually unanimous opinion among non-
    partisan health policy organizations is that the bill can, and will, be
    used by numerous states to dramatically roll back the pre-existing
    condition protections under current law. It is an unimaginable and
    unacceptable risk to our families.

    We hear Republicans in Washington tell us that Graham-Cassidy will give
    consumers more ``flexibility'' and ``choice.'' How is that remotely
    true, or helpful, for our families and our children? This bill would
    fundamentally disrupt the protections our families depend on. The
    ``flexibility'' the bill offers comes at the cost of our security. And
    the only ``choice'' it would likely provide us is an unthinkable one:
    incur debt far beyond our means, or forego medical care that will keep
    our children alive and able to achieve their potential.

    As we said at the outset, we recognize that our nation's health care
    laws can, and must, be fixed. But it is unjust, immoral, and contrary
    to any meaning of ``pro-life'' to pass a law that will make it harder
    for medically complex children to access the care they need, merely to
    score a political victory within an arbitrary, self-imposed deadline.
    Our children have done nothing wrong. They do not lack personal
    responsibility; in fact, they show more strength, courage, and
    resiliency in a single hospital visit than many people do in their
    entire lives. They are just kids who, through no fault of their own,
    need a little help.

    You can help them now. Stand with our children. Hear their stories.
    Ensure their access to health care is not diminished. We urge you to
    turn away from this hastily considered and damaging bill, return to
    regular order with committees and multiple hearings, and do the
    difficult but necessary work of finding bipartisan solutions that will
    improve health care access and affordability for Americans.

    Sincerely, The Little Lobbyists

    Co-Founders: Elena Hung, Silver Spring, MD (mother of Xiomara, age 3)

                 Michelle Morrison, Laurel, MD (mother of Timmy, age 6)

    Steering Committee: Austin Carrigg, Tucson, AZ (mother of Melanie, age
    5), Anna Kruk Corbin, Hanover, PA (mother of Jackson, age 12, and
    Henry, age 9), Laura Hatcher, Towson, MD (mother of Simon, age 11), and
    Benjamin Zeitler, Hyattsville, MD (father of Pierce, age 3)

    Co-signed by the following families of medically complex children across
                                  the country:

    Michael Corbin,          Joe and Takako Newman,   Tyler and Maggie
     Hanover, PA (father of   Campbell, CA (parents    Wells, Ringgold, GA
     Jackson, age 12, and     of Natalie, age 4)       (parents of Rowan,
     Henry, age 9)                                     age 14 months)
    Brian Hatcher, Towson    Kristin and Nick         Jennifer Harris,
     MD (father of Simon,     Chaset, San Francisco,   Lawrenceville, GA
     age 11)                  CA (parents of Megan,    (parent of Hannah,
                              age 2)                   age 10)
    Sanghee and Eric Lynn,   Elizabeth and Eric       Tera Fulmer. Augusta,
     Washington, DC           Katsuleres, Vallejo,     GA (parent of Eva,
     (parents of Teddy, age   CA (parents of Joseph,   age 2)
     6)                       age 2)
    Mark Morrison, Laurel,   Sarah Victoria Jaque-    Ann and Mike Weaver,
     MD (dad of Timmy, 6)     Kamp, Ph.D., Gregory     Naperville, IL
                              Kamp, Santa Clarita,     (parents of Tim, age
                              CA (parents of           23)
                              Cameron, age 18)
    Caroline Brouwer,        Justin and Jenny         Mary Cotton,
     Rockville MD (mother     McLelland, Clovis, CA    Coulterville, IL
     of Elliott, age 1)       (parents of James, age   (parent of Wyatt, age
                              6)                       5)
    Erin Mosley, Silver      Merce Wynne, Valencia,   Zachary Bartelt and
     Spring, MD (parent of    CA (parent of Wolfie,    Charlotte Bolthouse
     Addison, age 6)          age 5)                   Bartelt, Rockford, IL
                                                       (parents of
                                                       Angelique, age 4)
    Jill Messier, Highland,  Angela Howard,           Marissa Arevalo,
     MD (parent of            Centennial, CO (mother   Peoria, IL (parent of
     Christopher, age 22)     of Laura, 3)             Rocio age 5)
    Samantha McGovern,       Amanda Scott and Akeem   Stephanie Wyatt,
     Springfield VA (parent   Green, Lakewood, CO      Danville, IL (mother
     of Josephine age 1)      (parents of Dakarai,     of Christopher, age
                              age 3)                   13)
    Todd and Angie Voyles,   Lorena and Michael       Julie Corbier de Lara,
     Haymarket, VA (parents   DeCarlo, Fairfield CT    Evanston IL (mother
     of Annalyse, age 5)      (parents of Lucas, age   of Michael age 13)
                              1)
    Rebecca Wood,            Michelle and Oliver      Leona Blitzsten,
     Charlottesville, VA      Marti, New Canaan, CT    Chicago, IL
     (parent of Charlie,      (parents to twins Max    (grandparent of
     age 4)                   and Nick, age 8)         Michael)
    Kim Crawley, Ashburn,    Veronica Hernandez,      Barry Blitzsten,
     VA (mom of Isaac age     Cheshire, CT (mother     Chicago IL (uncle of
     8)                       of Arianna, age 3)       Michael)
    Jamie Foster, Pleasant   Tracy Tardiff, New       Margaret Storey and
     Plains, AK (parent of    Hartford, CT (parent     Jonathan Heller,
     Rowan, age 8 months)     of Sophia, age 9)        Evanston, IL (parents
                                                       of Josie, age 14)
    Heather Swanson,         Michelle and Oliver      Susan Agrawal,
     Anchorage, AK (parent    Marti, New Canaan, CT    Chicago, IL (parent
     of Connor, age 11)       (parents to twins Max    of Karuna, 2003-2014)
                              and Nick, age 8)
    Michelle Gray, Madison,  Charlie and Kristen      Guiller Bosqued and
     AL (parent of Emmet,     Patterson,               Shea Ako, Chicago, IL
     age 3)                   Tallahassee, FL          (parents of
                              (parents of Hadley,      Alejandro, age 6)
                              age 5)
    Nancy Smith, Hoover, AL  Carolyn Murray,          Jeff and Pamela
     (parent of Ivan, age     Jacksonville, FL         Marshall, Peoria, IL
     7)                       (mother of Daniel, age   (parents of Ethan,
                              18)                      age 7)
    Susan Colburn.           Todd and Cindy Vickers,  Jody Prunty, Wheaton,
     Montgomery, AL           Warner Robins, GA        IL (mother of Sophie,
                              (parents of Philip and   age 23)
                              Emily, twins age 3)
    Charlotte Hurley,        Janna Blum, Ph.D. and    Nicole and Robert
     Phoenix, AZ (parent of   Richard Blum, Ph.D.,     Boudreau, Aurora, IL
     Matthew, age 2)          Atlanta, GA (parents     (parents of Ella, age
                              of Abigail and Elijah,   2)
                              twins age 3)
    Jennifer Foster-         Abby Brogan, Wayland,    Nicole Gerndt,
     Degillo, Chandler, AZ    MA, (mother of Ellie,    Brookfield, IL
     (mother to Evander,      age 11)                  (mother of Finley,
     age 6)                                            age 7)
    Marsheila Rockwell,      Gretchen Kirby,          Kellie and Derek
     Gilbert, AZ (parent of   Amesbury, MA (mom to     Colby, IL (parents of
     Max, age 8)              Adrien and Tavish, age   Chase, age 1.5)
                              11, and Keva, age 10)
    Gabriela and Eugene      Gwendolyn Harter and     Eric and Natalie Hart,
     Mafi, Los Alamitos, CA   Adam Hall, Ashton, MD    Burlington, NC
     (parents of Gabriel      (parents of Jackson,     (parents of Collier,
     Mafi, 22 months)         age 12)                  age 3)
    Jamie Austin, St.        Kathleen and Roger       Dania Ermentrout and
     Charles, IL (parent of   Dartez, Baltimore, MD    Daniel Smith,
     Kiara, age 4)            (parents of Roman, age   Greensboro, NC
                              12)                      (parents of Moira,
                                                       age 5)
    Roberta Holzmueller,     Amy Copeland, Bethesda,  Samantha Stallings, NC
     Evanston, IL (parent     MD (parent of David,     (parent of Johnathan)
     to Aaron, age 17)        age 4)
    Francois Corbier de      Marie and David          Kate Eardly,
     Lara, Evanston, IL       Anderson, Baltimore,     Charlotte, NC (parent
     (father of Michael)      MD (parents of Ramona,   of Sloane, age 3)
                              age 5 months)
    John Hart, Cedar Lake,   Katie Angerer,           Justin and Jamie
     IN (father of Harley,    Reisterstown, MD         Burton, Staley, NC
     15 months)               (parent of Lucy, age     (parents of Eli, age
                              4)                       8)
    Dr. Jason and Heather    Kristin and Michael      Mitzi Cartrette,
     Tanner, Fort Wayne, IN   Stelmaszek, Novi, MI     Pfafftown, NC
     (parent of Colton, age   (parents of Emmaline,    (guardian of Ashton,
     4)                       age 7)                   age 11)
    Alicia Halbert,          Penny Millirans, Battle  Crystal Bryant,
     Indianapolis, IN         Creek, MI (parent of     Lexington, NC (parent
     (mother of Rory, 12)     Joseph, age 9)           of Caitlin, age 2)
    Ashley and Adam Hill,    Mary Ann and Dennis      Natalie Weaver,
     Fort Wayne, IN           Fithian, Dexter, MI      Cornelius, NC (parent
     (parents of August,      (parents of Faith, age   of Sophia age 8)
     age 4 months)            11)
    Becky Hufty,             Tricia Mihalic,          Jeff and Jill Bass,
     McCordsville, IN         Traverse City, MI        Rocky Mount, NC
     (parent of Jack, age     (parent of Nick, age     (parents of Carli,
     10)                      17)                      age 11)
    Emily Altemus,           Bill and Elaine Nell,    Stuart and Rebecca
     Valparaiso, IN (mother   Clemmons, NC (parents    Galbreath, Charlotte,
     of Sebastian, age 5)     of Lydia and Carol       NC (parents of Jake,
                              Nell, twins age 5)       age 3)
    Jane and Fred Fergus,    Sarah Potter,            Toby Lunstad, Mandan,
     Lawrence, KS (parents    Pfafftown, NC (parent    ND (parent of
     of Franklin, age 8)      of Matt, age 30)         Addilynn, age 2)
    Angeliina and Jonathan   Cassandra Littlefield,   Philip and Alison
     Lawson, Shawnee, KS      Durham, NC (parent of    Chandra, NJ (parents
     (parents to David, age   Clark, age 3, and        of Ethan, age 3)
     7)                       Joshua, age 7)
    Theresa Lemire,          Tamarin and Jonathan     Hilary and Jeremy
     Shawnee, KS (mother of   Zoppa, Mooresville, NC   Biehl, Santa Fe, NM
     Melissa, age 24)         (parents of Gabriella,   (parents of Aidan,
                              age 7)                   age 3)
    Carol Smith,             Stacy Staggs,            Sandra Stein, New
     Williamsburg, KY         Charlotte, NC (mother    York, NY (mother of
     (parent of Gunner, age   of Emma and Sara,        Ravi, age 8)
     3)                       twins age 4)
    Mike and Crystal         Bethany and Jared        Josh Fyman, West
     Simpson, Bell Count,     Reeves, Garner, NC       Hempstead, NY
     KY (parents of Gunnar,   (parents of Naomi, age   (parents of Penny,
     age 22 months)           18 months)               age 6)
    Kelly and Emily          Marybeth Weber,          Susan Demrick
     Greenwell, Union, KY     Slippery Rock, PA        Koprucki,
     (parents of Quinn, age   (mother of Janessa,      Williamsville, NY
     3)                       age 7)
    Kodi Wilson, Baton       Jennifer Rath, Mars, PA  Dianna and Chris Ryan,
     Rouge, LA (parents of    (parent of Austin, age   Pleasantville, NY
     Braden, age 11)          11)                      (parents of Emma, age
                                                       4)
    Ashley Myers, Metairie,  Nicole White, Cranston,  Michele Juda, Ballston
     LA (mom of Fiona, age    RI (mother of Kyrie,     Spa, NY (parent of
     8)                       age 5)                   Devon, age 16)
    Christine Heath,         Trina Morgan,            Debbie Buxton, New
     Monson, MA (mother of    Greenville, SC (parent   York, NY (parent of
     Joshua, age 16)          of Marge, age 16)        Joey, age 15)
    Caitlin Crugnale,        Lisa Annette Stanley,    Lisa Lucas,
     Holbrook, MA (parent     Houston, TX              Georgetown, TX
     of Benjamin, age 5       (grandmother of          (parent of Hannah who
     months)                  Solomon, age 2)          now resides in
                                                       Heaven, but I stand
                                                       with these families
                                                       with medically
                                                       fragile children)
    Cindy Hammerquist,       Brenda Martinez, San     Julie Melton,
     Huntington, NY (mother   Antonio, TX (parent of   Levelland, TX (parent
     of Thomas, 10)           Miranda, age 10)         of Michael, age 4)
    Craig and Julie Yoder,   Hannah and Manish        Nicole Ritchey,
     Sugarcreek, OH           Mehta, Flower Mound,     Oakhurst, TX (parent
     (parents of Isabella,    TX (parent of Aiden,     of Kyler, age 22
     age 8)                   age 10)                  months)
    Heather Denchik, R.N.,   Josh Hebert and Kyla     Ryan and Elizabeth
     and Andrew Denchik,      McKay, Pasadena, TX      Baker, Katy, TX
     MBA, Centerville, OH     (parents of Katie, age   (parents of Grayson,
     (parents of Reid, age    12)                      age 7)
     4)
    Nicole Stargel,          Gillian Quinn, Houston,  Jennifer and Matt
     Kettering, OH (mother    TX (parent of Raphael,   Jennings, Grand
     of McCarthy, age 17)     age 1)                   Prairie, TX (parents
                                                       of Mya, age 5)
    Carol Combs, Hamilton,   Jill and Jason           Korrie Everett,
     OH (mother to Grayson,   Bradshaw, Austin, TX     McKinney, TX (parent
     age 9)                   (parents of Elise, age   of Henry, age 14, and
                              4)                       Robin and Abigail,
                                                       age 17)
    Elizabeth Diamond,       Nathan and Dominique     Cynthia Ann Lopez, San
     Danville, OH (mother     Holzman, Cypress, TX     Antonio, TX (parent
     of Deacon, age 10)       (parents of Aiden, age   of Victor Angel
                              9)                       Ballez, III, age 12)
    April Apsey, Fremont,    Amber and Ronald Marin,  Sharon Elizabeth
     OH (parent of Alec,      Houston, TX (parent of   Robinson, Katy, TX
     age 8)                   Jessica, age 4)          (grandmother of
                                                       Grayson, age 7)
    Stephanie Ziemann,       Nishanth Menon and       Marcelo and Jennifer
     Toledo, OH (parent of    Khairunnisa Hassanali,   Garcia, El Paso, TX
     Ada-Lily, age 7)         Plano, TX (parents of    (parents of Sadie,
                              Alisha, age 3)           age 5)
    Brian and Amy Vavra,     Russell and Rebecca      Mary Ocampo, Flower
     Lakewood, OH (parents    Germany, Kerrville, TX   Mound, TX (parent of
     of Evelyn, age 2)        (grandparent and         Angelica Ocampo, age
                              guardian of Aubrey,      15 months)
                              age 5)
    Dr. Amy Rule,            Carol and Bill Daley,    Karen Merritt Kline,
     Cincinnati, OH           Arlington, TX (parents   Houston, TX
     (pediatrician and        of Will Daley, age 13)   (grandmother of
     parent of Oliver, age                             Grayson, age 7)
     1)
    Jade and Jarod Day,      Vicki Gilani, Houston,   Maud Marin, Houston,
     Muskogee, OK (parents    TX (speech therapist     TX (mother of Lucas,
     of Gavin, age 9)         for children 0-18)       age 4)
    Sierra Martin, Perry,    Caroline Cheevers,       Melissa Marrero, El
     OK (parent of Weston     Houston, TX (mother of   Paso, TX (parent of
     Ferrell, 6)              Tyler, age 9, Justin,    Jaxon, age 4)
                              age 7, Hailey, age 7,
                              and baby girl, age 3)
    Autumn and Hayden Ryan,  Shelia and Bill Heard,   Jacqueline Gonzalez,
     Tulsa, OK (parents of    Beckville, TX (parents   Houston, TX (mother
     Charlie, age 8)          of Adam, age 20)         of Abel Gonzalez, age
                                                       16)
    Sharon Link,             Paul and Amelia Beatty,  Eric and Jennifer
     Downingtown, PA          Annandale, VA (parents   Schulze, Seguin, TX
     (parent of Rachel, age   of Orion, age 2)         (parents of Garrett,
     22)                                               age 10)
    Meghann Luczkowski,      Debra Krieger, San       Josh Fultz, Navasota,
     Philadelphia, PA         Antonio, TX (parent of   TX (parent of Jadyn,
     (parent of Miles, age    Jeffrey, age 11)         age 10)
     3)
    Sarah Palya, Butler, PA  Corinne Kunkel, Lorton,  Laura Leeman,
     (parent of August        VA (parent of Dylan,     Colleyville, TX
     Palya, age 13)           age 5)                   (mother of Victor,
                                                       age 12)
    Lisa Kinsey, Kennett     Nicole Ritchey,          Julie Ross, Dallas, TX
     Square, PA (parent of    Oakhurst, TX (mother     (mother to Niko
     Sarah, age 4)            of Kyler, 22 months)     Tigerlily, age 5)
    Jennifer Zurn,           Carolyn and Tim          Scott and Shonda
     Pittsburgh, PA (parent   Anderson, Leesburg, VA   Kincaid, Kilgore, TX
     of Isaac, age 2)         (parents of Maren, age   (parents of Koen, age
                              2)                       4)
    Scott and Dena Dupuie,   Eric and Katrina Young,  Maud Marin, Houston,
     Driftwood, TX (mother    Norfolk, VA (parents     TX (mother of Lucas,
     of Brianna, 10 years     of Ethan, age 1)         4 yrs old)
     old)
    Jill Hutchings,          Martha Kilburn,          Brent and Suzette
     Mckinney, TX (parent     Roanoke, VA (mother to   Fields, Cedar Park,
     of Asher, age 6)         Mya, age 16, and Dee,    TX (parents of Chloe,
                              age 9)                   age 8)
    Joshua and Kaya          Courtney Anguizola,      Alison and Bruce
     Jackson, Austin, TX      Seattle, WA              Beckwith, Keller, TX,
     (parents of Bree, age                             (parents to Alex, age
     2)                                                13, and Maddy, age 3)
    Elizabeth Smith,         Matt and Katie           Tammy Hodson,
     Austin, TX (mother of    Sullenbrand, Madison,    Highland, Utah
     Holden, 4 months)        WI (parents of Eve,      (parent to Parker age
                              age 6)                   12, currently
                                                       inpatient at Primary
                                                       Children's Hospital)
    Steven and Jeorgi        Mary Maier-Hellenbrand,  Amy Hill, Richmond, VA
     Bernard, Salt Lake       Waunakee, WI             (parent of Declan, 1
     City, UT (parents of     (grandmother to Eve,     year old)
     Iris, age 21 months)     age 6)
    Babita Desai, Leesburg,  Kristen Peterson, Lac    Craig and Lindsay
     VA (parent of Ryan       du Flambeau, WI          Lykens, Ashburn, VA
     Desai, age 5)            (mother of Sage, 8       (parents of Gillam,
                              months)                  age 23 months)
    Marta and Mike Conner,   Brian and Christina      Megan and Tony Parisi,
     Clifton, VA (parents     Spencer, Alexandria,     Madison, WI (parents
     of Caroline, age 7)      VA (parents of           of Vincent, age 10)
                              Memphis, 5 months)
    Christy Judd, Inwood,
     WV (mother of Ethan,
     age 8)

                                     ______

                    Letter Submitted by Don and Laurine Lusk

    September 22, 2017

    Regarding: Stop the Graham-Cassidy-Heller-Johnson proposal, which would
    harm people with disabilities and seniors.

    We have a daughter, Megan, who is 37 years old. She was born with
    autism and intellectual/cognitive disabilities. Later she also
    developed spinal deformities of Kyphosis (curve of her upper spine) and
    Scoliosis (side to side curve of her entire spine). And she developed
    severe vertigo.

    In the Nation's dark history, not too many years ago, Megan would have
    been sent to an institution when she was born, so she could spend her
    lifetime shut away from the community. But in the 1960s the ``community
    integration'' movement took hold and Wisconsin and the entire Nation
    began providing needed services to people in their homes and other
    community settings. In 1980, the special education mandate was passed,
    to ensure children with disabilities access to public education. And in
    1990 the Birth to 3 mandate helped to ensure that infants and toddlers
    with disabilities would be helped by early intervention services, so
    learning could be maximized at a time when the brain was undergoing
    tremendous growth and change.

    You may wonder why these community-based services were mandated, so I
    will share what we have learned. For every $1 spent in community-based
    services, including services to babies, children, teens, and adults . .
    . there is a 1,000% return in the person becoming more capable and
    independent. The lives of people with disabilities and other community
    members are enriched. People with disabilities work jobs, volunteer,
    pay taxes, and vote. The alternative to community based support is
    institutional care, and that segregated care cost much more per day
    while warehousing people in settings where abuse was rampant.

    So why would the House and/or Senate consider cuts to Medicaid dollars
    that are necessary for people to live and work within their
    communities, while producing huge savings when compared to
    institutionalization? At first I thought it was mere ignorance or
    prejudice on the parts of Senators Graham, Cassidy, Heller, Johnson and
    the others who proposed Medicaid cuts in earlier attempts to pass
    changes to the Affordable Health Care Act. But we've come to realize
    that there may be a pervasive belief that people with disabilities and
    seniors who rely upon Medicaid for life-saving services . . . aren't
    worth keeping alive. Instead, it appears that many in Congress and the
    President wish to repay powerful individuals and corporations who
    funded their political campaigns. So, if Congress and the President can
    cut life-saving funds from America's most vulnerable, causing them to
    be institutionalize and/or to die, then their debt to wealthy and
    powerful corporations and individuals can be repaid through huge tax
    breaks for the rich. Do you think that we don't see this unfolding? It
    is clear that many politicians are working only for themselves and
    certainly are not working for their constituents! For that reason . . .
    we say this is America's shame! And anyone who supports cuts to
    vulnerable citizens, to give more to the rich . . . SHAME ON YOU!

    Throughout her lifetime, Megan has received Medicaid funded therapies
    and instruction. As an adult she now works two jobs, owns a condo, and
    she pays income and real estate taxes. If Congress succeeds in cutting
    or block granting Medicaid, Megan will no longer have the staff support
    needed to continue her two jobs or to maintain her home. Her needs are
    severe and years of evaluations have documented that she meets the
    ``nursing home level of care'' which means that we know cuts to
    Medicaid will result in her institutionalization.

    Ignorance is not an excuse for what Congress and the President are
    attempting to do to Medicaid. And bruised male egos that can't handle
    the fact that people call the Affordable Health Care Act ``Obamacare''
    are also no excuse.

    It doesn't matter the reason some in Congress wish to remove the safety
    net from millions of seniors and people with disabilities, including:

          To gather money for tax breaks for the rich, so these
    politicians can expect payback through campaign funds to help them win
    future elections, or
          Republican party bruised egos over a Democratic President
    championing a great health care law, or
          White Supremacy anger over a black President serving the country
    by passing the Act, or
          Prejudice against people with disabilities, or
          Ignorance about the fact that institutions are more expensive
    and inhuman.

    All of the above reasons for writing or supporting the terrible changes
    outlined in the Graham, Cassidy, Heller, Johnson proposal, and the
    previous similarly terrible proposals to cut or block grant Medicaid
    must be stopped! If not, thousands will die and millions will be
    institutionalized. This is unconscionable and certainly does not
    constitute representation of your constituents. As other countries rush
    to help people in their countries who are harmed by storms and
    earthquakes, America is witnessing a rise in a new, greedy, self-
    serving mentality that is obviously causing Congress to intentionally
    harm and kill the country's most vulnerable citizens, seniors and those
    with disabilities. They must be stopped! The Graham, Cassidy, Heller,
    Johnson proposal must be stopped, as the earlier proposals were
    stopped.

    Congress must pull their focus away from their bruised egos and their
    wish to please their rich co-conspirators and, instead, represent
    constituents like our daughter Megan and the millions of others who
    wouldn't be able to get out of bed, dress, eat, use the bathroom, or be
    employed if Medicaid funds were reduced. Stop playing around with
    Medicaid. Everyone who votes has an elderly person in their family, and
    at least 1 in 12 have someone with a disability in their family. And
    there are millions of doctors, nurses, vocational and residential
    caregivers who are watching the cruel politics playing out in
    Washington, DC. We are a huge voting block and we are disgusted by what
    we are watching Congress do. It's time to improve those few issues in
    Obamacare, while working between parties. Bring back advertisement for
    the Affordable Care Act, reassure providers, and stabilize the
    marketplace. Stop doing damage by intentionally sabotaging a good law.
    Remember who you are to represent . . . we the people!

    Don and Laurine Lusk

                                     ______

                           March of Dimes Foundation

                          Office of Government Affairs

                         1250 H Street, NW, Suite 400B

                              Washington, DC 20005

                            Telephone (202) 659-1800

                               Fax (202) 296-2964

                         https://www.marchofdimes.org/

    On behalf of the March of Dimes, a unique collaboration of scientists,
    clinicians, parents, members of the business community, and other
    volunteers representing every state, the District of Columbia and
    Puerto Rico, I appreciate this opportunity to submit testimony for the
    record of the hearing to consider the Graham-Cassidy-Heller-Johnson
    health care proposal.

    I will be blunt: this legislation poses a dire threat to the health of
    women, infants and families across our nation and should be rejected
    outright by every Senator.

    In particular, the Graham-Cassidy-Heller-Johnson bill poses a special
    danger to pregnant women and infants, some of the most vulnerable
    populations. At every turn, this proposal rejects approaches that would
    make it easier for women and families to obtain affordable,
    comprehensive care, instead erecting barriers to coverage and removing
    critical consumer protections.

    The March of Dimes is particularly concerned about the impact of this
    proposal in three areas: Medicaid, the individual insurance market, and
    state health care systems.

    Medicaid Impacts Would Be Devastating

    Each year, approximately half of all births in the U.S. are covered by
    Medicaid.\1\ Millions of pregnant women receive comprehensive prenatal
    care under Medicaid, and their infants are covered for hospitalization,
    vital well child care, and illness. Medicaid also covers a
    disproportionate share of high-risk births.\2\ In many states, Medicaid
    provides crucial wraparound services for families who have private
    coverage, but whose children face major health crises with catastrophic
    costs. For millions of families, Medicaid can make the difference
    between a healthy or sick pregnancy or baby, and serves as a bulwark
    against financial ruin for families of medically complex children.
    ---------------------------------------------------------------------------
        \1\ Markus, A.R., Andres, E., West, K.D., Garro, N., and
    Pellegrini, C., ``Medicaid covered births, 2008 through 2010, in the
    context of the implementation of health reform,'' Women's Health Issues
    2013;23(5):e273-e280.
        \2\ Markus, A., Garro, N., Krahe, S., Gerstein, M., and Pellegrini,
    C., ``Examining the Association Between Medicaid Coverage and Preterm
    Births Using 2010-2013 National Vital Statistics Birth Data,'' Journal
    of Children and Poverty 2016;23(1):79-94.

    Under the Graham-Cassidy-Heller-Johnson bill, states would lose the
    ability to cover additional populations under Medicaid, as permitted
    under the Affordable Care Act (ACA). The March of Dimes estimates that
    this rollback alone would result in up to 6.5 million women of
    childbearing age losing coverage,\3\ denying them the opportunity to
    get healthy before they get pregnant. Many of these low-income women
    would have no recourse for obtaining coverage or health care.
    ---------------------------------------------------------------------------
        \3\ http://www.marchofdimes.org/news/statement-of-stacey-d-stewart-
    president-march-of-dimes-on-release-of-the-better-care-reconciliation-
    act.aspx.

    The bill would also convert the existing Medicaid program from an
    entitlement program to a combined block grant and per capita cap
    funding structure, potentially wiping out the current requirements that
    states cover certain mandatory populations, such as pregnant women and
    children. In addition to these likely coverage losses, the conversion
    of Medicaid from an entitlement to a capped system is expected to
    eliminate numerous patient protections in the name of state
    flexibility. For example, states might no longer be required to adhere
    to the Early Periodic Screening, Diagnostic and Treatment (ESPDT)
    ---------------------------------------------------------------------------
    standard of providing medically necessary care to children.

    Finally, the Graham-Cassidy-Heller-Johnson bill is estimated to reduce
    federal funding Medicaid by over $713 billion through 2026 alone.\4\ It
    is simply impossible to drain this degree of resources from our health
    care system without extensive consequences for patients, providers, and
    other stakeholders. States will be forced to serve fewer people, offer
    fewer services, cut payments to doctors and hospitals, raise taxes, or
    some combination of all of these measures.
    ---------------------------------------------------------------------------
        \4\ http://avalere.com/expertise/managed-care/insights/graham-
    cassidy-heller-johnson-bill-would-reduce-medicaid-funds-to-states-by.
    ---------------------------------------------------------------------------

    The Individual Market Would Revert to Only Serving the Healthy

    Under the Graham-Cassidy-Heller-Johnson proposal, the Affordable Care
    Act's provisions around Marketplaces would be eliminated and states
    would receive funds to establish their own systems. In the name of
    flexibility, states would be allowed to permit insurers to charge sick
    people higher rates, not cover essential health benefits, and impose
    caps on services and benefit levels.

    In a nutshell, this bill would return us to the days when only healthy
    people could afford coverage in the individual market. Allowing
    insurance companies to engage in medical underwriting again will almost
    certainly set off a ``race to the bottom,'' where insurers compete for
    the healthiest customers by offering cheap plans that cover few
    services. Lower premiums may be achieved, but they will only be
    available to a limited population, and the plans with lower premiums
    may not cover the services people actually need. Prior to passage of
    the ACA, only 13% of plans in the individual market covered
    pregnancy;\5\ in most cases, women who needed this coverage had to
    purchase costly riders, or could not obtain maternity coverage at all.
    Numerous analysts have noted that maternity and newborn coverage will
    likely be among the first benefits insurers will choose to exclude from
    plans.
    ---------------------------------------------------------------------------
        \5\ https://www.marchofdimes.org/advocacy/affordable-care-is-
    essential-to-moms-and-babies.as
    px.

    Among those states that waive the essential health benefits (EHB)
    requirements, annual and lifetime caps will also make an unwelcome
    reappearance. Because the ACA's prohibition on annual and lifetime caps
    only applies to EHBs, the elimination of the EHB requirement will
    functionally void the ban on caps. Once again, families will be find
    themselves in dire straits when a single major illness or chronic
    condition could render a child uninsurable permanently. In some cases,
    an infant born extremely preterm or with other serious complications
    could exhaust her lifetime limit before even leaving the hospital.

    States Need Appropriate Time and Investment to Build New Health Systems

    The Graham-Cassidy-Heller-Johnson bill envisions each state undertaking
    the herculean task of building a new individual marketplace system in
    only 2 years. While some states may be capable of producing a full-
    fledged system within this timeframe, many will likely require more
    time. If states must have functional systems by 2020, it is highly
    probable that those systems will not adequately address the needs of
    maternal and child health.

    In fact, states are already struggling to serve maternal and child
    health appropriately. For the past 2 years, preterm birth rates have
    increased, after declining for the prior several years.\6\ Maternal
    mortality rates across the U.S. exceed those in most developed
    nations.\7\ In many U.S. communities, infant mortality rates rival
    those of third world countries.\8\ Stark disparities exist among birth
    outcomes for many racial and ethnic groups. Maternal and child health
    serves as an exquisitely sensitive barometer for the effectiveness of
    our health care system, and in too many communities it already
    indicates serious problems.
    ---------------------------------------------------------------------------
        \6\ https://www.cdc.gov/nchs/data/vsrr/report002.pdf.
        \7\ http://www.who.int/reproductivehealth/publications/monitoring/
    maternal-mortality-2013/en/.
        \8\ https://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_05.pdf.

    Moreover, the Graham-Cassidy-Heller-Johnson bill seems to expect that
    states will be able to impose cost-containment efforts that the federal
    government, with its more significant bargaining power and reach, has
    not. Any serious attempt to restrain costs in our health care system
    must recognize that the least effective approach is simply to reduce
    spending. Instead, the government should closely examine the actual
    drivers of costs and address them directly with targeted interventions.
    One of the most effective ways to restrain costs would be to engage in
    sensible, meaningful efforts to promote preventive care. For maternal
    and child health, this would mean increasing access to well woman,
    prenatal and well child care to improve outcomes for both mothers and
    ---------------------------------------------------------------------------
    their babies.

    States require time, resources, collaboration, and access to best
    practices in order to construct a health care system that supports
    healthy pregnancies, babies, and families. The Graham-Cassidy-Heller-
    Johnson proposal provides none of the tools necessary to make that
    possible.

    Conclusion

    Throughout our history, the March of Dimes has advocated for patient-
    centered systems of care that expand access, improve quality, and
    reduce costs for all parties in the system with the ultimate goal of
    healthy pregnancies and healthy babies. Unfortunately, the Graham-
    Cassidy-Heller-Johnson bill fails on all counts to satisfy these
    standards. Expecting states to produce dramatically better outcomes
    with radically fewer resources is little more than magical thinking.

    The March of Dimes urges all Senators to oppose the Graham-Cassidy-
    Heller-
    Johnson legislation. This bill is bad medicine for pregnant women,
    children, and families all across our nation.

                                     ______

             The Michael J. Fox Foundation for Parkinson's Research

                             Grand Central Station

                              Post Office Box 4777

                               New York, NY 10163

                              www.michaeljfox.org

        Statement of Ted Thompson, Senior Vice President, Public Policy

    Chairman Hatch, Ranking Member Wyden, and Members of the Committee:

    The Michael J. Fox Foundation for Parkinson's Research thanks the
    Senate Committee on Finance for holding this hearing on the Graham-
    Cassidy-Heller-Johnson healthcare proposal and appreciates the
    opportunity to submit this written statement to share the perspective
    of the between 750,000 and 1 million people in the United States living
    with Parkinson's disease.

    As the world's largest nonprofit funder of Parkinson's disease
    research, The Michael J. Fox Foundation for Parkinson's Research is
    dedicated to accelerating a cure for Parkinson's disease and developing
    improved therapies for those living with the disease today. In
    providing more than $750 million in research to date, the Foundation
    has fundament ally altered the trajectory of progress toward a cure for
    Parkinson's disease, which has an annual economic burden of between
    $19.8 and $26.4 billion.

    The Michael J. Fox Foundation for Parkinson's Research is incredibly
    concerned that several of the provisions contained within the Graham-
    Cassidy-Heller-Johnson healthcare proposal would have a distinctly
    negative imp act on Parkinson's patients across the United States.

    Maintaining the prohibition against pre-existing condition
    discrimination and keeping the essential health benefits package intact
    are imperative to preserving affordable access to quality healthcare
    for Parkinson's patients. The Graham-Cassidy Heller-Johnson healthcare
    proposal permits states, through waivers, to eliminate coverage for the
    essential health benefits currently mandated by the Affordable Care
    Act. This would allow states to erode coverage for individuals with
    pre-existing conditions, such as Parkinson's disease, and subject them
    to increased costs, as well as annual and lifetime caps.

    Both chronic disease management and prescription drug coverage are part
    of the essential health benefits package.\1\ The proposal provides
    significant and nearly unrestricted flexibility to states by requiring
    those seeking waivers to only explain the manner in which they intend
    to maintain access to adequate and affordable coverage for individual's
    with pre-existing conditions. There is, however, no requirement that
    states demonstrate whether or not it is realistic or possible for such
    access to be maintained. The net consequence of these waivers would be
    that Parkinson's patients' protection against discrimination and access
    to the essential health benefits will depend entirely upon the state in
    which he or she lives, and the protections afforded by each state. This
    is a dangerous and costly result for individuals with Parkinson's
    disease who may be financially unable to access new and necessary
    treatments.
    ---------------------------------------------------------------------------
        \1\ ``Information on Essential Health Benefits (EHB) Benchmark
    Plans,'' Centers for Medicare and Medicaid Services. Accessed on
    September 21, 2017, https://www.cms.gov/cciio/resources/data-resources/
    ehb.html.

    Preserving the essential health benefits package is vital to
    maintaining access to affordable, quality healthcare for Parkinson's
    patients who obtain coverage through their employers. Large employer
    plans are permitted to employ any state's definition of essential
    health benefits when determining the breadth of the prohibition on
    annual and lifetime limits to coverage.\2\ The waiver flexibility
    permitted by the Graham-Cassidy-Heller-Johnson healthcare proposal
    would allow large employers who provide coverage for Parkinson's
    patients to elect to utilize essential health benefits packages
    allotted by the least generous states, effectively subjecting employees
    to annual and lifetime caps that may financially prevent them from
    accessing the necessary care.
    ---------------------------------------------------------------------------
        \2\ Matthew Fiedler, ``Allowing states to define essential health
    benefits could weaken ACA protections against catastrophic costs for
    people with employer coverage nationwide,'' The Brookings Institute,
    May 2, 2017, https://www.brookings.edu/2017/05/02/allowing-states-to-
    define-essential-health-benefits-could-weaken-aca-protections-against-
    catastrophic-costs-for-people-with-employer-coverage-nationwide/.

    Maintaining the prohibition against community rating is essential to
    continuity of, and access to, quality healthcare for Parkinson's
    patients. Currently, the Affordable Care Act prohibits the use of
    actual or expected health status when setting group premiums.\3\
    Community Rating protects individuals with pre-
    existing conditions, such as Parkinson's disease, by ensuring that
    premiums offered by insurance providers are the same for all
    individuals within a specified geographic territory.
    ---------------------------------------------------------------------------
        \3\ ``Adjusted Community Rating FAQs,'' United Healthcare, October
    2013, https://www.
    uhc.com/content/dam/uhcdotcom/en/HealthReform/PDF/Provisions/
    AdjustedCommunity/ACR_FAQ.pdf.

    The Graham-Cassidy-Heller-Johnson healthcare proposal would allow
    states to waive this prohibition and permit insurers to charge higher
    premiums to individuals based on health status. Without the safeguards
    against community rating provided by the Affordable Care Act, premiums
    based on health status for individuals with pre-existing conditions or
    higher than average healthcare costs would skyrocket resulting in many
    patients with Parkinson's disease being priced out of the market and
    left without access to quality healthcare. Gaps in healthcare coverage
    as a result of inaccessibility due to affordability is particularly
    ---------------------------------------------------------------------------
    detrimental to Parkinson's patients.

    Currently, up to one-third of the Parkinson's community are dually
    eligible for both Medicare and Medicaid, leaving this population
    particularly vulnerable to the impact of the allocation of scarce
    resources by state Medicaid programs following federal funding cuts.
    The Graham-Cassidy-Heller-Johnson healthcare proposal would repeal the
    authority to cover adults through the Medicaid expansion immediately
    for non-expansion states and by 2020 for expansion states, repeal the
    enhanced Federal Medical Assistance Percentage for the Medicaid
    expansion that currently covers 15 million adults, and make significant
    cuts to traditional Medicaid.\4\, \5\ Furthermore, the
    proposal would create capped block grants that combine federal funds
    for the Medicaid expansion, cost-sharing subsidies, and Basic Health
    Programs for low-income residents that would be lower than current
    spending and would require states to limit coverage. These block grants
    would maintain the aforementioned federal funding through 2026, with no
    indication regarding funding after that date.
    ---------------------------------------------------------------------------
        \4\ ``Compare Proposals to Replace The Affordable Care Act,'' The
    Henry J. Kaiser Family Foundation, September 2017, http://
    www.easybib.com/guides/citation-guides/chicago-turabian/how
    -to-cite-a-website-chicago-turabian/.
        \5\ ``Five Ways the Graham-Cassidy Proposal Puts Medicaid Coverage
    at Risk,'' The Henry J. Kaiser Family Foundation, September 2017,
    http://www.kff.org/medicaid/fact-sheet/5-ways-the-graham-cassidy-
    proposal-puts-medicaid-coverage-at-risk/.

    In addition, the Graham-Cassidy-Heller-Johnson healthcare proposal
    allows states to require beneficiaries to re-certify their eligibility
    for Medicaid every 6 months.\6\ This requirement would be overly
    burdensome. Individual's with Parkinson's who are on Medicaid due to
    disability do not one day lose their disability. The disability status
    is permanent. Requiring recertification with such frequency is cruel
    and appears to be a mechanism to dissuade people from accessing this
    important program.
    ---------------------------------------------------------------------------
        \6\ Amendment to H.R. 1628, 115th Congress (2017).

    Lastly, Senator Cassidy has stated, ``funds are quite unequally
    distributed. Where you live should not determine how healthy you are.''
    \7\ As such, the funding formulary should not be skewed in a manner
    that would create inequity by increasing funding for states whose
    Senators have expressed concern regarding the Graham-Cassidy-Heller-
    Johnson healthcare proposal. Funding determinations should be made in a
    manner that best serve healthcare consumers and are most likely to
    provide access to affordable, quality healthcare coverage for the
    Parkinson's community and all Americans.
    ---------------------------------------------------------------------------
        \7\ Sarah Kliff, ``Cassidy makes the case for his plan to repeal
    Obamacare,'' Vox, September 15, 2017, https://www.vox.com/policy-and-
    politics/2017/9/15/16316852/cassidy-plan-to-repeal-obamacare.

    In conclusion, we thank the Senate Committee on Finance for providing
    The Michael J. Fox Foundation for Parkinson's Research and the between
    750,000 and 1 million patients living with Parkinson's disease the
    opportunity to share with you our thoughts regarding the Graham-
    Cassidy-
    Heller-Johnson healthcare proposal. We urge the committee to consider
    our concerns regarding various provisions of the Graham-Cassidy-Heller-
    ---------------------------------------------------------------------------
    Johnson healthcare proposal.

                                     ______

                  Michigan Developmental Disabilities Council

                Michigan Department of Health and Human Services

                              Nick Lyon, Director

                              320 S. Walnut Street

                            Lansing, Michigan 48913

                              (517) 335-3158 Voice

                               (517) 335-2751 Fax

                           https://www.michigan.gov/

    Rick Snyder
    Governor

    Paul Palmer
    Chairperson

    Vendella M. Collins
    Executive Director

    September 22, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Subject: Hearing to consider the Graham-Cassidy-Heller-Johnson
    proposal, September 25, 2017

    Dear Chairman Hatch:

    Michigan Developmental Disabilities Council respectfully submits the
    following written testimony expressing our strong opposition to the
    Graham-Cassidy-Heller-Johnson proposal to repeal and replace the
    Affordable Care Act and reshape the way Medicaid funds will be
    distributed to the states.

    The council's opposition to this legislation dives deeply into the
    negative consequences this legislation will have on people with
    disabilities (PWDs) should it be signed into law. For PWDs, Medicaid is
    far more than just a health plan, it is a vital lifeline of support and
    services needed to navigate the daily life needs of the individual. It
    is not an exaggeration or embellishment that we have termed Medicaid a
    ``lifeline,'' for some, it is their only source of supports and
    services they have. If any reduction of these services transpire due to
    the application of this legislation, it will, not it may, mean life and
    death decisions will have to be made regarding what provisions will be
    available to societies most vulnerable citizens.

    It is most appropriate to separate policy from politics and view this
    issue from an elevated perspective that allows comprehensive evaluation
    based on facts. Examining one of the core components this proposal,
    repealing and replacing the Affordable Care Act (ACA), we need to
    critically explore how repealing components of this act will negatively
    impact PWDs.

      Fact: not all people with disabilities are on Medicaid or Medicare.
    PWDs are also enrolled in private healthcare coverage. Prior to the
    enactment of the ACA, many people were denied coverage based on pre-
    existing conditions or reaching annual/lifetime limits. The ACA made
    these actions illegal and allowed many PWDs to enroll into healthcare
    coverage.
      Fact: the ACA made it possible for those with private insurance to
    access habilitative and rehabilitative services. Without such services,
    many may have ended up in a nursing facility creating an even greater
    hardship on the Medicaid program.
      Fact: the disability population is the fastest growing minority
    population in the country. It has no borders. It includes individuals
    of all ages, cultures, and genders. It can affect any person at any
    time. Repealing the ACA will increase the number of PWDs who are
    uninsured and who will be unable to obtain private healthcare coverage.
      Fact: age is one of the leading causes of disabilities in America.
    As a nation, we are rapidly gaining in age, henceforth, there will be a
    much greater need for access to healthcare, not less.
      Fact: uncompensated care rates for the major hospitals in Michigan
    was reduced by nearly 50% due to the increase in people having
    healthcare coverage. Repealing the ACA will INCREASE hospital
    expenditures and cost due to an increase in uncompensated care. This
    will also impact private insurers who will raise their rates to help
    cover the added cost, creating a cascade of out of control healthcare
    coverage costs.

    An additional element of the Graham-Cassidy-Heller-Johnson proposal
    that will create great hardship for people with disabilities is the
    dismantling of the current Medicaid funding model and transitioning
    into block granting states under the moniker of ``state flexibility.''
    To its credit, Michigan provides PWDs with a level of benefits that is
    above the minimum requirements established by Center for Medicare
    Medicaid Services (CMS). This is accomplished by the state being able
    to work with CMS and the federal government in establishing programs
    that promote better health, increased self-sustainability, decreased
    healthcare costs, and provide better supports and services that enable
    people to live on their own. That is true flexibility. If block grants
    are imposed on individual states (which will result in reduced funding
    and flexibility), it is highly likely that PWDs will experience a
    substantial reduction in the services they need to stay independent.
    Flexibility means the ability to give and take; not being rigid, the
    capacity to work together. Block granting does not encourage state
    flexibility but rather fosters a state's inability to work collectively
    with our federal partners. If flexibility is truly the desired outcome,
    increased 1115 demonstration projects should be the focus and more
    importantly, how the states and CMS can work more closely together to
    address the healthcare and support crisis facing our country.

    As mentioned, Michigan does a fairly good job in ensuring PWDs have
    access to the services most needed. Even with these standards in place,
    we are continually running into insurmountable hurdles that create
    hardships for PWDs, seniors and their families.

      Fact: Michigan has a shortage of over 2,000 direct support workers
    who help PWDs and seniors with their daily living needs. If state
    Medicaid funding is reduced, this shortage will be substantially
    increased reducing staff numbers to an already short supply.
      Fact: there are no states that expanded Medicaid to people below
    138% of the federal poverty level with budget surpluses large enough to
    cover the losses in federal Medicaid revenue should block-granting be
    implemented. This will substantially increase a state's uninsured rate
    as well as place greater hardships on state's limited resources.
      Fact: Michigan has over 600,000 lives covered under Healthy
    Michigan. This means that over 6% of Michigan's population is below
    138% of the federal poverty level. This figure does not include those
    who were/are eligible for traditional Medicare or Medicaid. PWDs who
    were not covered under traditional Medicaid will be removed from
    healthcare coverage.
      Fact: The United States is in the midst of a substance use crisis
    related to opiate abuse. Reducing Medicaid funding to states that could
    be used to help fight substance use disorders through continued
    coverage will only exasperate this problem.

    Even though the above facts are Michigan specific, it is easily argued
    that many other states face similar problematic issues that federal
    Medicaid block granting will create or intensify.

    Lastly, it is extremely important to realize that in 2014 nearly two-
    thirds of Medicaid funding is used for PWDs and seniors. Over one-third
    of Medicaid beneficiaries are people who receive Social Security Income
    (SSI). The Medicaid reduction proposed through block granting (reducing
    funding going to states in excess of hundreds of billions of dollars)
    targets PWDs and seniors, period. Acknowledging that PWDs and seniors
    are the greatest utilizers of the supports and services provided by
    Medicaid, it only stands to reason that these cuts will impact the most
    vulnerable of our society the most. Reiterating the fact that
    disabilities know no boundaries, these proposed cuts will create an
    widespread reduction of available supports and services that will only
    be amplified by the continuance of the increasing medium age and the
    level of disabilities experienced by the people in this great country.

    Should you have any questions or concerns regarding our opposition to
    the Graham-Cassidy-Heller-Johnson proposal, please feel free to contact
    our Public Policy Analyst, Brett Williams at 517-284-7289.

    Sincerely,

    Paul Palmer
    Michigan Developmental Disabilities Council-Chairperson

                                     ______

                            NARAL Pro-Choice America

                        1156 15th Street, NW, Suite 700

                              Washington, DC 20005

                       https://www.prochoiceamerica.org/

                                  202-973-3000

                                202-973-3070 fax

    September 26, 2017

    The Honorable Orrin Hatch           The Honorable Ron Wyden
    Chairman                            Ranking Member
    U.S. Senate                         U.S. Senate
    Committee on Finance                Committee on Finance

    RE: Written statement for the record, September 25, 2017 Senate Finance
    Committee hearing to consider the Graham-Cassidy-Heller-Johnson
    proposal

    Dear Chairman Hatch and Ranking Member Wyden:

    NARAL Pro-Choice America is pleased to submit this written statement
    for the record for the September 25, 2017 Hearing to Consider the
    Graham-Cassidy-Heller-Johnson (Graham-Cassidy) Proposal before the
    Senate Finance Committee. For the reasons outlined below, NARAL Pro
    Choice America strongly opposes the Graham-Cassidy-Heller-Johnson
    proposal.

    NARAL is a national advocacy organization dedicated since 1969 to
    supporting and protecting, as a fundamental right and value, a woman's
    freedom to make personal decisions regarding the full range of
    reproductive choices, including preventing unintended pregnancy,
    bearing healthy children, and choosing legal abortion. Through
    education, organizing, and influencing public policy, NARAL and our 1.2
    million member activists work to guarantee every woman this right,
    regardless of her income, where she obtains her health-care coverage,
    or her zip code.

    NARAL is deeply concerned by the Graham-Cassidy proposal's impact on
    women and families across the country. By ensuring coverage and
    affordability of maternity care, family-planning services, and other
    reproductive-health services, the Affordable Care Act (ACA) represented
    a major step forward. Additionally, Planned Parenthood is an integral
    part of the public-health system, serving 2.5 million patients each
    year. Dismantling the ACA and defunding Planned Parenthood would be
    nothing short of devastating for public health. Yet, the Graham-Cassidy
    measure would do just that--from dismantling Medicaid as we know it to
    allowing states to waive critical consumer protections and prohibiting
    women from purchasing comprehensive coverage, including for abortion
    care. This bill would upend the entire health-care system and
    jeopardize access to vital health-care coverage across the country.

    Under the devastating funding cuts and Medicaid restructuring in the
    Graham-
    Cassidy proposal, millions of Americans\1\ will lose health-care
    coverage altogether. Furthermore, those who remain covered will lose
    critical protections provided under the ACA. Women are among those with
    the most at stake. For example, Graham-
    Cassidy provides an avenue for states to permit insurers to ignore
    outright coverage requirements for essential health benefits and
    preventive care--including maternity care and no-copay birth control.
    Prior to the ACA, only 18 states required insurers to cover or offer
    coverage for maternity care in individual or small group insurance, but
    thanks to the ACA, women in all 50 states and the District of Columbia
    are guaranteed this coverage in their marketplaces. Under Graham-
    Cassidy, women desiring this coverage would be forced to pay for an
    insurance rider--a separate policy to cover maternity care--which could
    cost more than $1,000 per month (on top of the premium a woman is
    already paying for her ``comprehensive'' coverage).\2\ Additionally
    62.4 million women now have contraceptive coverage with no additional
    out-of-pocket cost.\3\ Women are saving $1.4 billion per year, just on
    the birth-control pill.\4\
    ---------------------------------------------------------------------------
        \1\ Congressional Budget Office, ``Preliminary Analysis of
    Legislation That Would Replace Subsidies for Health Care With Block
    Grants'' (September 2017), at https://www.cbo.gov/system/files/115th-
    congress-2017-2018/costestimate/53126-health.pdf.
        \2\ Congressional Budget Office, ``Cost Estimate of H.R. 1628,
    American Health Care Act of 2017, as Passed by the House of
    Representatives on May 4, 2017'' (May 24, 2017), at https://
    www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/
    hr1628aspassed.pdf.
        \3\ National Women's Law Center, ``New Data Estimates 62.4 Million
    Women Have Coverage of Birth Control Without Out-of-Pocket Costs''
    (September 2017), at https://nwlc.org/wp-content/uploads/2017/09/New-
    Preventive-Services-Estimates-3.pdf.
        \4\ Nora Becker and Daniel Polsky, ``Women Saw Large Decrease in
    Out of Pocket Spending for Contraceptives After ACA Mandate Removed
    Cost Sharing,'' 34 Health Affairs 1204 (2015).

    The Graham-Cassidy proposal also mounts an unprecedented attack on
    abortion access. In the short term, the bill prohibits women and small
    businesses who receive tax credits from purchasing insurance plans that
    cover abortion care. Once the tax credits cease, the abortion coverage
    restrictions continue: the bill also funnels state grants through a
    children's health insurance fund that bans abortion coverage except in
    the most narrow of circumstances. The proposal also prohibits women
    from using their own health savings accounts to pay for plans that
    cover abortion services. The end result--and ultimate goal--is to
    effectively eliminate abortion coverage from the private insurance
    ---------------------------------------------------------------------------
    market altogether.

    In sum, the Graham-Cassidy proposal would be catastrophic for women and
    families, whether they lose coverage altogether because of Medicaid
    cuts, become priced out of the market, maintain a policy but do not
    have the comprehensive coverage and protections they need most, or lose
    access to their trusted Planned Parenthood provider. For these reasons,
    NARAL Pro Choice America strongly opposes the Graham-Cassidy proposal
    and urges senators to work towards policies that expand access to care,
    rather than taking it away.

    Thank you for your consideration.

    Respectfully,

    Ilyse Hogue
    President

                                     ______

                  National Association of School Nurses (NASN)

                          1100 Wayne Avenue, Suite 925

                         Silver Spring, Maryland 20910

                              866-627-6767 (phone)

                               301-585-1791 (fax)

                           https://www.nasn.org/home

    October 5, 2017

    Senator Orrin Hatch                 Senator Ron Wyden
    Chairman                            Ranking Member
    U.S. Senate                         U.S. Senate
    Committee on Finance                Committee on Finance
    Washington, DC 20510                Washington, DC 20510

    Dear Senators Hatch and Wyden:

    The National Association of School Nurses (NASN) opposes the Graham-
    Cassidy or any version of healthcare legislation that contains
    provisions that either fund Medicaid via block grants or has a per
    capita cap on Medicaid.

    NASN represents over 16,000 school nurses across the country working to
    optimize the academic success of student sure they are healthy, and
    safe, and ready to learn. Children today face more chronic and complex
    health conditions than ever before. Children are the currency of our
    future and as such, must have their health needs met throughout the
    day, including during school hours.

    Schools are part of the safety net for children and Medicaid plays a
    significant role, particularly in funding vital medical services for
    children in special education under the Individuals with Disabilities
    Education Act (IDEA) and for those students in general education who
    are eligible for Medicaid. Medicaid reimbursement to schools for the
    healthcare of children generates between $4-5 billion a year or
    approximately 1 percent of all Medicaid funds.

    The proposed Graham-Cassidy legislation will impact the ability of
    students with disabilities and students in poverty to receive critical
    school health services that enable them to engage in learning. This
    includes services provided by the school nurse, such as vision and
    hearing screenings and management for students with diabetes and
    asthma. The Early and Periodic Screening, Diagnostic, and Treatment
    (EPSDT) Programs are funded by Medicaid and ensure that children
    receive the preventive health check-ups and early intervention needed
    to hold chronic diseases at bay. Additional services funded by Medicaid
    are mental and behavioral health, speech language pathology,
    occupational and physical therapy, and essential equipment for students
    including wheelchairs and hearing aids. Schools utilize Medicaid
    funding to offset the cost of these professional healthcare services,
    thereby preserving education dollars for student education.

    Medicaid covers nearly 36 million children. While children are
    approximately 44 percent of Medicaid beneficiaries, they comprise only
    19 percent of the cost of cost of Medicaid. Chronic health conditions
    and barriers that limit access to healthcare disproportionately affect
    lower income children. Children must be healthy and safe to be ready to
    learn.

    NASN has long supported Medicaid, CHIP and other programs that help all
    children to be covered by and have access to quality, affordable health
    insurance. NASN opposes all efforts that weaken those supports for
    children, most especially per capita caps or block grants to Medicaid.

    Sincerely,

    Nina Fekaris
    President

                                     ______

                     National Council for Behavioral Health

                          1400 K Street, NW, Suite 400

                              Washington, DC 20005

                                  202-684-7457

                      https://www.thenationalcouncil.org/

        Statement for the Record from Linda Rosenberg, President and CEO

    Last week, the ugly health care debate reared its head again on Capitol
    Hill with the introduction of a new bill by Senators Graham (R-SC),
    Cassidy (R-LA), Heller (R-NV) and Johnson (R-WI) to drastically cut
    Medicaid and other federal health funds to states.

    This bill may go by a different name than previous efforts to reshape
    the health care system, but it maintains and even worsens the
    devastating provisions from those bills that led to a massive
    constituent outcry earlier this summer. It's the same pig with
    different lipstick.

    Like past versions of the Senate health bill, the new legislation would
    result in catastrophic outcomes for the millions of Americans living
    with addiction or mental illness.

          It caps federal Medicaid spending at a rate designed to grow
    more slowly than inflation, shifting costs to states and forcing them
    into difficult decisions about which populations and services to cut.
          It repeals the Medicaid expansion, taking away states' number
    one tool in fighting the opioid epidemic. Medicaid pays for 35-50% of
    all medication-assisted opioid treatment in states that have been hit
    hardest by the opioid epidemic, like Alaska, Ohio, and West Virginia.
          It eliminates subsidies that keep insurance affordable,
    stripping people with complex conditions like addiction or mental
    illness of the support they need to afford coverage.
          It sets states up for future budget shortfalls, replacing the
    Medicaid expansion and insurance subsidies with a block grant that
    would not grow in response to increased enrollment or costs.
          It allows states to opt out of pre-existing coverage protections
    and essential health benefits, returning us to the days when people
    with addiction or mental illness could not get coverage for their
    conditions.

    The results for Americans with addiction or mental illness are stark:
    massive coverage losses and reduced access to lifesaving treatment.

    The Senate Health, Education, Labor, and Pensions Committee has spent
    the past month working on bipartisan legislation that would stabilize
    the health insurance market and create a better health care system.
    With legislation from these efforts expected soon, now is not the time
    to renew the failed partisan effort that slashes billions of Medicaid
    dollars from state budgets, costing hundreds of thousands of lives.

    We implore Senators to focus on the bipartisan efforts underway and
    ignore this politically driven effort to rush a devastating bill
    through the Senate without time for debate and consideration of the
    impact on states and constituents.

    Now is the time to unite across party lines, stand up for what is right
    and ensure that the millions of Americans facing addiction and mental
    illness continue to get the care they deserve.

                                     * * *

    The National Council for Behavioral Health is the unifying voice of
    America's health care organizations that deliver mental health and
    addictions treatment and services. Together with our 2,900 member
    organizations serving over 10 million adults, children and families
    living with mental illness and addictions, the National Council is
    committed to all Americans having access to comprehensive, high quality
    care that afford every opportunity for recovery. The National Council
    helped introduce Mental Health First Aid USA and more than 1 million
    Americans have been trained.

                                     ______

                   National Disability Rights Network (NDRN)

    Dear Chairman Hatch, Ranking Member Wyden, and Honorable Senate Finance
    Committee Members:

    On behalf of the National Disability Rights Network (NDRN) and the
    nationwide network of Protection and Advocacy (P&A) and Client
    Assistance Program (CAP) agencies, we urge you to reject the Graham-
    Cassidy-Heller-Johnson bill, which will have devastating effects on the
    over 57 million people with disabilities in this country.

    NDRN is the non-profit membership organization for the federally
    mandated P&A and CAP agencies for individuals with disabilities. The
    P&A and CAP agencies were established by the United States Congress to
    protect the rights of people with disabilities and their families
    through legal support, advocacy, referral, and education. P&As and CAPs
    are in all 50 states, the District of Columbia, Puerto Rico, and the
    U.S. Territories (American Samoa, Guam, Northern Mariana Islands, and
    the U.S. Virgin Islands), and there is a P&A and CAP affiliated with
    the Native American Consortium which includes the Hopi, Navajo and San
    Juan Southern Paiute Nations in the Four Corners region of the
    Southwest. Collectively, the 57 P&A and CAP agencies are the largest
    provider of legally based advocacy services to people with disabilities
    in the United States.

    Every day, P&A and CAP agencies seek to improve the lives of people
    with disabilities to be more fully integrated into the community, and
    an important aspect of achieving that goal is the ability to receive
    services through the Medicaid program. Whether it is an individual with
    a disability trying to live in the community, an individual trying to
    get a job at a competitive wage and in an integrated setting, or
    receive a quality education, the Medicaid program plays a critical role
    in achieving that goal. As we have stated concerning multiple proposals
    considered by the Senate, we cannot overstate the danger facing the
    millions of adults and children with disabilities if the proposal's
    Medicaid provisions are adopted. The proposal's imposition of a per
    capita cap and the elimination of the adult Medicaid expansion would
    decimate a program that has provided essential healthcare and long term
    services and supports to millions of adults and children with
    disabilities for decades. We are also extremely concerned about the
    changes proposed to the private individual health insurance market and
    the tax credits that currently assist low-income individuals, including
    individuals with disabilities, to purchase insurance.

    Some 10 million people with disabilities and, often, their families,
    depend on the critical services that Medicaid provides for their
    health, functioning, independence, and well-being. For decades, the
    disability community and bipartisan Congressional leaders have worked
    together to ensure that people with disabilities of all ages have
    access to home- and community-based services that allow them to live,
    work, go to school, and participate in their communities instead of
    passing their days in institutions. Medicaid has been a key driver of
    innovations in cost-effective community-based care, and is now the
    primary program covering home and community-based services (HCBS) in
    the United States. Older adults and people with disabilities rely on
    Medicaid for nursing and personal care services, specialized therapies,
    intensive mental health services, special education services, and other
    needed services that are unavailable through private insurance.

    Like other proposals considered by the Senate, this legislation upends
    those critical supports. Per capita caps--which have nothing to do with
    the Affordable Care Act--would radically restructure the financing of
    the traditional Medicaid program and divorce the federal contribution
    from the actual costs of meeting people's health care needs. Caps are
    designed solely to cut federal Medicaid support to states, ending a
    decades-long bipartisan state/federal partnership to improve
    opportunities and outcomes for of our most vulnerable. Slashing federal
    funds will instigate state budget crises that stifle the planning and
    upfront investments required to create more efficient care systems.
    Caps will force states to cut services and eligibility that put the
    lives, health, and independence of people with disabilities at
    significant risk. In fact, because HCBS (including waivers) are
    optional Medicaid services, they will likely be among the first targets
    when states are addressing budgetary shortfalls. The structure of this
    legislation's cap--like the structure in previous bills--exacerbates
    the cuts after it reduces the growth rate in 2025. The Congressional
    Budget Office score on similar per capita cap proposals showed cuts to
    federal support by $756-834 billion by 2026, with steeper cuts the
    following years, amounting to a draconian 35% cut by 2036. Such caps
    would cause tens of millions of Americans to lose Medicaid coverage.

    Targeted carve outs and targeted funding pots included in this
    legislation are a mockery in comparison to the scope of these cuts. For
    example, this legislation offers a 4-year $8 billion dollar
    demonstration to expand Medicaid home and community-based services--
    which is not even half of the $19 billion cut to the Community First
    Choice option that eight states have implemented to expand access to
    necessary in-home services for people with disabilities.\1\ All
    individuals on Medicaid will be significantly impacted by cuts of this
    magnitude, despite any limited, temporary demonstration funding or
    restricted funding carve out for a fraction of the children with
    disabilities that Medicaid supports. Throwing billions in extra
    temporary funds cannot curb, and is disingenuous by hiding, the
    inevitable, long-term loss of critical Medicaid services that people
    with disabilities will face as a result of per capita caps.
    ---------------------------------------------------------------------------
        \1\ Congressional Budget Office, ``Cost Estimate for H.R. 1628,''
    33 (June 26, 2017).

    In addition, this legislation ends the Medicaid Expansion and the
    current tax credits and cost sharing reductions that assist low income
    individuals in purchasing health insurance by 2020, replacing this
    assistance with a block grant that would reduce funding by $239 billion
    by 2026. After 2026, there would be no federal funding to help the
    millions of Americans, including millions with disabilities, who rely
    on Medicaid Expansion and Marketplace coverage to access health care.
    These are people who previously fell through the cracks in our health
    care system. This includes individuals with disabilities in a mandatory
    waiting period before their Medicare coverage begins and millions of
    people with a behavioral health condition who previously had no pathway
    to steady coverage. Others who gained coverage through the Medicaid
    expansion also includes millions of family caregivers whose full time
    uncompensated job is caring for a child or older adult with a
    disability and hundreds of thousands of low wage direct care workers
    who serve people with disabilities. Medicaid expansion helps stabilize
    our long-term care support networks by keeping caregivers healthy and
    ---------------------------------------------------------------------------
    reducing turnover.

    Likewise, Marketplace coverage ensures that people with disabilities
    can buy comprehensive and affordable health care and have equal access
    to much needed health care including examinations, therapies to regain
    abilities after an illness or injury, and affordable medications. We
    have serious concerns about this legislation's private market
    provisions, including the state waiver authority to eliminate
    protections for people with preexisting conditions (including people
    with disabilities), older adults, and people who need access to
    essential health benefits. The nondiscrimination provisions and health
    insurance reforms, the expanded access to long-term supports and
    services, and the expanded availability of comprehensive and affordable
    health care have helped many more individuals with disabilities live in
    the community and be successful in school and the work place. No longer
    do individuals with disabilities and their families have to make
    horrifying choices about whether to pay their mortgage, declare
    bankruptcy, or choose between buying groceries and paying for needed
    medications.

    In short, this legislation makes health insurance unaffordable for
    millions of people, particularly people with disabilities, older
    adults, and those with chronic health conditions. The cumulative effect
    of the private insurance and Medicaid proposals will leave people with
    disabilities without care and without choices, caught between Medicaid
    cuts, unaffordable private insurance, and limited high risk pools. The
    CBO estimated that Affordable Care Act (ACA) repeal without a
    replacement would cause 32 million people to lose insurance. This
    legislation would be even worse, as it effectively repeals all the ACA
    coverage expansions after 2026, and also implements per capita caps on
    the rest of Medicaid that will lead to additional enrollment cuts.

    Finally, we are extremely disappointed that the proposal has not been
    considered under regular order and in fact usurped an active bipartisan
    effort to bolster Marketplace coverage. The Senate has a longstanding
    history of deliberating policy proposals through transparent processes,
    including public hearings, open comment periods on discussion drafts,
    and multi-stakeholder meetings. We are particularly concerned that
    Senators are expressing support of this proposal without a
    Congressional Budget Office (CBO) score that thoroughly examines the
    short and long-term financial and coverage impacts. The complete
    restructuring proposed for the individual private insurance market is
    likely to have repercussions on coverage that prior CBO estimates do
    not take into account. We ask all Senators to reject this proposal and
    instead engage in the process of regular order and work toward
    bipartisan solutions that ensure that all adults and children with
    disabilities have access to the healthcare they need.

                                     ______

                         National Health Council (NHC)

                          1730 M Street, NW, Suite 500

                              Washington, DC 20036

    On behalf of all people with chronic diseases and disabilities and
    their family caregivers, the National Health Council (NHC) submits this
    statement for the record to oppose the amendment to the American Health
    Care Act (AHCA) proposed by Senators Lindsey Graham, Bill Cassidy, Dean
    Heller, and Ron Johnson, just as we oppose the underlying AHCA. Both
    pieces of legislation will harm those with pre-
    existing conditions.

    Founded in 1920, the NHC is the only organization that brings together
    all segments of the health community to provide a united voice for the
    more than 133 million people with chronic diseases and disabilities and
    their family caregivers. Made up of more than 100 national health
    related organizations and businesses, the NHC's core membership
    includes the nation's leading patient advocacy organizations, which
    control its governance and policy-making process. Other members include
    professional and membership associations, nonprofit organizations with
    an interest in health, and representatives from the pharmaceutical,
    generic drug, health insurance, device, biotechnology, and
    communications industries.

    The amendment being considered today falls well short of addressing the
    many concerns the patient advocacy community has continually raised
    with previous bills such as the AHCA and the Better Care Reconciliation
    Act (BCRA). It contains many of the same harmful provisions that will
    negatively impact people with pre-existing medical conditions.

    First, we are deeply concerned about cuts in funding for and removal of
    the requirement for subsidies to help those who cannot afford their
    insurance. In addition to providing assistance to help lower-income and
    middle-class Americans afford coverage, premium subsidies have had the
    greatest impact in encouraging people to enroll in insurance, which
    helps create a more balanced and stable risk pool. Likewise, the cost-
    sharing reduction assistance greatly helps lower-
    income people afford out-of-pocket expenses such as deductibles,
    copays, and coinsurance. The repeal of these programs, reduction in
    funding, and lack of requirement that funding allocated to states be
    used to help people afford their health care is incredibly troublesome.
    We are also concerned that the funding is not guaranteed beyond 2026.

    We also are adamantly opposed to the expansion of states' ability to
    waive key patient and consumer protections. Graham-Cassidy allows any
    state that receives funding to waive protections such as the
    requirement that premiums cannot vary based on health status as well as
    essential health benefit (EHB) requirements. These actions would
    combine to completely undermine pre-existing condition protections for
    individuals with chronic conditions, as the cost of coverage could
    become prohibitively expensive or plans could exclude coverage for
    specific conditions and treatments. Waiving EHB requirements is further
    detrimental to people with chronic health conditions, both physical and
    mental health, and those who require costly care, as it will expand the
    ability to impose lifetime and annual limits on coverage and lessen the
    cap on out-of-pocket expenses. These protections only apply to EHBs, so
    this proposal will essentially open the door for discriminatory plan
    design elements to return to the insurance market. While the proposal
    does require that states applying for a waiver include a description of
    ``how the State intends to maintain access to adequate and affordable
    health insurance coverage for individuals with pre-existing
    conditions,'' it is unclear how this standard will be applied and
    enforced.

    Finally, the proposed amendment's cuts and changes to the Medicaid
    program are simply unacceptable to the patient community. Graham-
    Cassidy follows the same path as previous efforts to repeal and replace
    the Affordable Care Act (ACA) by ending the expansion of Medicaid and
    fundamentally reforming it by limiting long-term funding to the
    program. The combination of these two efforts will result in states
    making drastic changes to their program, which will result in reduced
    access to care for the nation's most vulnerable populations.

    In addition to the substantive concerns with the legislation, the NHC
    is deeply troubled that such an impactful bill may be voted on without
    a full analysis from the nonpartisan Congressional Budget Office (CBO).
    CBO has indicated that they will not be able to provide estimates on
    how many Americans will lose coverage or how the legislation will
    impact premiums or deductibles. However, independent studies have
    indicated that the impacts will be similar to the AHCA and BCRA,
    causing millions to lose coverage and deductibles and other out-of-
    pocket expenses to greatly increase. These impacts were a main reason
    why the patient-advocacy community opposed these bills, and we would
    welcome the opportunity to have a greater understanding of the impacts
    before the legislation is considered. Further, the implementation
    timeline outlined in the bill is incredibly unfeasible for states and
    the federal government to completely transition to a new health
    insurance marketplace. It will create tremendous uncertainty and has
    the likelihood of destabilizing the market for the foreseeable future.

    While we urge the Senate to reject Graham-Cassidy, we understand that
    the ACA has flaws that must be addressed by Congress. We were heartened
    by the bipartisan effort being spearheaded by Senators Alexander and
    Murray. Through hearings held in the Committee on Health, Education,
    Labor, and Pensions, we heard from many state regulators and governors
    of both parties who offered solutions to help stabilize the insurance
    market. We encourage the Finance Committee to join in these efforts to
    address issues within its jurisdiction to develop bipartisan solutions
    to these complex issues. To this end, the NHC has developed a set of
    recommendations.\1\ At a high level, we recommend that Congress:
    ---------------------------------------------------------------------------
        \1\ http://www.nationalhealthcouncil.org/sites/default/files/
    NHC%20ACA%20Stabilization%
    201-Pager%20V5.pdf

          Assure funding for cost-sharing reductions;
          Establish a stability fund;
          Support navigator programs;
          Maintain financial assistance;
          Maintain coverage of essential health benefits, including the
    standard that benefits typical of an employer group health plan be
    required in the individual market;
          Strengthen and fund outreach and marketing; and
          Monitor and address bare or limited-choice counties.

    As the Senate Finance Committee examines the proposal introduced by
    Senators Graham, Cassidy, Heller, and Johnson, we encourage the
    Congress to reject this proposal and consider the impact it will have
    on every American. Most importantly, please consider how it will
    negatively impact the 133 million Americans with chronic diseases and
    disabilities and their family caregivers.

                                     ______

                          National Health Law Program

                         1444 I Street, NW, Suite 1105

                              Washington, DC 20005

                                 (202) 289-7661

    The National Health Law Program is a national, non-profit organization
    that protects and advances the health rights of low income and
    underserved individuals. We strongly oppose the Graham-Cassidy-Heller-
    Johnson amendment (``Graham-
    Cassidy'') as its substance would decimate the Medicaid program and
    throw the country's health care system into chaos. Further, we are
    extremely concerned about the lack of transparency regarding
    consideration of the Graham-Cassidy proposal. We strongly urge the
    Senate to ensure that any effort to restructure or change Medicaid--a
    program whose financing structures have been in place for over 50
    years--and the Affordable Care Act not move forward without formal
    hearings and mark-ups and a full score from the Congressional Budget
    Office regarding both impact on the deficit and coverage.

    Medicaid is a vital program not only to the 74 million individuals
    enrolled at any point in time but also to health care providers, our
    communities, and states. Moreover, studies have shown that the Medicaid
    program has a positive economic effect for states and the influx of
    federal funds magnifies this impact. Medicaid funds not only directly
    support tens of thousands of health care providers and their staff
    throughout the country but the influx of federal dollars results in a
    multiplier effect indirectly affecting other businesses and industries
    as well.\1\ The Graham-Cassidy proposal would effectively repeal
    Medicaid expansion (not even allowing states to continue covering
    expansion enrollees at a regular Medicaid match) and convert Medicaid
    into a per capita cap coupled with billions of dollars in cuts. Every
    state will be impacted and all will be forced to make deep cuts in
    services and eligibility. Any legislation that fundamentally
    restructures Medicaid will have profound effects not only on the 74
    million individuals currently covered, but also on the hospitals,
    community health centers, managed care plans, nursing facilities, group
    homes and other providers that serve them, as well as the state and
    counties and communities in which they live.
    ---------------------------------------------------------------------------
        \1\ Kaiser Family Foundation, ``Medicaid Financing: How Does it
    Work and What are the Implications?'', (May 20, 2015), available at
    http://kff.org/medicaid/issue-brief/medicaid-financing-how-does-it-
    work-and-what-are-the-implications/.

    We also strongly oppose the changes the Graham-Cassidy proposal makes
    to the Affordable Care Act and the marketplaces. States would receive
    fixed funding and virtually unlimited flexibility to determine how to
    spend it. States would not be required to provide financial assistance
    to low-income individuals as the proposal repeals the ACA's tax credits
    and cost-sharing reductions. The one hearing scheduled in the Senate
    Finance Committee does not provide the transparency that changes of
    this magnitude deserve. Nor could it be considered ``regular order'' to
    move ahead without a full score from the Congressional Budget Office
    (CBO), as the Committees and the full Senate propose to do. The
    implications of the Graham-Cassidy proposal restructuring one-sixth of
    the economy of the country and its dramatic impact on low-income
    individuals, providers, states and counties, and for the integrity of
    the Medicaid program are too significant to rush the legislative
    ---------------------------------------------------------------------------
    process.

    If the Senate takes up this legislation without undertaking the
    considered steps of ``regular order'' and without awaiting a full score
    from the Congressional Budget Office, the Senate will abdicate its
    basic responsibility to the American people. We strongly urge the
    Senate to return to the regular order that recently produced a bi-
    partisan bill to reauthorize the Children's Health Insurance Program
    and that was working on bipartisan solutions to stabilize the
    marketplaces.

    We have specific concerns about the impact of the Graham-Cassidy
    proposal about Medicaid, women's health, and people with disabilities
    that we outline below.

    Medicaid

    Octavio is a sweet 8-year-old boy from Texas. He likes to swim, hike,
    bowl, and visit the zoo. He has autism and receives SSI Medicaid for
    his care. At age 2, he said only three words, and due to severe oral-
    motor and sensory issues, he could not eat solid food and still drank
    from a baby bottle. Thanks to speech and occupational therapies,
    Octavio began speaking, drinking from a cup, and eating regular food.
    Although he has made significant progress, Octavio is still
    developmentally delayed and needs many more years of therapy to become
    an independent adult. His mother, Rosanna stays at home to care for
    him. She says, ``I am very concerned about Republican proposals to cut,
    cap, or block grant Medicaid. My son relies on Medicaid to cover his
    speech, occupational, and physical therapies as well as his doctor and
    dental visits. As it is, some doctors and therapists have stopped
    taking Medicaid because of red tape and low reimbursements rates.
    Further cuts and caps will destroy the program.''

        1.  Per Capita Cap (PCC). Since 1965, Medicaid has operated as a
    federal-state partnership where states receive on average 63% of the
    costs of Medicaid from the federal government. The federal share is
    based on actual costs of providing services, and lower income states
    receive more federal funding. Graham-
    Cassidy limits the federal contribution to states, based on a state's
    historical expenditures inflated at a rate projected to be less than
    the yearly growth of Medicaid health care costs.\2\ Beginning January
    1, 2020, funding for state Medicaid programs will shrink over time,
    resulting in states cutting coverage and services for all
    beneficiaries. In addition, starting in 2025, states would be limited
    to an even lower growth rate than in the initial PCC years. Graham-
    Cassidy also imposes a penalty on states that spend above the national
    mean, starting in 2020 (2 years earlier than BCRA). This penalty would
    be imposed even if a state spends more because care is more costly due
    to geography or other factors or because enrollees are older or sicker
    than in another state. If a state spends 25% more than the national
    mean for a particular eligibility group (e.g., seniors or people with
    disabilities), it would lose .5-2% of its aggregate cap amount for the
    applicable group for that year unless the state is a ``low density''
    state (less than 15 individuals per square mile). We oppose converting
    Medicaid into per capita caps and strongly believe Medicaid's current
    financing structure must remain in place.
    ---------------------------------------------------------------------------
        \2\ Graham-Cassidy's growth rate from the state's base year through
    2019 is the medical component of the Consumer Price Index (CPI-M). For
    2019-2025, the growth rate would be CPI-M plus 1% for elderly enrollees
    and enrollees with disabilities and CPI-M for adults and children.
    Beginning in 2025, the growth rate would lower to the ``regular'' CPI
    which grows even slower than CPI-M and does not include long term care
    costs.

        2.  Medicaid Expansion. Graham-Cassidy goes a step further than
    prior Senate bills by reducing the FMAP to 0% for any state that covers
    Medicaid expansion enrollees after 2020 (except Native Americans who
    meet certain ``grandfathering'' requirements). Experts estimate that
    1.3 million individuals covered in the Medicaid expansion have a
    serious mental health diagnosis. Medicaid expansion has been associated
    with reducing significant unmet mental health care needs. By repealing
    Medicaid expansion, Graham Cassidy turns back the clock on this
    progress. Even if a state wanted to continue covering Medicaid
    expansion enrollees, it could not get any federal funding and would
    have to pay 100% of the costs. Graham-Cassidy creates a new block grant
    for states to help pay for health coverage for consumers who would have
    been covered by Medicaid expansion, as well as those who would have
    received tax credits and cost-sharing reductions, among other factors.
    But the block grant funding is set at 17% less than current funding. We
    ---------------------------------------------------------------------------
    oppose repealing the Medicaid Expansion option for states.

        3.  Shorter Eligibility Periods for Medicaid Expansion Enrollees.
    While states can continue Medicaid Expansion through December 31, 2019
    with a 90% federal match, Graham-Cassidy allows states to require those
    in the Medicaid expansion population to submit eligibility renewal
    paperwork every six months just to stay on Medicaid, beginning October
    1, 2017. This will certainly result in more eligible enrollees losing
    their Medicaid coverage. We oppose requirements for additional
    documentation due to shorter eligibility periods.

        4.  Work Requirements. Graham-Cassidy allows states to impose work
    requirements on people who are not disabled, elderly, or pregnant
    Medicaid enrollees. Currently, nearly 8 in 10 Medicaid enrollees are
    part of a working family. Another 14% of Medicaid enrollees are
    currently looking for work. Yet, Graham-Cassidy would allow states to
    require work as a condition of eligibility, including enrollees who are
    caring for a parent or spouse and both parents in a two-parent
    household. Individuals receiving mental health or substance use
    disorder services who are eligible through Medicaid expansion (rather
    than a disability category) would be required to work as a condition of
    receiving treatment, which could undermine their progress and recovery.
    Medicaid coverage makes it easier to find and sustain work and should
    not be denied to those who need care before being able to work. We
    oppose work requirements in Medicaid.

        5.  Block Grant for Certain Populations. In addition to requiring
    all states to operate within fixed caps, Graham-Cassidy also gives
    states the option to operate part of Medicaid program as a block grant
    as opposed to a PCC for people who are not elderly, disabled, pregnant
    adults. States would be locked in for a 5-year period, and the growth
    rate would be lower than the initial per capita cap growth rate
    (although by 2025, both the PCC and block grant growth rates would be
    the same). We oppose allowing states to operate Medicaid through a
    block grant for any eligibility group.

        6.  Presumptive Eligibility. In addition to repealing the Medicaid
    expansion, Graham-Cassidy prevents states from using ``presumptive
    eligibility'' and express lane eligibility after January 1, 2020. This
    includes repealing the ability of states to permit their hospitals to
    use presumptive eligibility for pregnant women, children, individuals
    with breast and cervical cancer, and for family planning services and
    supplies to obtain immediate Medicaid coverage when they end up in
    emergency rooms or hospitalized for treatment without insurance means
    they will end up with medical debt. We oppose repealing presumptive
    eligibility.

        7.  Retroactive Eligibility. Medicaid currently provides coverage
    up to three months before the month an individual applies for coverage.
    This ``retroactive coverage'' protects individuals from medical
    expenses they incurred before they apply for Medicaid. An individual
    may not be able to apply for Medicaid immediately due to
    hospitalization, a disability, or other circumstances. Retroactive
    coverage provides that critical coverage and ensures providers are
    reimbursed for their costs and that low-income individuals do not end
    up facing severe medical debt or bankruptcy due to these medical
    expenses. Graham-Cassidy reduces retroactive coverage for most Medicaid
    beneficiaries to 2 months starting October 1, 2017. It requires states
    to maintain 3 months of retroactive coverage only for seniors and
    people with disabilities. We oppose reducing retroactive eligibility.

        8.  Essential Health Benefits (EHBs) for Medicaid Expansion
    Beneficiaries. Under the ACA, states that expanded coverage to non-
    pregnant childless adults had to provide coverage in at least the 10
    ``essential health benefit'' categories. Graham-Cassidy repeals this
    requirement, effective December 31, 2019, resulting in beneficiaries
    losing services such as mental health and substance use disorder
    services and some no cost preventive health services. We oppose
    repealing EHBs for Medicaid expansion enrollees.

        9.  Provider Taxes. Graham-Cassidy reduces states' ability to use
    provider taxes to help pay the state's share of Medicaid. Cutting or
    eliminating provider taxes is a substantial cost shift to states and
    threatens access to care for millions of Medicaid enrollees. It also
    undermines state flexibility to administer the Medicaid program without
    doing anything to achieve programmatic efficiencies or improve quality.
    We oppose reductions to provider taxes.

    Women's Health

    For Shyronn, a woman living with HIV in Georgia, having Medicaid allows
    her to be active in her community. With Medicaid, she does not worry
    about dying prematurely. Because of the services she receives through
    Medicaid, she can live a normal life expectancy, remain a productive
    citizen, and be there for her three children, including a 19-year-old
    son who is actively serving our country in the United States Marine
    Corps, a 14-year-old son who is engaged in school and community service
    projects, and her 4-year-old daughter who is a ray of life who
    brightens every soul she encounters. Medicaid has allowed her entire
    family to stay healthy even when money is tight. Shyronn is passionate
    about HIV prevention and empowering people living with HIV. She
    volunteers her time to educate her community, youth, and policymakers
    both in person and online about HIV risk, prevention and care. She is
    also a member of Positive Women's Network-USA, a national membership
    body of women that works to empower women living with HIV and develop
    their leadership skills. Shyronn relies on essential supportive
    services covered by Medicaid, such as mental health and case
    management, in order to contribute to her family and community. She
    says, ``the mental health counseling and case management I receive
    through Medicaid work hand-in-hand to strengthen and support my ability
    to handle the ups and downs of life. Having Medicaid has motivated me
    to adhere to my medical appointments and treatment plans. When I did
    not have Medicaid, I rarely sought medical attention.''

        1.  Planned Parenthood. The Graham-Cassidy bill resurrects the
    previous ACA repeal bills' provisions targeting Planned Parenthood by
    prohibiting the organization from participating in the Medicaid program
    for one year, starting on the date of the bill's enactment. This would
    mean many Medicaid enrollees would no longer be able to receive
    Medicaid-covered services from their trusted provider of choice.
    Excluding Planned Parenthood from the Medicaid program reduces access
    to essential preventive care, such as contraception, tests and
    treatment for sexually transmitted infections, and breast and cervical
    cancer screenings. Other safety-net providers such as community health
    centers lack the capacity to serve all the Medicaid enrollees who could
    no longer receive care at Planned Parenthood. As a result, in some
    areas of the country, particularly rural areas, people would lose
    access to critical reproductive health services. We oppose excluding
    Planned Parenthood from the Medicaid program.

        2.  Private Coverage. Nearly 7 million women and girls selected a
    private insurance marketplace plan during the 2016 open enrollment
    period.\3\ The majority relied on the ACA's federal subsidies to help
    make the coverage more affordable. Graham-Cassidy eliminates the ACA's
    current income-based premium tax credits and cost-sharing reductions
    effective January 1, 2020. The bill then proposes to replace both
    Medicaid expansion and marketplace subsidies with a time-limited block
    grant that is set at 17% less than current funding, and which would
    phase out completely after 2026.\4\ Taken together, these changes would
    raise premiums, increase deductibles, and make it harder for women and
    girls to afford high-quality comprehensive health care that meets their
    needs. We oppose repealing the ACA's provisions governing marketplaces,
    tax credits and cost-sharing assistance.
    ---------------------------------------------------------------------------
        \3\ U.S. Department of Health and Human Services, Office of the
    Assistant Secretary for Planning and Evaluation, ``Health Insurance
    Marketplaces 2016 Open Enrollment Period: Final Enrollment Report''
    (March 2016), https://aspe.hhs.gov/system/files/pdf/187866/
    Finalenrollment
    2016.pdf.
        \4\ Center on Budget and Policy Priorities, ``Like Other ACA Repeal
    Bills, Cassidy-Graham Plan Would Add Millions to Uninsured, Destabilize
    Individual Market'' (September 2017), https://www.cbpp.org/research/
    health/like-other-aca-repeal-bills-cassidy-graham-plan-would-add-
    millions-to-uninsured.

        3.  Abortion Care in Private Plans. The Graham-Cassidy bill
    includes restrictions that prohibit individuals and small employers,
    effective January 1, 2018, from using federal tax credits to purchase
    private health insurance plans that include abortion coverage beyond
    the Hyde exceptions.\5\ The bill also specifically prohibits
    individuals from using their Health Savings Accounts to pay for a High
    Deductible Health Plan that covers abortion beyond the Hyde exceptions,
    also effective January 1, 2018. These provisions could cause insurance
    companies to stop offering plans that include abortion coverage
    altogether, thereby putting abortion access further out of reach for
    women in the private market. The provisions are also of particular
    concern for states that broadly require abortion coverage in all or
    most of their private plans, such as California and New York. The
    restriction either forces these states to change their policies on
    abortion coverage, or run the risk of dramatically reducing the number
    of state residents who are eligible for federal tax credits. We oppose
    restrictions on purchasing plans that cover abortion.
    ---------------------------------------------------------------------------
        \5\ The Hyde exceptions are abortions that are necessary to save
    the life of the mother, or to terminate pregnancies that are the result
    of rape or incest.

    Rachel, who lives in Illinois, was overjoyed, but also overwhelmed when
    she found out that she was pregnant. Though her pregnancy was planned,
    Rachel did not have maternity coverage though her part-time job. She
    intended to find a way to scrape together money and pay for her
    prenatal care out of pocket. Rachel knew she wanted to give birth at
    home, so she started to do research about what was available in her
    hometown. Rachel met with a midwife shortly after she confirmed her
    pregnancy. The midwife told Rachel that she was probably eligible to
    get Medicaid to help her with the cost of prenatal care and labor and
    delivery. The midwife advised Rachel on how to apply, and explained to
    her exactly what she needed to do and bring to the Medicaid office in
    order to apply. Rachel was found eligible for pregnancy-based Medicaid,
    which she used throughout her pregnancy. She was able to use Medicaid
    for all the care she needed during her pregnancy including labs, dental
    care, ultrasounds, and screening tests. Her pregnancy was healthy and
    uneventful, and she gave birth to her son Owen at home surrounded by
    her family and friends, just as she wanted. After giving birth, Rachel
    was able to get all of her postpartum care through Medicaid too,
    including getting an IUD put in to avoid getting pregnant again before
    she was ready. Rachel struggled with breastfeeding, but with Medicaid
    she was able to see a lactation consultant and get a breast pump; she
    was also connected to a breastfeeding support resource group. In
    addition, her newborn son was immediately enrolled into Medicaid and
    was able to get the well visits, screenings, and immunizations he
    needed in his first year of life. After giving birth, Rachel was still
    working part-time and trying make ends meet. Rachel says that her
    ability to stay on Medicaid while she was adjusting to having a newborn
    was ``so important!'' She adds, ``Medicaid is what allowed me to get
    the care I needed as new mom and to take care of my baby.''

    People With Disabilities

    Julie, who lives in Colorado, was diagnosed with Multiple Sclerosis in
    the late 1980s at age 20. Over the next several years, she had more
    than a dozen hospitalizations with no way to pay for them, even though
    she was working. After almost dying from being uninsured and
    uninsurable, she was able to get coverage through Medicaid Home and
    Community Based Services (HCBS). In more than 20 years on Medicaid
    HCBS, she has not been in a hospital at all. To get on Medicaid, Julie
    had to stop working for pay and go on Social Security Disability. In
    late 2012, Colorado created a Medicaid Buy-In for Working Adults with
    Disabilities. As a result, she was able to start working for pay, with
    her salary ranging from $10,000 to $50,000 over the past few years. She
    was able to give up Social Security Disability and now receives only
    Medicaid and happily pays a premium. Medicaid provides her personal
    care, including a high quality wheelchair for both indoors and outdoors
    which is not available through Medicare or most insurance companies.
    She also requires more than $1,000 a month of medications and supplies.
    Because she can work, she is able to give back to the community
    personally and through her job as the director of a nonprofit
    organization, the Colorado Cross-Disability Coalition. Without
    Medicaid, Julie fears she would be unable to function enough to work
    and certainly cost the system more via inability to meet needs causing
    illnesses that require hospital visits that she cannot afford. She says
    that making changes to Medicaid, such as block granting would be
    devastating. Julie says, ``Those of us with disabilities are always
    blamed for costing the most in the system--but prevention with us costs
    more. Instead of a $30 vaccination preventing $1,000 ER visit for the
    flu, it might be a $15,000 wheelchair with complex rehab seating
    systems preventing $1 million in pressure sores. People with
    disabilities are the canaries in the coal mines of health care.''

        1.  Home and Community Based Services. As Graham-Cassidy would
    impose deep cuts to Medicaid, states will have to make difficult
    choices in their budgets between absorbing costs, cutting non-health
    related state services (such as education) or cutting Medicaid. Some of
    the services most at risk for cuts are Medicaid-funded Home and
    Community Based Services (HCBS), including personal care services,
    employment supports, residential supports, and specialized therapies.
    HCBS are cost-efficient when compared to institutional care, but HCBS
    are optional for states to provide while institutional care, like
    nursing facilities, is often mandatory. Severe federal Medicaid cuts
    put HCBS services directly in the crosshairs of state budget cuts. We
    oppose per capita caps in Medicaid that will lead to cuts in HCBS.

        2.  Waitlists. Many HCBS services are delivered via Medicaid
    waivers. Waivers let states limit the number of people getting services
    and set special income limits to provide eligibility above regular
    Medicaid eligibility limits. Unlike regular Medicaid, states can set up
    a ``waitlist'' for some waivers. Thus, individuals who meet the waiver
    program requirements may still have to wait for services until one of a
    limited number of slots becomes available. In fact, over half a million
    individuals are already on these waiting lists. Graham-Cassidy would
    cut Medicaid by hundreds of billions, likely leading to even longer
    waitlists as states struggle to provide required services to eligible
    individuals before providing optional waiver services. We oppose per
    capita caps in Medicaid that will lead to increase in waiting lists.

        3.  Home and Community-Based Attendant Supports. Graham-Cassidy
    takes direct aim at the ``Community First Choice Option'' (CFC), which
    provides states enhanced federal funding for home and community-based
    services and supports under State Medicaid Plans. CFC services assist
    individuals with Activities of Daily Living (ADLs) and habilitative
    services. Graham-Cassidy repeals the 6% enhanced funding to cover these
    services, which CBO predicts will reduce federal supports to
    participating states by $19 billion. Instead,
    Graham-Cassidy proposes $8 billion in demonstration funds, lasting just
    4 years and limited to 15 states, with a preference for more rural
    states. A limited, short-term demonstration program is no substitute
    for the CFC option. We oppose cuts to the Community First Choice
    funding.

        4.  Institutional Care. Medicaid traditionally does not fund
    services in large (more than 16 beds) psychiatric facilities for adults
    under age 65, such as state long-term hospitals, but it does fund
    community-based rehabilitation services. In this way, Medicaid's
    structure encourages states to limit the use of large, congregate
    facilities--the trend has been to develop smaller, more community-based
    facilities instead. Graham-Cassidy could reverse this trend--first by
    offering funding to states for medium-length stays in these
    institutions (30 days or less in a 6 month period), and then mandating
    that states accepting this funding maintain the same number of licensed
    beds at psychiatric hospitals owned, operated or contracted by the
    state. By forcing states to maintain a specific number of ``beds,''
    whether or not the demand exists, this provision creates an incentive
    for states to fill such beds, even if people can be served in less
    restrictive, more integrated environments. Not only does this raise
    Medicaid concerns, but it also creates conflict with the state and
    provider obligations under Olmstead to ensure people receive services
    in the most integrated setting appropriate to their needs. We oppose
    provisions that incentivize institutional care.

        5.  Pathways to Coverage for Children With Disabilities. Nearly all
    states disregard parental income for children with significant
    disabilities living at home to provide them Medicaid coverage. This
    option, called the ``Katie Beckett program,'' saves parents from the
    unbearable dilemma of having to place their child in institutional
    care, where parental income is automatically disregarded, so their
    child can qualify for Medicaid. The Katie Beckett program allows these
    children to get the care they need while living at home. However, these
    children tend to have expensive health needs and the coverage is
    optional for states. Graham-Cassidy gives states an incentive to reduce
    Medicaid enrollment and costs. In response, states may severely curtail
    or eliminate their Katie Beckett programs. We oppose per capita caps
    that could lead states to curb their Katie Beckett programs.

        6.  Parents and Home Care Workers. Juggling doctors' appointments,
    therapies, and school meetings may mean parents of children with
    disabilities cannot work full time. Medicaid expansion helps low-income
    parents by making health care available to them, so they can keep
    themselves healthy and take care of their children. Similarly, the home
    care workers that actually provide HCBS for individuals with
    disabilities often rely on Medicaid for their own care. One-in-three
    home care workers live in households that qualify for Medicaid
    expansion. Medicaid expansion indirectly supports individuals with
    disabilities by making health care available to their parents and the
    workers who provide HCBS. Converting Medicaid expansion into a block
    grant and competing with other state health care funding needs will
    likely result in decreased coverage for these parents and home care
    workers. We oppose repeal of Medicaid expansion.

    Other Provisions

        1.  Pre-Existing Conditions. Prior to passage of the ACA, insurers
    regularly charged women higher premiums, or outright denied them
    coverage, based on pre-existing condition exclusions such as being
    cancer survivors, having had a cesarean section, having received
    medical treatment from domestic violence or sexual assault, or for
    being pregnant.\6\ The ACA changed this by prohibiting health plans
    from either denying coverage or charging higher premiums to people with
    pre-existing conditions. In addition to the issues specifically related
    to maternity and newborn care above, health plans in states that choose
    to modify or eliminate EHBs would likely offer less comprehensive plans
    that lack the specific services people with pre-existing conditions
    need. People with pre-existing conditions would be forced to pay higher
    premiums for more comprehensive coverage that includes their needed
    services. The result would be an end run around the ACA's prohibition
    on discriminating against people with pre-existing conditions.
    Elimination of this ACA protection could prevent women with chronic and
    other pre-existing conditions from obtaining health insurance that
    meets their needs, or indeed from obtaining health insurance at all.
    This also effectively excludes individuals with disabilities from
    plans, as many disabilities are, by definition, pre-existing
    conditions. We oppose provisions weakening protections for individuals
    with pre-existing conditions.
    ---------------------------------------------------------------------------
        \6\ Id.

        2.  Essential Health Benefits (EHBs). Currently, insurers in the
    small group and individual market must provide coverage in at least 10
    ``essential health benefit'' categories. Graham-Cassidy allows states
    to waive this requirement. This has direct implications for people with
    disabilities and for women's health. If a state waives EHBs such that
    mental health benefits are excluded altogether from plans, mental
    health parity protections are rendered meaningless because mental
    health parity only applies if plans offer mental health benefits.
    Similarly, insurers could choose not to provide habilitative services.
    Even if plans include mental health or habilitative services, the
    prohibition on lifetime and annual limits only applies to EHBs. If
    states waive EHB requirements, any insurers that still cover these
    important services could impose lifetime and annual limits.
    Habilitation services are likely to be necessary in the long term for
    families with children with I/DD. EHBs also includes maternity and
    newborn care, as well as other services essential to basic reproductive
    health such as preventive and wellness services, mental health and
    substance use disorder services, and prescription drugs. One study
    found that if a state eliminated the EHB requirement to cover maternity
    care, the premium for a maternity care rider would cost a woman an
    additional $17,320 in 2026.\7\ Prior to passage of the ACA, only 12% of
    individual health plans across the country covered maternity care,
    resulting in high out-of-pocket costs for pregnant women.\8\
    Elimination of the EHB requirement would again leave many women without
    adequate maternity care or force them to incur debt to obtain care. It
    would also effectively allow plans to practice gender discrimination by
    requiring women to pay more for plans that do include maternity care.
    We oppose waivers of EHB requirements.
    ---------------------------------------------------------------------------
        \7\ Sam Berger and Emily Gee, Center for American Progress,
    ``Senate Health Care Bill Could Drive Up Coverage Costs for Maternity
    Care and Mental Health and Substance Use Disorder Treatment'' (June
    2017), https://www.americanprogress.org/issues/healthcare/news/2017/06/
    20/434670/senate-health-care-bill-drive-coverage-costs-maternity-care-
    mental-health-substance-use-disorder-treatment.
        \8\ National Women's Law Center, ``Women and the Health Care Law in
    the United States'' (May 2013), https://nwlc.org/wp-content/uploads/
    2015/08/us_healthstateprofiles.pdf.

    If you have any questions about this statement, please contact Mara
    Youdelman, Managing Attorney of the National Health Law Program's DC
    ---------------------------------------------------------------------------
    office, (202) 289-7661,Youdelman@healthlaw.org.

                                     ______

                      National Multiple Sclerosis Society

                     1100 New York Avenue, NW, Suite 440-E

                              Washington, DC 20005

                              tel +1 202-408-1500

                              fax +1 202-408-0696

                       https://www.nationalmssociety.org/

         Statement of Bari Talente, Executive Vice President, Advocacy

    The National Multiple Sclerosis Society has urged all members of
    Congress to work towards bipartisan solutions to strengthen access to
    comprehensive and more affordable health coverage and care so people
    living with Multiple Sclerosis (MS) can live their best lives. The
    proposal put forth by Senators Graham, Cassidy, Heller and Johnson
    (Graham-Cassidy) is neither bipartisan nor a solution, and we urge all
    to oppose it. The voices of people living with the disease must not be
    left out of the decisions that determine their ability to secure the
    care they need and deserve.

    Graham-Cassidy would repeal current protections for people with pre-
    existing and high-cost conditions like MS. It would end Medicaid
    expansion coverage and federal subsidies for health insurance, leaving
    over 23 million currently insured people in jeopardy of losing their
    access to health care altogether.\1\
    ---------------------------------------------------------------------------
        \1\ Manatt Health, ``State Policy and Budget Impacts of New Graham-
    Cassidy Repeal and Replace Proposal,'' September 2017.

            As a Texan living with Multiple Sclerosis, the Graham-Cassidy
            bill keeps me awake with worry each night. . . . It took
            $170,000 to keep me, the vegan triathlete who happens to have
            an incurable neurodegenerative disease, healthy and able-bodied
    ---------------------------------------------------------------------------
            for one year.

                --Jennifer Kiser, Roanoke, TX

    The proposal would give states wide latitude to waive current insurance
    benefit requirements and other standards of fairness for people with
    pre-existing conditions. People with MS in states that waive these
    protections could face substantially higher premiums or find themselves
    in plans without coverage for the medications, rehabilitation benefits,
    MRIs or other services that help them remain healthy, productive and
    independent.

            Any legislation, such as Graham-Cassidy, that will allow states
            to set their own rules and offer low-quality insurance
            policies, will have life and death consequences for millions of
            people across the country, and could be financially devastating
            for people with MS like me and families that have had a loved
            one fall ill.

                --Bob Finkelstein, Philadelphia, PA

    If enacted, Graham-Cassidy would dramatically cut and redistribute
    federal funds to states, with some states seeing reductions of up to
    50% or more in support of care for low-income individuals.\2\ People
    living with MS know the current system is far from perfect, but are
    fearful of measures that would erode improvements in access to quality
    MS care they have witnessed in recent years.
    ---------------------------------------------------------------------------
        \2\ Ibid.

            When diagnosed with Multiple Sclerosis in 1999, I became a
            medical hostage. Since this was pre-Affordable Care Act, my
            same insurance company could refuse coverage, slot me into a
            high-risk pool, or keep me from receiving the ``too new''
            disease stalling medications debuting at that time, which have
            since become the standard of care. It's not okay to gamble with
            our health. I don't want to return to the days when we lacked
            protections and access. Please don't gamble with our health.
    ---------------------------------------------------------------------------
            Reject Graham-Cassidy.

                --Vivian Leal, Reno, NV

    In addition to the dangerous policies contained in Graham-Cassidy, the
    Society is dismayed that only one hearing is being held on the
    proposal, and by the absence of regular order. Legislation that impacts
    one sixth of the U.S. economy and the well-being of millions requires
    thoughtful consideration and debate. It is also reckless to vote on
    such significant legislation without a comprehensive score from the
    Congressional Budget Office that provides data on its impact on
    premiums and coverage. The Society implores Congress to reject Graham-
    Cassidy and return to bipartisan work that will improve access to
    affordable, quality health coverage and care for people with MS.

                                     ______

                  National Partnership for Women and Families

                     1875 Connecticut Avenue, NW, Suite 650

                              Washington, DC 20009

                Statement Submitted by Debra L. Ness, President

    Chairman Hatch and Ranking Member Wyden,

    The National Partnership for Women and Families is a nonprofit,
    nonpartisan organization that has fought for decades to strengthen our
    health care system and advance the rights and well-being of women. On
    behalf of women across the country who are the health care decision-
    makers for themselves and their families, we write in strong opposition
    to the Graham-Cassidy-Heller-Johnson proposal (``the Graham-Cassidy
    proposal'') to repeal the Affordable Care Act. The Graham-Cassidy
    proposal is yet another assault on the health care women and families
    rely on.

    The Graham-Cassidy proposal would devastate women's health care and
    coverage. For example, it would:

          Repeal the ACA marketplace financial assistance, endangering the
    health and economic security of the 6.8 million women who depend on the
    Marketplace for affordable health coverage.\1\
    ---------------------------------------------------------------------------
        \1\ U.S. Department of Health and Human Services. (March 11, 2016).
    ``Issue Brief: Health Insurance Marketplaces 2016 Open Enrollment
    Period: Final Enrollment Report.'' Retrieved September 22, 2017, from
    https://aspe.hhs.gov/system/files/pdf/187866/Finalenrollment2016.pdf.

          End Medicaid as we know it, harming the nearly 1 in 5 adult
    women who are covered by Medicaid.\2\
    ---------------------------------------------------------------------------
        \2\ National Partnership for Women and Families. (September 2017).
    ``Fact Sheet: Women's Health Coverage: Sources and Rates of
    Insurance.'' Retrieved September 22, 2017, from http://
    www.nationalpartnership.org/research-library/health-care/womens-health-
    coverage-sources-and-rates-of-insurance.pdf.

          Block Medicaid enrollees from accessing care at Planned
    Parenthood, denying millions of people access to essential preventive
    ---------------------------------------------------------------------------
    services such as birth control and cancer screenings.

          Eliminate guaranteed coverage of critical health services for
    women, like maternity care, prescription drug coverage and mental
    health services.

          Allow insurance companies to discriminate against people with
    pre-existing conditions, including 67 million women and girls.\3\ This
    means coverage could become prohibitively expensive for those in dire
    need of care. For example, insurers would charge about $17,320 more in
    premiums for pregnancy.\4\
    ---------------------------------------------------------------------------
        \3\ U.S. Department of Health and Human Services. (January 5,
    2017). ``Issue Brief: Health Insurance Coverage for Americans with Pre-
    Existing Conditions: The Impact of the Affordable Care Act.'' Retrieved
    September 22, 2017, from https://aspe.hhs.gov/system/files/pdf/255396/
    Pre-ExistingConditions.pdf.
        \4\ Berger, S., and Gee, Emily. Center for American Progress.
    (September 18, 2017). ``Graham-Cassidy ACA Repeal Bill Would Cause Huge
    Premium Increases for People With Pre-Existing Conditions.'' Retrieved
    September 22, 2017, from https://www.americanprogress.org/issues/
    healthcare/news/2017/09/18/439091/graham-cassidy-aca-repeal-bill-cause-
    huge-premium-increases-people-pre-existing-conditions/.

          Discourage private insurance coverage of abortion by penalizing
    health plans that offer it with burdensome bureaucratic requirements,
    and pushing abortion coverage further out of reach for many women.
    Denying coverage for abortion means women must cover the costs of care
    themselves--often delaying care to come up with the funds, or
    ---------------------------------------------------------------------------
    sacrificing other essential expenses to do so.

          Lead to 32 million people losing coverage;\5\ $4 trillion in
    cuts to states over the next 2 decades;\6\ and a 20 percent increase in
    premiums for the same coverage.\7\
    ---------------------------------------------------------------------------
        \5\ Collins, Sara R. (September 20, 2017). ``What Are the Potential
    Effects of the Graham-
    Cassidy ACA Repeal-and-Replace Bill? Past Estimates Provide Some
    Clues.'' Commonwealth Fund. Retrieved September 22, 2017, from http://
    www.commonwealthfund.org/publications/blog/2017/sep/potential-effects-
    of-graham-cassidy.
        \6\ Carpenter, E., and Sloan C. Avalere. (September 20, 2017).
    ``Graham-Cassidy-Heller-Johnson Bill Would Reduce Federal Funding to
    States by $275 Billion'' [press release]. Retrieved September 22, 2017,
    from http://avalere.com/expertise/life-sciences/insights/graham-
    cassidy-hell
    er-johnson-bill-would-reduce-federal-funding-to-sta.
        \7\ Congressional Budget Office. (December 8, 2016). ``Repeal the
    Individual Health Insurance Mandate.'' Retrieved September 22, 2017,
    from https://www.cbo.gov/budget-options/2016/52232.

    Put simply: this proposal would devastate the health and economic
    ---------------------------------------------------------------------------
    security of women and families.

    It is long past time for Congress to work in a bipartisan way to
    stabilize the insurance markets and make quality, affordable care
    available to all, not continue trying to repeal the Affordable Care
    Act, which has been the greatest advance for women's health in a
    generation.

    If you have any questions, please reach out to Katie Martin, vice
    president for health policy and programs, at
    kmartin@nationalpartnership.org or 202-986-2600.

                                     ______

                          National Women's Law Center

                        Statement of Gretchen Borchelt,
               Vice President for Reproductive Rights and Health

    The National Women's Law Center (``Center'') has worked for 45 years to
    advance and protect equality and opportunity for women and girls in
    every aspect of their lives, including health care and economic
    security. The National Women's Law Center submits this statement in
    strong opposition to the Graham-Cassidy-Heller-
    Johnson (``Graham-Cassidy'') proposal to repeal the Affordable Care Act
    (ACA).

    If passed, the Graham-Cassidy proposal would threaten women's health,
    take away women's access to health services and coverage, and
    jeopardize the economic security of women and families. By gutting
    federal support, ending the Medicaid program as we know it, permitting
    insurance practices that discriminate against women, imposing
    restrictions that effectively eliminate abortion coverage, and barring
    Medicaid funding to Planned Parenthood health centers, the Graham-
    Cassidy proposal would undo progress women have made since the ACA was
    passed, and leave women without access to the affordable and quality
    health care and coverage that they need.

    The Graham-Cassidy Proposal Would Gut Federal Funding for Health Care,
    Leaving Women Without Critical Coverage

    The Graham-Cassidy proposal would fundamentally change federal
    financing of health coverage. It would eliminate federal funding for
    the ACA's tax credits and cost sharing reductions and the Medicaid
    expansion starting in 2020, and replace it with a smaller block grant
    to the states that would disappear in 2026. This block grant would be
    inadequate, with states receiving less money than they would under the
    ACA and, according to the Center for Budget Policy Priorities, would
    ``cause many millions of people to lose coverage.'' \1\ This radical
    restructuring would be especially devastating to women.
    ---------------------------------------------------------------------------
        \1\ Jacob Leibenluft, et al., ``Like Other ACA Repeal Proposals,
    Cassidy-Graham Plan Would Add Millions to Uninsured, Destabilize
    Individual Market'' (September 20, 2017), available at https://
    www.cbpp.org/research/health/like-other-aca-repeal-proposals-cassidy-
    graham-plan-would-add-millions-to-uninsured.

    Due to the restructuring, women would lose health insurance coverage
    that they have recently gained thanks to the ACA. According to the most
    recent Census data, the Center calculates that more than 89.4 million
    women have health insurance, with an additional 7.2 million women
    gaining health insurance from 2013-2016. This coverage contains
    protections that, among other things, ensure women are not charged more
    than men for the same coverage, are not treated as a pre-existing
    condition, and have coverage for essential and preventive health care
    needs, like maternity care, birth control, and well-woman visits. The
    Graham-Cassidy proposal would take this important coverage away from
    ---------------------------------------------------------------------------
    women.

    By eliminating the ACA's tax credits and cost sharing reductions, the
    Graham-
    Cassidy proposal would also put affordable health coverage out of reach
    for the millions of women who rely on federal financial assistance to
    afford coverage. According to the Center's calculations, as of 2014,
    over 9 million women who would otherwise have gone without affordable
    health insurance were eligible to benefit from the ACA's tax credits,
    including a high number of women of color. Separately, the cost sharing
    reductions help to reduce copayments, deductibles, and other out-of-
    pocket costs for marketplace enrollees. More than 5.6 million people,
    or almost 60 percent of ACA marketplace enrollees, received cost
    sharing reductions in 2016, and on average, cost sharing reductions
    help to reduce individuals' out-of-pocket costs by roughly $1,100 per
    person.\2\ These reductions are significant for women who, according to
    data both pre- and post-ACA, are more likely to forego health care
    because of costs, including increased out-of-pocket costs. Eliminating
    the federal assistance to purchase health insurance, as the Graham-
    Cassidy proposal does, would only compound existing barriers to
    purchasing health coverage for women, who are more likely to live in
    poverty than men, earn less than men, and are more likely to work in
    low-wage jobs with less ability to absorb extra costs. These cost
    barriers are particularly prohibitive for women of color who are more
    likely to live in poverty than whites and who were more likely to be
    uninsured pre-ACA due to costs.
    ---------------------------------------------------------------------------
        \2\ Sarah Lueck, Center on Budget and Policy Priorities,
    Interactive map: ``Cost-Sharing Subsidies at Risk Under House GOP
    Health Proposal'' (March 21, 2017), available at https://www.cbpp.org/
    blog/interactive-map-cost-sharing-subsidies-at-risk-under-house-gop-
    health-proposal.

    Elimination of the Medicaid expansion would be especially devastating
    for women. According to the Center's calculations, states expanding
    Medicaid have seen the largest increases in Medicaid enrollment of
    women ages 18-64 between 2013-2015. Medicaid expansion has been
    particularly important for low-income, childless women who were not
    eligible for Medicaid before expansion. Without coverage, low-income
    women are more likely to go without health care because of cost, are
    less likely to have a regular source of care, and utilize preventive
    ---------------------------------------------------------------------------
    services at lower rates than low-income women with health insurance.

    The Graham-Cassidy Proposal Would End Medicaid as We Know It, Posing
    Particular Harm to Women Struggling to Make Ends Meet

    In addition to ending funding for the Medicaid expansion, the Graham-
    Cassidy proposal makes radical changes to the Medicaid program, which
    would end the program as we know it and pose particular harm to women
    who are already struggling to make ends meet.

    The Graham-Cassidy proposal would dismantle the Medicaid program by
    converting Medicaid's current federal-state partnership, which
    automatically responds to changing needs, into a per capita cap system.
    It would allow states to convert their Medicaid programs into either a
    block grant or per capita cap system. Block grant and per capita cap
    systems limit and cut federal funding and shift to states the risk of
    increases in Medicaid costs. Either one would force states to cut
    Medicaid coverage and benefits--and possibly other services as well.\3\
    For example, block granting Medicaid could give states the ability to
    reduce the number of people covered by Medicaid by eliminating
    eligibility for some people now entitled to benefits under law (for
    example, pregnant women with family incomes below 133% of poverty);
    denying or delaying services to eligible people by establishing
    enrollment caps and wait lists; and creating administrative barriers to
    enrolling and maintaining enrollment. A Medicaid block grant could
    allow states to reduce Medicaid benefits by eliminating some services
    that are currently required (for example, family planning services and
    diagnostic and treatment services for young children); setting limits
    on the utilization of benefits; and raising the amount that low-income
    families must pay for such services through premiums, deductibles, and
    co-payments.
    ---------------------------------------------------------------------------
        \3\ For a more detailed analysis of how per capita caps and block
    grants harm women; see National Women's Law Center, ``The Stealth
    Attack on Women's Health: What Caps on Medicaid Funding Would Mean for
    Women'' (April 2017), available at https://nwlc.org/wp-content/uploads/
    2017/04/Medicaid-Per-Capita-Caps.pdf. See also National Women's Law
    Center, ``The Stealth Attack on Women's Health: The Harmful Effects
    Block Granting Safety Net Programs Would Have on Women'' (April 2017),
    available at https://nwlc.org/wp-content/uploads/2017/04/Medicaid-
    Block-Grants.pdf.

    This would be devastating to women, who disproportionately make up the
    Medicaid population. The Center calculates that in 2016, over 17.4
    million women had Medicaid coverage, with over 4.4 million gaining
    coverage between 2013-2016. These women are now receiving coverage for
    critical maternity care, family planning services, and long-term care,
    among other benefits.\4\ And this coverage is helping to make women
    more economically secure, by keeping women and their families from
    medical debt and bankruptcy, providing coverage not linked to
    employment so that women can seek positions that offer higher wages or
    better opportunities, and covering birth control, which allows women to
    determine whether and when to start a family, expanding their
    educational and career opportunities. Medicaid payments to providers
    also directly support women's jobs.\5\ With its radical changes that
    would throw women off Medicaid coverage and change the program, the
    Graham-Cassidy proposal threatens the health and economic security of
    low-income women and families across the country.
    ---------------------------------------------------------------------------
        \4\ Although Medicaid covers a range of services women need, it is
    important to note that federal law restricts federal Medicaid coverage
    of abortion except if the pregnancy is the result of rape or incest, or
    if the woman's life is in danger.
        \5\ National Women's Law Center, ``Medicaid Is Vital for Women's
    Jobs in Every Community'' (June 2017), available at https://nwlc.org/
    wp-content/uploads/2017/06/Medicaid-Jobs-Re
    port.pdf.

    Moreover, the Graham-Cassidy proposal allows states to condition
    Medicaid coverage upon punitive work requirements. A work requirement
    is unprecedented in Medicaid; it goes against the objective of the
    Medicaid program, which is to provide health coverage to low-income
    people who cannot otherwise, afford it, which helps them attain or
    retain the capacity for independence and self-care. A work requirement
    contravenes these objectives by jeopardizing the vital coverage that
    provides enrollees with the care they need to obtain or maintain
    employment. Women are especially likely to lose health care coverage
    under a Medicaid work requirement, because they are more likely than
    men to face particular barriers to employment such as being the sole
    caregiver of children or aging parents.\6\ Work requirements are
    particularly indefensible given that they have proven not to work when
    applied to other programs, and because they are based on the false
    narrative that Medicaid enrollees do not work and are taking advantage
    of the program's benefits, which belies reality and is predicated on
    over-invoked racialized stereotypes of enrollees that ignore the lived
    experiences of all low-income people across racial lines.
    ---------------------------------------------------------------------------
        \6\ For a more detailed analysis of how work requirements imposed
    on Medicaid enrollees would harm women, see National Women's Law
    Center, ``The Stealth Attack on Women's Health: Medicaid Work
    Requirements Would Reduce Access to Care for Women Without Increasing
    Employment'' (May 2017), available at https://nwlc.org/resources/the-
    stealth-attack-on-womens-health-medicaid-work-requirements-would-
    reduce-access-to-care-for-women-without-increasing-employment/.

    The Graham-Cassidy Proposal Would Allow Plans to Reinstate Practices
    ---------------------------------------------------------------------------
    That Discriminated Against Women

    The latest version of the Graham-Cassidy proposal would allow states to
    modify rules for plans funded through the block grants created by the
    proposal. This could include changing the requirement that plans
    provide coverage of the ACA's 10 essential health benefits, which
    include coverage that women need like prescription drug coverage,
    mental health care, and maternity and newborn care. This would allow
    plans to once again refuse to offer the critical benefits that women
    need. For example, as the Center documented, prior to the ACA, only 12
    percent of the most popular plans on the private insurance market
    offered maternity coverage.\7\ Lack of coverage for maternity care left
    women shouldering costs ranging from over $30,000 for vaginal births to
    over $50,000 for caesarian births.\8\ These high costs can be
    impossible for women to pay out-of-pocket and may result in women
    foregoing needed prenatal care and suffering compromised health
    outcomes, including maternal and infant mortality, which is already
    alarming high among black women.
    ---------------------------------------------------------------------------
        \7\ National Women's Law Center, ``Turning to Fairness: Insurance
    Discrimination Against Women Today and the Affordable Care Act'' (March
    2012), available at https://www.nwlc.org/sites/default/files/pdfs/
    nwlc_2012_turningtofairness_report.pdf.
        \8\ Truven Health Analytics, ``The Cost of Having a Baby in the
    United States'' (January 2013), available at http://
    transform.childbirthconnection.org/wp-content/uploads/2013/01/Cost-of-
    Having-a-Baby1.pdf.

    In addition, the latest version of the Graham-Cassidy proposal would
    allow states to modify the rules for coverage of women's preventive
    services. This historic provision of the ACA requires plans to provide
    women--without cost-sharing--coverage for an evidence-based set of
    women's preventive services, including birth control, breastfeeding
    supports and supplies, and well-woman visits.\9\ In passing this
    provision, Congress intended to remedy gaps in preventive services
    requirements, and recognized that the failure to cover women's
    preventive health services meant that women paid more in out-of-pocket
    costs than men for basic and necessary preventive care and in some
    instances were unable to obtain this care at all because of cost
    barriers. According to the Center's calculations, over 62.4 million
    women now have this coverage, which has been critical to women's health
    and economic security. For example, no-cost coverage of birth control
    has enabled women to access the birth control method that is most
    appropriate for them when they need it without cost being an
    obstacle.\10\ It has also furthered women's economic security; one
    study found that the provision helped women to save $1.4 billion in one
    year on the birth control pill alone.\11\ Allowing states to get rid of
    this requirement, as the Graham-Cassidy proposal would do, will send
    women back to a day when cost-sharing and lack of coverage determined
    whether they had the care they need, with long-term effects on the
    health and economic security of women, children, and families across
    the country.
    ---------------------------------------------------------------------------
        \9\ The list of women's preventive services was reaffirmed as
    recently as December 2016 by a panel of experts convened by the
    American College of Obstetricians and Gynecologists, as part of the
    Women's Preventive Services Initiative. ``Women's Preventive Services
    Initiative, Recommendations for Preventive Services for Women: Final
    Report to the U.S. Department of Health and Human Services,'' Health
    Resources and Services Administration (HRSA), Washington, DC: American
    College of Obstetricians and Gynecologists (December 2016).
        \10\ For more information showing how the birth control benefit is
    working, see National Women's Law Center, ``The Affordable Care Act's
    Birth Control Benefit: Too Important to Lose'' (May 2017), available at
    https://nwlc.org/resources/the-affordable-care-acts-birth-control-
    benefit-too-important-to-lose/.
        \11\ Nora V. Becker and Daniel Polsky, ``Women Saw Large Decrease
    in Out-of-Pocket Spending for Contraceptives After ACA Mandate Removed
    Cost Sharing,'' 34 Health Affairs 1204 (July 2015), available at http:/
    /content.healthaffairs.org/content/34117/1204.abstract.

    The proposal also threatens the health and economic security of the
    estimated 65 million women with pre-existing conditions by allowing
    states to set their own rules, including allowing health insurance
    issuers to charge higher premiums based on health status. This means
    that although health insurance coverage may be theoretically available
    to a woman with a pre-existing condition, the insurance company could
    price the premium in such a way that she is effectively denied
    coverage. Prior to the ACA, the Center published extensive research
    documenting insurance practices of charging women more for coverage
    because of ``pre-existing conditions'' unique to them, such as
    undergoing a Cesarean delivery.\12\ The Graham-Cassidy proposal would
    allow insurance companies to reinstate this discriminatory practice. No
    woman should again be charged more because she has had a prior
    pregnancy or Cesarean delivery, because she received fertility
    treatment, had breast or cervical cancer, is a survivor of domestic
    violence, or because she had medical treatment following a sexual
    assault.
    ---------------------------------------------------------------------------
        \12\ National Women's Law Center, ``Still Nowhere to Turn:
    Insurance Companies Treat Women Like a Pre-Existing Condition'' (2009),
    available at https://nwlc.org/wp-content/uploads/2015/08/
    stillnowheretoturn.pdf.

    The Graham-Cassidy Proposal Effectively Bans Plans From Offering
    ---------------------------------------------------------------------------
    Comprehensive Coverage That Includes Abortion

    The Graham-Cassidy proposal contains a host of abortion restrictions.
    During the time that the Graham-Cassidy proposal allows the ACA tax
    credits to exist, the proposal denies tax credits to individuals who
    choose comprehensive plans that cover abortion and denies the small
    business tax credit to those businesses that offer comprehensive plans
    that include abortion. The proposal also prohibits individuals from
    using money in personal health savings accounts for abortion and bans
    states from using the newly created block grants to fund plans that
    cover abortion. These provisions have no other purpose than to ban
    private insurance companies from covering abortion. Eliminating access
    to abortion coverage would deny women meaningful access to basic health
    care and endanger women's health. Provisions like these that deny
    insurance coverage of abortion exacerbate the economic instability of
    women and their families and actually increase the risk that women and
    their families will be forced into a cycle of poverty. When women are
    forced to pay for abortion care, studies show many divert funds from
    necessities like food, electricity, or rent in order to pay for the
    costs of an abortion. For those women unable to get the care they need,
    they are more likely to be living in poverty a year later than women
    who are able to obtain an abortion.\13\
    ---------------------------------------------------------------------------
        \13\ For more information on the harm of insurance coverage bans on
    women, see National Women's Law Center, ``State Laws Regulating
    Insurance Coverage of Abortion Have Serious Consequences for Women's
    Equality, Health, and Economic Stability'' (August 2017), available at
    https://nwlc.org/wp-content/uploads/2017/08/50-State-Insurance-
    Coverage-of-Abortion-1.pdf.

    The Graham-Cassidy Proposal Would Force Medicaid Patients to Give Up a
    ---------------------------------------------------------------------------
    Trusted Provider of Critical Preventive Services

    The Graham-Cassidy proposal bars Medicaid patients from going to
    Planned Parenthood health centers for care, including cancer
    screenings, birth control, and treatment for sexually transmitted
    infections. For decades, Planned Parenthood has been an essential
    health care provider for women with Medicaid, and more than half of
    Planned Parenthood patients rely on Medicaid for health coverage.\14\
    Planned Parenthood health centers are a trusted source of critical
    family planning services for individuals in a way unmatched by other
    providers. Taking away patients' ability to access the critical care
    Planned Parenthood provides would have consequences for women's health,
    economic security, and lives.\15\ The non-partisan Congressional Budget
    Office (CBO) estimates that if Planned Parenthood is denied federal
    Medicaid funding, an estimated 390,000 people will completely lose
    access to preventive health care and 650,000 will face reduced access
    to preventive care,\16\ and ``the number of births in the Medicaid
    program would increase by several thousand'' in one year due to reduced
    access to birth control.\17\
    ---------------------------------------------------------------------------
        \14\ Planned Parenthood Action Fund, ``Medicaid and Reproductive
    Health'' (last visited May 17, 2017), https://
    www.plannedparenthoodaction.org/issues/health-care-equity/medicaid-and-
    reproductive-health.
        \15\ For a more detailed look at what it would mean to individuals
    to lose the ACA and Planned Parenthood, see National Women's Law
    Center, ``Double the Trouble: Health Care Access Without the Affordable
    Care Act or Planned Parenthood'' (2017), available at https://nwlc.org/
    wp-content/uploads/2017/06/final_nwlc_DoubleTrouble2017.pdf.
        \16\ Congressional Budget Office, ``Cost Estimate: H.R. 3134 Defund
    Planned Parenthood Act of 2015'' (September 16, 2015) at 3, available
    at https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/
    costestimate/hr3134.pdf.
        \17\ Congressional Budget Office, ``Cost Estimate: American Health
    Care Act'' (March 13, 2017) at 23, available at https://www.cbo.gov/
    system/files/115th-congress-2017-2018/costestimate/
    americanhealthcareact.pdf.

                                 * * * * * * *

    The Affordable Care Act has changed the landscape for women's health,
    enabling women to obtain affordable health care and coverage that
    better meets their needs. The Graham-Cassidy proposal would upend that
    progress, taking insurance coverage away from women, allowing insurance
    companies to once again discriminate against women, and jeopardizing
    women's health, lives, and economic security. Like every other ACA
    repeal effort that has been introduced and considered in this Congress,
    the Graham-Cassidy proposal would be devastating to women and families
    across this country. It is time to stop playing politics with women's
    health. The Center urges senators voting on this proposal to oppose it.

                                     ______

                      Oklahoma Council of the Blind (OCB)

                                 P.O. Box 1476

                            Oklahoma City, OK 73101

                              Phone: 405-740-6227

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

             Statement Submitted by Vicky Lynn Golightly, President

    The Oklahoma Council of the Blind (OCB) is a statewide organization of
    approximately 400 blind and visually impaired Oklahomans and their
    family members. Virtually all of our members, who span all ages, have
    pre-existing medical conditions. They use a variety of health
    insurance.

    Following are our major priorities for any health care and health
    insurance reform measures that may be considered by Congress.

    Preserve these critical protections provided by the Affordable Care Act
    (ACA):

          The prohibition against denial of coverage for pre-existing
    conditions;
          The guaranteed renewability of coverage;
          The prohibition against individual underwriting;
          The requirement that essential health benefits be part of every
    qualified health plan;
          The prohibition against lifetime monetary caps;
          The prohibition against discrimination in health programs; and
          The extension of mental health parity to the individual and
    small group market.

    Above all, we urge that any new health care system ensure that
    Americans will not be charged higher premiums, copays, and deductibles,
    or be subjected to coverage exclusions or limitations, based on
    disability, age, or pre-existing medical condition.

    We oppose giving states the option to waive patient protections now in
    place, because in our view, this type of option will ultimately lead to
    unavailable, unaffordable, and/or substandard health coverage for
    blind, disabled, and elderly citizens.

    Medicaid is an essential provider of health services for Americans who
    are aged, blind, or disabled. For children and youth with disabilities,
    health and related services received through Medicaid lay the
    foundation for healthier adult life that makes employment possible. For
    youth and adults with the most severe developmental and intellectual
    disabilities, Medicaid's home-and-community-based waiver options are
    essential to prevent even more costly nursing home care and to enable
    these individuals to achieve their potentials, whether through work or
    daily life. The home and-community long term care waivers for elderly
    and disabled under Medicaid currently enable many Oklahomans to stay
    living at home, retaining as much independence as possible, and
    avoiding the higher cost of nursing home care. Because Medicaid today
    offers states several ways to advance health, maximize personal
    independence, and improve quality of life--all while preventing
    excessive institutionalization and higher long-term care expenditures,
    we strongly urge Congress to maintain these effective features of the
    Medicaid program and provide the funding needed to sustain them.

    The Council recognizes that challenges inherent in crafting a health
    care system that meets the goals of quality coverage for all Americans
    at affordable prices, while reining in the constant growth of health
    care costs. We only hope that in trying to find ways to address those
    challenges, Congress will commit to preserving the ACA patient
    protections that allow blind and disabled Americans to obtain and
    afford health coverage. Many of us remember a time when these
    protections were not in place, leaving disabled individuals without
    needed medical care, forcing more to seek public benefits, while
    driving families into bankruptcy. A return to those days would be very
    costly for the nation, both in terms of people and prosperity.

    Thanks to the Committee for holding this public hearing on health care
    reform. We appreciate the chance to offer comments for the hearing
    record.

    Regards,

    Vicky Lynn Golightly
    President

                                     ______

                     Letter Submitted by Lecia Papadopoulos

    September 24, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    I am writing this letter in two capacities as a citizen:

        1.  As the mother and guardian of a disabled young woman who likely
    would not be alive today without the benefits from the Home and
    Community Based Services (HCBS) funded by Medicaid and the State of
    Colorado.
              While my daughter is a lovely young woman, her needs are
    significant medically and in regard to mental health, as well as
    cognitively, requiring constant oversight and supervision. Without the
    present-day HCBS supports through Medicaid, she would not have access
    to the extensive medical and mental health care she needs, and I would
    have to choose between working and providing sufficient supervision to
    ensure her safety.
        2.  As a former small business owner who contributed jobs, tax
    revenue and opportunity in Colorado for nearly 20 years, with up to six
    contractors in various locations nationally, Fortune 500 clients, and
    consistently six figures in annual revenue.
              Ultimately, I chose to close that business for reasons that
    included the increasing cost and challenges to obtaining sufficient
    supports for my daughter's medical, mental health, developmental, and
    cognitive needs.

    In these capacities, I am compelled to bring to this committee's
    attention several stark and fiscally imprudent shortcomings about the
    Graham-Cassidy proposal.

    The proposal to shift to a block grant per capita Medicaid funding
    model and eliminate key provisions of the Affordable Care Act will not
    produce the stated intended results and will in fact contribute to
    worsening the current healthcare access and affordability crisis.
    Specifically it:

        1.  Will not stabilize the individual health insurance market and
    reduce premiums--Numerous citations document the expected turmoil and
    cost increases that American citizens can expect as a result of this
    proposal including:
        2.  As many as half of the nation's population needing maternity
    care, mental health and substance abuse benefits, rehabilitative and
    habilitative services, and pediatric dental benefits would likely face
    increases in their out-of-pocket costs. Some people would have
    increases of thousands of dollars in a year.
        3.  Residents with pre-existing conditions in states housing one-
    sixth of the nation's population ``would be unable to purchase
    comprehensive coverage with premiums close to those under current law
    and might not be able to purchase coverage at all'' [emphasis added].
              Prior estimates of less-draconian healthcare proposals by
    the CBO expect a likely 20% increase in premium prices in 2018 as a
    result of similar legislation.
        4.  Will not reduce healthcare costs--According to the Kaiser
    Family Foundation.org, reducing federal Medicaid spending by using
    block grant reductions and slow-growing per capita limits slows the
    federal government's spending on healthcare by setting grant amounts
    and caps below expected spending levels. It does not slow the spending
    in healthcare overall, nor does it address the growing need of
    vulnerable populations for healthcare services or the fluctuating needs
    related to economic downturns, natural disasters, etc. All such
    variables and shortfalls are left to the states to determine whom and
    what to cut.
        5.  Will not increase states' flexibility--as reported in the
    FamiliesUSA.org's Medicaid Fact Sheet, states already have ``a lot of
    flexibility in their Medicaid programs,'' including flexibility to
    define:
            i. What services are covered.
            ii. How providers are paid for servicers.
            iii. How services are delivered.
            iv. Eligibility levels.
           Limiting federal dollars for Medicaid, according to the Kaiser
    Family Foundation.org, would create a system that is ``less responsive
    to state decisions and changing program needs,'' in effect reducing
    flexibility. The proposal also allows states to use the block grants
    for different programs than states may currently be supporting,
    creating greater uncertainty.
        6.  Will not improve efficiencies in healthcare delivery to
    citizens--Again, according to the Kaiser Family Foundation.org, ``most
    Medicaid programs have few options for easy ways to trim spending. Many
    efficiencies were adopted by states during the last two major
    recessions when revenues dropped and budgets were constrained. Medicaid
    already grows at slower rates compared to private health insurance
    premiums. Most states currently operate programs with low
    administrative costs and provider reimbursement levels below other
    payers.''
        7.  Will not increase access to care--According to the Center on
    Budget and Policy Priorities, if the Graham-Cassidy proposal is
    adopted, ``millions of people with pre-existing conditions would lose
    access to these protections, and, as a result, would lose access to
    needed coverage and care.'' The Center on Budget and Policy Priorities
    further reports that ``The Congressional Budget Office (CBO) has
    previously estimated that the repeal-without-replace approach would
    ultimately leave 32 million more people uninsured. Cassidy-Graham would
    presumably result in even deeper coverage losses than that in the
    second decade as the cuts due to the Medicaid per capita cap continue
    to deepen.''
        8.  Will not protect people with pre-existing conditions--According
    to the Center on Budget and Policy Priorities, a ``provision of the
    block grant funding states would receive under the plan would let them
    obtain waivers of ACA pre-existing conditions protections and benefit
    standards for any insurance plan subsidized by block grant funding. For
    example, a state that used a small portion of its block grant funding
    to provide even tiny subsidies to all individual market plans could
    then waive these protections for its entire individual market.
    Likewise, states that used block grant funding to offer or subsidize
    coverage for low-income people could offer plans with large gaps in
    benefits. States seeking waivers would have to explain how they
    `intend' to maintain access to coverage for people with pre-existing
    conditions, but they wouldn't have to prove that their waivers would
    actually do so.''
        9.  Will not ensure that states' plans provide equitable and
    meaningful coverage--According to the Center on Budget and Policy
    Priorities, prior to enactment of the ACA:
            i. 75% of individual markets excluded maternity coverage.
            ii. 45% excluded substance abuse treatment.
            iii. 38% excluded mental health care.
           As to the likelihood of whether states will take advantage of
    these waivers of exclusion, the Center on Budget and Policy Priorities
    reports that the Graham-Cassidy proposal is similar to the waiver
    authority included in so-called ``MacArthur amendment'' waivers that
    were included in the House-passed ACA repeal proposal. Analyzing those
    waivers, the Congressional Budget Office (CBO) concluded:
            i.  States accounting for one-sixth of the nation's population
    would choose to let insurers charge higher premiums based on health
    status. In those states, ``less healthy individuals (including those
    with preexisting or newly acquired medical conditions) would be unable
    to purchase comprehensive coverage with premiums close to those under
    current law and might not be able to purchase coverage at all''
    [emphasis added].
            ii.  States accounting for half of the nation's population
    would choose to let insurers exclude essential health benefits. In
    those states, ``services or benefits likely to be excluded . . .
    include maternity care, mental health and substance abuse benefits,
    rehabilitative and habilitative services, and pediatric dental
    benefits.'' People needing these services ``would face increases in
    their out-of-pocket costs. Some people would have increases of
    thousands of dollars in a year.''
        10.  Will contribute to increased healthcare costs overall--
    According to the Centers for Disease Control and Prevention, preventive
    services, studies have shown that:
              Cost-sharing strategies such as deductibles, co-insurance
    and co-payments reduce the likelihood that preventive services such as
    mammograms will be used. The Graham-Cassidy proposal will increase cost
    sharing by removing access to health insurance for many people and
    dramatically increasing out-of-pocket costs, as reported by the Center
    on Budget and Policy Priorities.
              Also reported by the Center on Budget and Policy Priorities,
    the use of preventive services can prevent and greatly reduce the costs
    related to chronic diseases such as diabetes, heart disease and cancer,
    which together are responsible for 7 out of 10 deaths of Americans each
    year and 75% of the nation's healthcare spending. Financial barriers
    deter many Americans, even those with insurance, from obtaining
    preventive health services. Building these services into the standard
    costs of care is advantageous to everyone.
        11.  Will have negative economic impacts that affect everyone--The
    National Immigration Law Center reports that access to health
    insurance:
              Reduces both health and non-health related debt. . . .
    Uninsured individuals who become hospitalized experience a host of
    financial setbacks over the next four years, including reduced access
    to credit and a significantly higher likelihood of filing for
    bankruptcy.
              Enables consumers to spend more in local economies . . .
    individuals and families [have] more disposable income to spend on
    goods and services. In addition to increasing tax revenues, this
    additional spending produces a ``multiplier effect,'' as increased
    business revenues are passed on to suppliers and employees, who use
    them in turn. One estimate puts the multiplier effect of Medicaid
    expansion at between 1.5 and 2 times the amount of new federal Medicaid
    spending.\6\
              Increases workplace productivity and economic output. . . .
    People without insurance are often in poor health due to deferred
    treatment and uncontrolled chronic conditions. Poor health results in
    multiple dimensions of lost productivity: adults whose health status
    prevents them from working, workers who miss time from their jobs
    because of health problems, and workers who are working but less
    productive because of their health conditions. One study found that
    workers who were uninsured missed almost five more days of work each
    year than those who had insurance. This assessment while illuminating,
    leaves out the reduced productivity and economic impact on families
    with one or more members who chronically and seriously ill.
              The Centers for Disease Control report that ``[h]ealth
    problems are a major drain on the economy, resulting in 69 million
    workers reporting missed days due to illness each year, and reducing
    economic output by $260 billion per year. Increasing the use of proven
    preventive services can encourage greater workplace productivity.''

    To close, I want to forcefully request that the Graham-Cassidy-Heller-
    Johnson proposal be shelved and not brought forward for debate or vote.
    All efforts to address our nation's healthcare challenges must take
    place in public to bring in bipartisan ideas and concerns, as well as
    to explore and make use of expert perspectives from people who have
    dedicated their lives to improving public health, and above all to be
    focused on dealing with the real issues:
          Containment of overall healthcare costs, not just federal,
    state, or individual spending.
          Control over individual, state, and federal cost outlays through
    innovative knowledge sharing, skill development, and cost-saving
    programs that improve patient outcomes.
          Increased use of technologies and structures that improve the
    use of preventive medicine, counseling, cross-disciplinary teams, and
    other proven techniques.
          Access to affordable and meaningful care that includes common
    needs at no additional surcharge, such as preventive services, mental
    health and behavioral services, services for substance abuse, pediatric
    and adult dental services, vision services, rehabilitative and
    habilitative services, women's health and pregnancy services, services
    for the elderly, and no lifetime caps or pre-existing condition
    exclusions.
          Greater simplicity in accessing consistent types and qualities
    of services regardless of geographic location, employer, and income
    level.
          Elimination of for-profit health insurance and healthcare
    services providers.
          Etc.

    Thank you kindly for the opportunity to contribute to this important
    national discussion that so profoundly affects my family and literally
    every American.

    Best regards,

    Lecia Papadopoulos

    Enclosed: the attached pages briefly summarize my experience as the
    mother of a daughter with numerous complex and serious medical,
    developmental, cognitive, and mental health conditions.

                                     ______

    Highlights from my experiences with the American healthcare system
    before and after the ACA, including Medicaid Home and Community Based
    Services (HCBS) in Colorado, as mother to a daughter born with
    significant needs

    For several years before my daughter was born, back in 1997, I had to
    pay extra to have an insurance policy that would cover pregnancy costs.
    When I learned that she had cystic fibrosis, the most common life-
    shortening inherited condition among Caucasians in the U.S., I tried
    not to think about what I would do once her lifetime cap was reached.

    My daughter can never be without group medical insurance. Imagine my
    despair, as a fully employed mom of a seriously ill infant, when I
    learned that I could not relocate near my family because none of the
    four states near them offered group insurance options for self-employed
    people at any price. Nor could I take a staff job as I needed
    flexibility to work odd hours to be able to manage my daughter's many
    doctor appointments and hospitalizations to keep her alive.

    Due to the many interventions, including tube feedings and
    hospitalizations she required as an infant and toddler, my daughter
    didn't learn to eat by mouth until she was nearly through grade school.
    In the late 90s, ``supplemental'' nutrition was not a covered benefit,
    even though she could eat no food other than what would go through the
    tube; we battled insurance for an exception.

    When children don't learn to eat at the right time, they may never
    learn to eat or, if they do, they may never really enjoy it. This
    window is relatively small. Fortunately for my daughter, she was
    waitlisted ``only'' 6 to 8 months for the Colorado Children's HCBS
    Medicaid waiver before she was enrolled and gained access to the
    specialized therapies my expensive health insurance wouldn't cover. It
    took years to teach her to eat; rehabilitative benefits are designed
    for stroke patients who are re-acquiring a skill they've already
    learned. My daughter had to acquire a new skill, which takes much
    longer to address.

    The Medicaid wavier removed the risk of bankruptcy for our family. I
    could get support for Lily's care during parts of the day so that I
    could still work. The bulk of her medical bills were always paid, and I
    could keep up with the co-payments. Some equipment and medicines would
    not have been available without Medicaid, namely a vest for her
    respiratory treatments, which she needs 2-4 times daily, and enzymes
    needed with every meal and snack so her body can obtain nutrition from
    her food. The enzymes can be thousands of dollars monthly, with co-pays
    in the hundreds of dollars, and that is only one required medication
    out of roughly two dozen.

    Medicaid gave her access to the medications, equipment and physicians
    she needed, first for keeping her alive despite cystic fibrosis, and
    then to address developmental and behavioral deficits related to a
    hereditary genetic anomaly called Trisomy X, Autism and mental health
    conditions. In short, the Medicaid HCBS waivers in Colorado, funded by
    a mix of federal and state dollars, saved her life and allowed her to
    grow up, in a home, with a gainfully employed parent. Today, the adult
    waivers allow her to remain in the community, to continue to learn and
    work on gaining job skills and to keep her health in a good status
    despite the progressive and debilitative nature of cystic fibrosis.

                                     ______

                          The Partnership for Medicaid

                         600 13th Street, NW, Suite 500

                              Washington, DC 20005

                         www.partnershipformedicaid.org

    The Partnership for Medicaid--a nonpartisan, nationwide coalition of
    organizations representing health care providers, safety net health
    plans, counties and labor--is opposed to the Graham-Cassidy-Heller-
    Johnson proposal to restructure the Medicaid program into a block grant
    or per capita cap model. We call on the Senate to protect Medicaid and
    to reject continued efforts that will roll back coverage for the 70
    million people that depend on this vital program.

    The Partnership is dedicated to preserving and improving the Medicaid
    program, so that it better meets the needs of the beneficiaries it
    serves. Medicaid delivers necessary health care services and other
    related supports to our nation's most vulnerable children, pregnant
    women, parents, individuals with disabilities, seniors, and other
    adults. Any legislation that makes fundamental changes to the Medicaid
    program must not undermine the quality of services or access to care
    for the populations that this safety net program has served for 52
    years.

    We strongly oppose continued efforts in the Senate to explore
    devastating cuts to the Medicaid program. The Graham-Cassidy-Heller-
    Johnson proposal maintains near identical Medicaid provisions to those
    in the failed Better Care Reconciliation Act that would impose funding
    caps that threaten the viability of the Medicaid program. Medicaid
    beneficiaries rely on Congress to preserve the program and to make
    improvements that promote access and quality.

    Cuts to Medicaid for budget gains are unacceptable and undermine the
    long-term stability of the program. The policies in this proposal are
    designed to meet fiscal objectives. They do not strengthen the Medicaid
    program, nor do they guarantee access to care. We remain in opposition
    to efforts that simply shift the cost burden onto local and state
    governments, health care providers and individual beneficiaries.

    The Partnership strongly urges the Senate to protect Medicaid and
    reject efforts to dismantle the program as called for in the Graham-
    Cassidy-Heller-Johnson proposal.

    While this statement represents the collective views of the Partnership
    as a coalition, it has not been officially endorsed by each individual
    Partnership member organization.

    AFL-CIO                             American Academy of Family
                                        Physicians
    American Academy of Pediatrics      American Congress of Obstetricians
                                        and Gynecologists
    American Dental Association         American Dental Education
                                        Association
    American Health Care Association    America's Essential Hospitals
    Association for Community
    Affiliated Plans                    Association of Clinicians for the
                                        Underserved
    Catholic Health Association of the
    United States                       Children's Hospital Association
    Easterseals                         The Jewish Federations of North
                                        America
    Medicaid Health Plans of America    National Association of Community
                                        Health Centers
    National Association of Counties    National Association of Pediatric
                                        Nurse Practitioners
    National Association of Rural
    Health Clinics                      National Council for Behavioral
                                        Health
    National Health Care for the
    Homeless Council                    National Hispanic Medical
                                        Association
    National Rural Health Association

                                     ______

                               Prevent Blindness

                       211 West Wacker Drive, Suite 1700

                            Chicago, Illinois 60606

                             toll free 800-331-2020

                               local 312-363-6001

                                fax 312-363-6052

                       https://www.preventblindness.org/

    The Honorable Orrin Hatch           The Honorable Ron Wyden
    Chairman                            Ranking Member
    Committee on Finance                Committee on Finance
    U.S. Senate                         U.S. Senate
    Washington, DC 20510                Washington, DC 20510

    Dear Chairman Hatch and Ranking Member Wyden:

    Prevent Blindness is the nation's leading nonprofit, voluntary
    organization committed to preventing blindness and preserving sight.
    Prevent Blindness represents millions of people of all ages across the
    country who live with low vision and vision-related eye diseases. We
    appreciate the opportunity to submit a Statement for the Record in
    response to the Senate Finance Committee's September 25th hearing to
    consider the Graham-Cassidy-Heller-Johnson proposal.

    After reviewing the Graham-Cassidy-Heller-Johnson amendment to H.R.
    1628, the American Healthcare Act (ARCA) as introduced by U.S. Senators
    Lindsay Graham, Bill Cassidy, Dean Heller, and Ron Johnson (deemed
    ``Graham-Cassidy''), we have very serious concerns with the precedent
    that this legislation establishes for patients seeking vision and eye
    healthcare services. Understanding that the Congressional Budget Office
    (CBO) has not released a complete economic impact statement and score
    for this proposal, we are nonetheless troubled by consistent estimates
    of significant loss of healthcare coverage for millions of Americans
    starting in just over 2 years not just for those who rely on Medicaid
    but for the uncertainty these proposals would create in the health
    insurance market for individuals purchasing non-group policies. We
    outline our additional concerns below.
    Impacts of a Block Grant Medicaid Program
    Prevent Blindness is deeply concerned with projections that Medicaid
    spending will be reduced by $1 trillion over the coming decade. The
    proposals set forth to convert federal funding into a block grant
    program will force states to cut eligibility for vulnerable patients.
    In some states, Medicaid is often the only source of vision and eye
    care for many adults and children. Facing an uncertain and underfunded
    future of the Medicaid program, states will likely have no choice but
    to cut vision screenings and eye health services that can potentially
    curb the progression of and, in some cases, prevent altogether
    incidents of vision loss for children, aging Americans; and patients
    with chronic diseases.
    Protections for Patients With Pre-Existing Conditions
    We have serious reservations that the legislation does not go far
    enough to ensure, without question, that patients with a pre-existing
    condition will be able to acquire affordable insurance plans. Under
    such financial constraints, patients will not be empowered to
    prioritize their vision and eye health and will likely forgo cost-
    effective, sight-saving preventive care.
    Essential Health Benefits
    As written, we believe this bill will have a particularly detrimental
    impact on people with chronic conditions, such as diabetes, as the
    legislation would significantly weaken EHBs for both adults and
    children.

          Chronic Disease Management: Eye disorders rank 5th among the top
    8 chronic conditions in the United States, with the overall cost of
    vision problems calculated at $145 billion annually. Eye health
    problems have a strong correlation to many chronic health conditions
    such as smoking, depression, and falls. Diabetes, one of the most
    common chronic diseases among adults, can lead to vision loss through
    diabetic retinopathy, diabetic macular edema, cataracts, and glaucoma.

          Children's Vision and Eye Exams: Vision impairments and eye
    disorders are the 3rd leading chronic condition among children with
    costs for direct medical care; vision aids and devices; and caregivers
    amounting to $10 billion per year. Our nation's families are already
    shouldering 45% of these costs. Common childhood eye disorders and
    vision impairments are easily treatable if caught early; however, as
    written, the Graham-Cassidy legislation jeopardizes early detection and
    cost-effective treatments that could prevent lifelong vision impairment
    or permanent loss of vision.

    We know that prevention works. Ensuring that Americans of all ages have
    access to the most basic and preventive services will only contribute
    to healthy development in young children, successful school
    performance, and the long-term health of our nation.
    Proposal to Implement a ``Per Capita Cap'' Medicaid Formula
    The proposal to tie federal funding to a state program's enrollment
    places an untenable burden on states to maintain enrollment using their
    own resources. As the difference between federal funding and the cost
    of Medicaid programs increase, states will have no choice but to decide
    between increasing their contributions or cutting them by restricting
    access and benefits, including services for vision and eye health, or
    cutting off enrollment altogether. Both options place vulnerable
    patients in a situation in which their access to care is severed as a
    result of ineligibility or a lack of available services.

    Prevent Blindness strongly urges the Senate to reconsider many of the
    problematic provisions of the Graham-Cassidy legislation that would
    jeopardize cost-effective, preventive interventions to avoidable vision
    loss. We stand ready to assist the Committee as needed, and urge you to
    work in a bipartisan manner to confront our nation's healthcare
    challenges. If you should have any questions, please reach out to Sara
    D. Brown, Director of Government Affairs at (312) 363-6031 or sbrown@
    preventblindness.org.

    Sincerely,

    Hugh R. Parry
    President and Chief Executive Officer

                                     ______

                      Letter Submitted by Brenda Prochnow

    September 22, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Members of the Senate Committee on Finance,

    I am writing you today as the parent of a daughter who is medically
    fragile and has major medical and developmental disabilities. As you
    may know, Medicaid funding provides individuals with disabilities the
    opportunity to receive community based, non-institutional supports in
    order that they can continue to live at home with their families or
    move into supported living arrangements within the community. Without
    these supports, these individuals could be forced into nursing homes
    and other more expensive living options. This program is funded through
    a mix of federal and state funds. It is a lifeline for families with
    children and adults with disabilities who need ongoing supports for
    health and safety as well as improved quality of life. The Graham-
    Cassidy-Heller-Johnson bill will negatively impact our daughter and all
    the population of people with disabilities and put them at risk.

    My daughter, Tara, is 30 years old and is able to live in our loving
    home with us because of the Medicaid program Family Care. Without this
    funding, she would be forced into a nursing home and not have a good
    quality of life. She is G-tube fed 24 hours a day on a feeding pump,
    has a tracheostomy and ventilator dependent. She is cognitively
    impaired and non-verbal. Believe it or not, she is happy and currently
    has a good quality of life! She has in home nursing care that provides
    total care for her. With the current proposed Medicaid cuts and caps it
    leaves us extremely worried about the quality of care she may receive
    or worse yet, she may not be able to live with us in our loving
    environment, due to cheaper alternatives. The cuts will also affect the
    livelihood of nurses who provide care to people with disabilities in
    the homecare setting.

    I am writing on behalf of my family and many other individuals who are
    receiving or waiting to receive services through Medicaid funding.
    These services provide basic, stable supports that would enable each of
    us; disabled individuals and caregivers alike, to more adequately
    support ourselves and our families, while contributing more fully to
    our communities.

    I hope you, as legislators, are remaining informed to adequately fund
    essential Medicaid services and that you support funding for these
    services. The system is becoming less and less stable as providers and
    families struggle with the long term impact of ongoing funding cuts. A
    stable support system for families and service providers significantly
    improves the quality of life for people with developmental disabilities
    like our daughter, Tara, while increasing each person's opportunities
    to become much more productive members of our society. I urge you to
    vote ``no'' on the Graham-Cassidy-Heller-Johnson bill and instead ask
    the Senate to continue its work through the bipartisan market
    stabilization efforts.

    Sincerely yours,

    Brenda Prochnow

                                     ______

               Resource Center for Accessible Living, Inc. (RCAL)

                               727 Ulster Avenue

                               Kingston, NY 12401

                               TTY (845) 331-4527

                               FAX (845) 331-2076

                              Main (845) 331-0541

                  Statement of Alex Thompson, Systems Advocate

    The Resource Center for Accessible Living (RCAL) is an independent
    living center in the upper Hudson Valley of New York. RCAL strongly
    opposes the Graham-
    Cassidy amendment (S. Amdt. 1030) to the American Health Care Act of
    2017 (H.R. 1628) heretofore known as ``the bill.'' RCAL serves people
    with disabilities in Ulster County, New York. People with disabilities
    in our area are currently struggling with numerous barriers to
    accessible housing, employment, adequate healthcare, and community
    living. The Graham-Cassidy bill, should it become law, would cause
    significant harm to people with disabilities by exacerbating barriers
    to adequate healthcare.

    The bill proposes per capita caps on the money spent to provide care
    for Medicaid recipient populations. It also proposes the elimination of
    the adult Medicaid expansion created by the Affordable Care Act, which
    has been utilized by people with disabilities, their families, and
    caregivers. The per capita caps are essentially cuts due to a
    underlying financing scheme which is based is wishful thinking rather
    than fulfilling essential needs, and would severely limit the
    availability of home- and community-based services. These types of
    services are vital because they allow people to live and work in the
    community as opposed to an institutional setting where freedom of
    choice is limited. People we serve at RCAL depend on some form of home-
    and community-based services. Medicaid is a necessity for many and
    should not be cut with frivolous disregard for the many people with
    disabilities, seniors, and others that depend on its services as a
    safety net program.

    It is important that you understand that home- and community-based
    services are rarely available through private insurance plans or are
    too restrictive to account for someone's actual needs. The
    Congressional Commission on Long Term Care of 2013 made known in its
    published report the deficiencies in the private marketplace for long
    term care coverage and the necessity of Medicaid as a major provider of
    Long Term Supports and Services. For example, a person living with
    paralysis, may need personal care services to help with the activities
    of daily living - such as dressing, bathing, using the bathroom, and
    eating. A private insurance plan may only cover an hour of assistance
    per day, which would be wholly inadequate to cover these activities,
    let alone other important activities like getting to and from work or
    class, visiting the grocery store, etc.

    Medicaid helps people with disabilities get an education and prepare to
    work by providing funds for access and care in school. Medicaid helps
    people with disabilities work by funding medical equipment and services
    that gives us independence. Without the right kind of care, a person
    would not be able to learn, work and live independently, but could be
    stuck in a nursing home. The economy actually suffers when people with
    disabilities are trapped in beds instead of being able to live the life
    they want in their community.

    States, like New York, help ensure people with disabilities can live in
    the community by implementing the Community First Choice program. The
    Affordable Care Act increased the amount the federal government would
    match State spending on related services. The Graham-Cassidy bill
    ignores the value of the program and would eliminate federal funding
    (approximately $19 billion) for all state community first choice
    programs. The bill tries to make up for this massive blow to
    independent living by giving a (temporary) 4 year ``demonstration'' of
    $8 billion to assist States wanting to continue offering ways for
    people to live independently in the community Currently, only eight
    States have Community First Choice plans in the post Affordable Care
    Act environment. Therefore, it should be obvious that the temporary
    demonstration is not adequate bridge a gap in service while also
    eliminating a program that has proven to increase the well-being of
    people with disabilities.

    We support and encourage bipartisan efforts to improve the health and
    well-being of people with disabilities; the bill before you is not
    that.

                                     ______

                        Letter Submitted by Eva Shiffrin

    To: U.S. Senate Finance Committee

    Re: Testimony submitted for consideration to the hearing to consider
    the Graham-Cassidy-Heller-Johnson proposal on September 25, 2017

    Dear Senate Finance Committee Members,

    I write to express my opposition to the Graham-Cassidy-Heller-Johnson
    Proposal (the Proposal). The Proposal includes draconian, cruel and
    amoral substantive provisions, stripping health care from tens of
    millions of vulnerable Americans while purporting to fix health care
    and make it available and affordable to all Americans. It was also
    developed in a deeply shameful, undemocratic process that flies against
    the desires of 88% of Americans.

    The Proposal's cuts to traditional Medicaid are draconian. Millions of
    elderly individuals and people with disabilities rely on traditional
    Medicaid for their lives, their well-being, and their independence.
    Although the Congressional Budget Office Analysis has not been
    completed for this Proposal, it is similar or worse to previous bills
    that would radically restructure Medicaid, kicking millions of
    Americans off health care. Thousands of people will die as a result.
    Previous and less draconian versions of this bill estimate that federal
    support will drop by $750-$800 billion by 2026, with deeper cuts to
    follow. I work with people with disabilities every day and know
    firsthand how important and lifesaving Medicaid health care can be.
    People with disabilities rely on critical Medicaid services like
    tracheotomy care, nursing care, dialysis, cancer treatments,
    occupational therapy, speech therapy, life-saving medications, durable
    medical equipment, and more to work and live lives with dignity and
    independence. These people are our family members, our neighbors, our
    coworkers, and our friends. We are the wealthiest country in the world.
    We can and should provide Medicaid for the elderly and people with
    disabilities.

    This Proposal will also impact pregnant women and children, who are
    insured by Medicaid in high numbers. In Wisconsin, 28% of all kids are
    covered by Medicaid. Nearly half of all U.S. births are covered by
    Medicaid. For many children with disabilities and extensive health care
    needs, Medicaid is lifesaving and cutting it could literally put
    children's lives at risk. Children who receive regular health care to
    treat things like asthma, diabetes, and treatable medical problems fare
    better in school, miss fewer days of school, are more likely to
    graduate, and earn higher wages than those without health care. We as a
    country have always thought that the children are our future. This
    Proposal takes us backwards. The potential impacts of this Proposal for
    children and pregnant women are frankly deeply disturbing.

    The changes to the Affordable Care Act are also deeply troubling. The
    proposal opens up the door to imposing pre-existing condition
    exclusions again, limiting essential health services, and reducing the
    affordability of health insurance, which will result in millions more
    losing health insurance they only recently gained. All of the studies
    done thus far on health outcomes for individuals newly insured through
    the ACA show the enormous positive impact of insured status. I
    personally know many individuals with disabilities who relied on ACA
    coverage when they could no longer work due to a diagnosis, but had to
    wait 2 years after a disability determination before Medicare would
    begin and who were not eligible for Medicaid. I also know multiple
    friends who relied on the ACA to receive treatment for cancer. These
    individuals could not work, but they also did not qualify for Social
    Security. These friends owe their lives to the Affordable Care Act. I
    also have friends with full time jobs that did not offer health
    insurance and could only afford health insurance offered through the
    ACA with subsidies. These individuals were able to obtain services to
    treat chronic illnesses such as diabetes, illnesses that would worsen
    without treatment and then require costly treatment, but are
    preventable. The Proposal fails to make insurance more affordable and
    in fact, will price ordinary Americans out of any insurance market,
    returning to the days when a cancer patient who couldn't work but
    couldn't access health care, where a person with asthma couldn't afford
    health insurance due to a pre-existing condition, where a person
    working a full-time job couldn't afford health insurance. This is not
    what Americans want.

    Many of the very sponsors of this Proposal vowed that they would
    replace the ACA with something better and more affordable. This
    Proposal fails miserably in all respects. It has also been crafted,
    introduced, and discussed in a deeply undemocratic manner. The fact
    that many Senators are unwilling to even wait to discuss the Proposal
    and provide for full and fair hearings on it after it has been analyzed
    by the Congressional Budget Office exposes this process as a deeply
    shameful charade, one that ignores the desires of the vast majority of
    the American people. The last bill scored by the CBO had an approval
    rating of 12%, yet this bill is moving forward and is even worse than
    the last bill scored.

    I am submitting this testimony to the committee to ensure that it is
    entered into the official record of these proceedings. If this bill
    passes and goes into effect, I want the record of this committee to
    show that those who voted for this Proposal were fully aware of its
    devastating and destructive impact and were told by millions of
    American citizens that this is not what we want.

    Eva Shiffrin
                                     ______

                   Letter Submitted by Barbara Burke Sorensen
    To: The United States Senate Committee on Finance, I submit these
    comments for the hearing to consider the Graham-Cassidy-Heller-Johnson
    Proposal, September 25, 2017.

    My full name is Barbara Burke Sorensen. I submit these comments for the
    hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
    September 25, 2017.

    I write on behalf of my son Olaf A. Sorensen. Olaf is 35 years old and
    has been disabled from birth. Olaf's initial diagnosis was autistic
    disorder, with the added diagnoses over the years of generalized
    anxiety, then PTSD (Post Traumatic Stress Disorder) and depression with
    psychotic features.

    Olaf was recommended for institutional placement at age 2 or 3. I have
    worked in the ensuing 32-33 years with health care providers to keep
    Olaf out of institutional placement. Because of the Katie Beckett
    children's waiver, there was funding for physical therapy, occupational
    therapy, and speech therapy, and Olaf was able to learn to walk, talk
    and interact in the community--all things that it was predicted by
    medical doctors Olaf would never achieve. With the funding available
    under home and community Medicaid waivers, Olaf was able to remain in
    his community since he qualified for a CIP IB waiver at age 11, at a
    much lower cost than the institutional placement would have been, up to
    the present, although the name has changed to IRIS waiver. Currently
    the monthly cost for Olaf's IRIS waiver Medicaid supports (he requires
    24/7 care and supervision) is approximately $14,000.00. The monthly
    cost for the institutional placement would be $33-$34,000.00. And would
    have been, over the many years I have labored day in and day out, to
    make a place for Olaf in this world.

    I cannot express clearly enough to the authors and co-sponsors of this
    bill that their bill will condemn my son Olaf to institutional
    placement because this bill decimates the level of funding that Olaf's
    level of disability requires for him to stay where he is. As a former
    member of the Wisconsin BPDD, I am aware of the many disabled adults
    across this nation, for whom this bill is tantamount to a death
    sentence.

    That breaks my heart completely, as both a mom and as an American, to
    know that our federal legislators would propose devastating cuts to
    funding for disabled people. It is especially heart breaking coming
    from legislators who assure us and the nation that they are pro-life.

    The ``least among us'' require consistent funding and care. Miniscule
    Medicaid funding that is left will not allow for that outcome. I hope
    and pray that this government will declare its support for people with
    disabilities even in times of economic stress.

    Recorded history shows that in Germany, resentment of the economic
    burden on society of disabled children led to their ultimate deaths
    through ``mercy killings.'' I hope that our American society will not
    take that slippery slope. Please, Senators, do not forsake the
    disabled. America is better than that.

    Sincerely, Barbara Burke Sorensen

                                     ______

     Statewide Parent Advocacy Network (SPAN) and Family Voices-New Jersey

                          35 Halsey Street, 4th Floor

                                Newark, NJ 07102

                       (973) 642-8100 (973) 642-8080 Fax

                            Website: www.spannj.org

                             Email: span@spannj.org

                   http://www.familyvoices.org/states?id=0031

    SPAN and Family Voices-New Jersey comments to the Senate Finance
    Committee for the hearing on the Graham-Cassidy healthcare bill

    Thank you for the opportunity to comment on the Graham-Cassidy
    healthcare bill. Family Voices is a national network that works to
    ``keep families at the center of children's healthcare.'' The NJ State
    Affiliate Organization for Family Voices is housed at the Statewide
    Parent Advocacy Network (SPAN), NJ's federally designated Parent
    Training and Information Center, Family-to-Family Health Information
    Center, Parent to Parent USA affiliate, and chapter of the Federation
    of Families for Children's Mental Health. The Family Voices Coordinator
    also serves on the Board of the National Alliance on Mental Illness
    (Mercer-NJ) and the Progressive Center for Independent Living. She is
    also NJ's representative (volunteer) of the Caregiver Action Network,
    representing caregivers across the lifespan.

    While SPAN provides information, training, technical assistance, parent
    to parent support, advocacy, and leadership development for all NJ
    families of children ages birth to 26, our priority is on children at
    greatest risk due to disability, special health care or emotional
    needs, poverty, discrimination based on race, culture, language,
    immigrant status, or economic status, or involvement in the child
    welfare or juvenile justice systems. Thus, we are particularly
    concerned with ensuring that the needs of children with special
    healthcare needs and their families are adequately addressed in
    federal, state and local policies and practices.

    We understand that this hearing is to gather information on state
    flexibility and fiscal burden. At SPAN, our priority is serving the
    needs of children, youth, young adults and families, especially those
    who face the greatest challenges. Thus, we value access to affordable,
    high quality care over state flexibility and relief from fiscal burden.
    We also note that we strongly believe that there should be consistency
    nationally, particularly given mobility across states. The proposed
    legislation will result in inequity of healthcare across states. We
    remain concerned with annual/
    lifetime caps and note that rescinding policies will increase medical
    debt and bankruptcy, not improve our economy (according to Families,
    USA 60% of bankruptcies are due to medical debt.) We are deeply
    concerned that this bill is a total repeal without replacement.
    Millions will lose coverage, Medicaid will be cut and transformed in
    negative ways that will hurt low-income individuals, children and
    families, including in particular those with disabilities and special
    healthcare needs, and those with pre-existing conditions will be
    harmed.

    We are very concerned that if states (including but not limited to New
    Jersey) lose Federal Medical Assistance Percentages (FMAP) for
    Medicaid, they won't have same amount of funding to provide services at
    their current levels, levels which are already inadequate to meet
    children and families' needs.

    We acknowledge your expressed concern with the individual mandate but
    note that, without it, there will be adverse selection. The individual
    mandate is critical to ensure that the health insurance marketplace
    includes young and healthy as well as older individuals and those with
    disabilities and special healthcare needs. This individual mandate is
    similar to the requirement for individuals to ``purchase'' retirement
    insurance via Social Security. Further, it is in the public interest to
    require all Americans to have health insurance, as health insurance is
    a cost-effective way to ensure that people have access to health care
    when and if they become ill or develop a disability or special
    healthcare need.

    Regarding reduction of fiscal burden, we don't see the Graham-Cassidy
    bill doing this for consumers as premiums will increase, plan values
    decrease, and cost-
    sharing increase. In addition, we do not think that insurers and health
    companies should get tax breaks which are being offset by cuts to
    Medicaid. Lastly, we are concerned that there will not be access to
    coverage as people with pre-existing conditions, disabilities, or the
    elderly will not be able to participate in the market due to pricing.

    We acknowledge that the Department of Health and Human Services is
    charged with providing essential human services such as Medicaid,
    Medicare, and better access to private coverage. HHS responsibilities
    include mental health treatment, services to older individuals, and
    direct health services delivery. However, we remain deeply concerned as
    current proposals to amend the Affordable Care Act (ACA) and Medicaid
    demonstrate that Essential Health Benefits are no longer being seen as
    necessary and the critical safety nets of Medicaid/Medicare are under
    attack. Access to private coverage will be also affected by allowing
    pre-existing condition exclusions, 6 month waiting periods, annual/
    lifetime caps, and rescission of policies. Repealing the ACA has
    nothing to do with the cuts being proposed to Medicaid, other than the
    expansion population. According to the AAP (American Academy of
    Pediatrics), 37 million children are covered under Medicaid. In
    addition, there are over 60 million covered for mental health or
    substance abuse per the APA (American Psychiatric Association), and
    their data shows that the opioid epidemic is rising in every state.
    There is nothing in the proposed legislation that will improve health
    coverage or health care, and many components that will negatively
    impact health coverage and health care and endanger the lives and
    health of millions of Americans.

    We understand that consideration is being given as to whether HHS rules
    advance or impede priorities in the areas of stabilizing markets,
    affordability, returning regulatory authority to states, streamlining/
    flexibility, reducing burden, and identifying regulations that reduce
    jobs. In the area of stabilization, adverse selection due to the
    elimination of the individual mandate will destabilize the market. With
    regard to affordability, people with pre-existing conditions or the
    elderly will be priced out. And work provisions for Medicaid are
    unnecessary as 75% of people on Medicaid work; the rest are children,
    disabled, and the elderly. In relation to returning authority to
    states, access to healthcare shouldn't be based on where you live;
    state waivers will complicate issues and also affect service delivery
    due to state budget deficits. In the area of streamlining and
    flexibility, this terminology is being misused in order to provide
    fewer services. Regarding reducing burden, instead of starting at the
    beginning it seems more efficient to revise as needed what is already
    in place under the ACA. In regard to job reduction, homecare for
    elderly and direct support professionals for people with disabilities
    will be impacted resulting in the loss of home care jobs (estimate
    between 305,000 and 713,000 jobs lost) due to Medicaid per capita caps
    per the Center for Consumer Engagement in Health Innovation. In
    addition, this is in violation of the Supreme Court Olmstead decision
    and returning more people to more costly institutional care rather than
    providing home and community based services which is movement backward
    not progress.

    We acknowledge that HHS previously solicited comments on the ``Patient
    Protection and Affordable Care Act; Market Stabilization,'' to affect
    premiums, ``curb abuses, lower prices, and reduce adverse selection.''
    We support lower premiums; however the CBO (Congressional Budget
    Office) will not be able to complete a report in the timeframe.
    Premiums will rise for all, especially for the elderly or disabled.
    Regarding curbing abuses, the percentage of Medicaid fraud is extremely
    low--and the majority of fraud is perpetuated by providers as opposed
    to patients. It is unconscionable to cut this program as a trade-off
    for tax cuts for the wealthy. Finally, for adverse selection, this will
    actually be increasing due to the elimination of the individual
    mandate. Further, high-risk pools for those with pre-existing
    conditions will be unaffordable and states using this model have
    already demonstrated that this tactic fails.

    While HHS claims that it has initiated these steps to attempt to
    address stabilizing the market, affordability, and affirming the
    traditional authority of the States, the reality is that the market
    will be de-stabilizing due to high risk pools and adverse selection. We
    disagree that there will be choice if consumers can't afford health
    care as all should have access and if consumers can't get affordable
    coverage due to pre-existing conditions or lack of affordable options
    that provide Essential Health Benefits. We also disagree that this will
    address affordability as premiums are rising and others will be priced
    out due to their condition or age. We are very concerned with state
    options as this will allow annual/lifetime caps and rescission of
    policies otherwise.

    Please note that the largest major medical group (American Medical
    Association), patient/provider groups (ALS Association, American Cancer
    Society Cancer Action Network, American Diabetes Association, American
    Heart Association, American Lung Association, Arthritis Foundation,
    Cystic Fibrosis Foundation, Family Voices, JDRF, Lutheran Services in
    America, March of Dimes, National Health Council, National Multiple
    Sclerosis Society, National Organization for Rare Diseases, Volunteers
    of America, WomenHeart), and even insurance groups (Blue Cross Blue
    Shield plans and America's Health Insurance Plans) are opposing this
    plan as it will negatively impact women, children, people with
    disabilities, and the elderly resulting in a sicker, more costly,
    American populace. Please consider our constructive comments above in
    response to your request for information.

    Sincerely,

    Diana MTK Autin                     Lauren Agoratus, M.A., parent
    Executive Co-Director, SPAN         NJ Coordinator, Family Voices @
                                        SPAN
    Email: diana.autin@spannj.org       Email: familyvoices@spannj.org

                                     ______

                       Letter Submitted by Shawn M. Steen

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    September 21, 2017

    Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
    September 25, 2017

    Dear Senate Finance Committee Members,

    I write to express my deep opposition to the Graham-Cassidy-Heller-
    Johnson proposal. The sponsors of this proposal vowed that it would
    replace the ACA with something better and more affordable--yet it fails
    miserably in all respects. I demand a full and fair hearing on this
    legislation after it has been analyzed by the Congressional Budget
    Office (CBO). The last bill scored by the CBO had an approval rating of
    12%, yet this bill is moving forward and is even worse than the last
    bill scored. The proposal introduces pre-existing condition exclusions,
    limits essential health services, and reduces the affordability of
    health insurance. This is unacceptable.

    The Graham-Cassidy-Heller-Johnson proposal will price ordinary
    Americans out of any insurance market, returning to the days when a
    cancer patient who couldn't work couldn't access health care; when a
    person with asthma couldn't afford health insurance due to a pre-
    existing condition; when a person working a full-time job couldn't
    afford health insurance. This is not what Americans want.

    Millions of elderly individuals and people with disabilities rely on
    traditional Medicaid for their lives, well-being, and independence.
    Medicaid saves the lives of people with disabilities who rely on things
    like tracheotomy care, nursing care, dialysis, cancer treatments,
    occupational therapy, speech therapy, life-saving medications, durable
    medical equipment, and more to work. These people are our family
    members, our neighbors, our coworkers, and our friends. We are the
    wealthiest country in the world. We can and should provide Medicaid for
    the elderly and people with disabilities.

    This proposal will impact pregnant women and children, who are insured
    by Medicaid in high numbers. In Wisconsin, 28% of all children are
    covered by Medicaid. Nearly half of all US births are covered by
    Medicaid. For many children with disabilities and extensive health care
    needs, Medicaid is crucial--and cutting it puts children's lives at
    risk. Children who receive regular health care to treat things like
    asthma, diabetes, and treatable medical problems fare better in school,
    miss fewer days of school, are more likely to graduate, and earn higher
    wages than those without health care. Taking away their health care
    thus also negatively impacts our economy.

    I am submitting this testimony to the committee to ensure that it is
    entered into the official record of these proceedings. I want the
    record of this committee to show that those who voted for this proposal
    were fully aware of its devastating and destructive impact despite
    being told by millions of American citizens that this is not what we
    want.

    Sincerely,

    Shawn M. Steen

                                     ______

                       Letter Submitted by Earline Thomas

    September 22, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
    September 25, 2017

    Senator Hatch and Republican members of the Senate Finance Committee:

        I would like to offer my testimony for the Graham-Cassidy-Heller-
    Johnson proposal. Please include my letter in the record for this
    hearing.

        Obamacare probably saved my life. Now you, an affluent U.S.
    Senator, want to take my lifeline away. Why? For more campaign funds
    from richer than rich contributors? To fall in rank with GOP party
    lines that are driven by corporations, agencies, and individuals that
    control your campaign purse strings? To satisfy campaign promises that
    were never made? You did not promise to take away medical care or
    Medicaid! Have you totally lost your moral guidance?

        When was the last time you visited sick children dependent on
    Medicaid? When did you last talk with a senior dependent on Medicaid
    for their care? When did you last visit a homeless veteran who cannot
    get proper housing, transportation or medical care? When did you get
    turned away from medical care because you could not afford it? When did
    you have to choose between insurance and other necessities?

        When my seeming small insignificant injury healed over it looked
    like a blood blister on my arm. It was not painful, not in my direct
    line of sight and easy to ignore. After a few months it was still
    there, but not noticeable if I wore a blouse with sleeves. My partner
    and a neighbor convinced me to have it looked at so I went to a
    dermatologist because I had insurance. My partner had an appointment
    with her primary care physician the next day. They physician suggested
    he could remove it surgically. It turned out to be a deep melanoma and
    had just started to invade the lymph system.

        Follow-up surgery took out more tissue and I now have a cancer
    diagnosis of IIIB. If I had waited any longer to see a physician, the
    cancer would have been stage IV, and I likely would have died. If I
    didn't have insurance at the time, I could not have been convinced to
    see a doctor until I became sick. All I had was a strange-looking
    lesion on my arm that was not painful.

        The follow-up surgeries, scans and appointments over the past 2
    years would have been financially difficult. But now the proposed
    changes in health care by the BCRA, the repeal of ACA, the Graham-
    Cassidy bill and other attempts to destroy affordable health insurance,
    would take away my ability to continue to get good care. The costs of a
    metastatic cancer diagnosis will be approximately $150,000.00 per year
    for this pre-existing condition. No one can afford that type of
    insurance premium.

        Your constituents are quite aware that you are trying to pass a
    bill that will destroy their chance to get good medical care, and that
    you have no concerns for their health or their financial stability.
    They know you are voting for your wealthy supporters and not for the
    families of your states. They will remember in the 2018 election year
    that you took away healthcare from their families. They will remember
    in election year 2020 and 2022 that you tried undermine AND harm the
    health of the nation. You as a group and as individuals will be shamed
    by the people of this great nation for the harm you are purposely
    inflicting.

                Sincerely,

                Earline Thomas

                                     ______

                       Letter Submitted by Emily Todebush

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Building
    Washington, DC 20510-6200

    Re: Graham-Cassidy-Heller-Johnson proposal hearing, September 25, 2017

    The Honorable Orrin Hatch, Chairman of the Senate Finance Committee and
    the other distinguished members of this committee:

    It is with heavy heart that I submit my testimony in opposition of the
    Graham-
    Cassidy-Heller-Johnson proposal. I would like my written testimony to
    be included in the hearing record.

    Birthdays, phone numbers, addresses. Our lives are oftentimes summed up
    by a series of numbers that help tell the story of where we came from
    and where we're going. On February 26, 2013, I added another number to
    my collection: 340, the international diagnostic code for multiple
    sclerosis. I was 27-years-old.

    Let me back up.

    In early October 2012, I was experiencing a very specific pain behind
    my right eye. The pain was excruciating and hurt every time I moved my
    eye. Have you ever wondered how much you move your eye in a 10-minute
    span? Spoiler alert: It's a lot.

    I had started a new job just 60 days earlier and for 30 more days, I
    was only covered by a ``catastrophic'' insurance plan, which meant I
    could only see a doctor in the ER and my deductible was $10,000. No
    other doctor's visits were covered. Not exactly generous, but I was a
    healthy twenty-something. What could go wrong?

    Because I am not rich, I had to wait until my new insurance kicked in
    before I could see a doctor. Once I was finally covered and finally
    seeking help, I spent months dealing with neurological symptoms that
    evolved from eye pain to total numbness and tingling along the right
    side of my body to difficulty walking. I would oftentimes lay awake at
    night thinking how in the world I would get to work if I couldn't walk
    reliably. My life was changing in front of me, but I wasn't in control
    of any of it.

    My experience is no different than anyone else with a pre-existing
    condition. Whether it's MS or cancer, the reality is the same; you are
    completely at the mercy of your insurance provider. That's only a
    portion of what makes Graham-Cassidy-Heller-Johnson so terrifying.

    Here's why it matters to me and everyone else with a pre-existing
    condition.

    Before implementation of the Affordable Care Act, insurance companies
    were allowed to impose a ``lifetime maximum'' to your policy. Those
    lifetime maximums were oftentimes $1,000,000, which is a number big
    enough that it seems unlikely you'll ever reach it. Unlikely unless
    you've experienced a serious health episode, that is. The Affordable
    Care Act outlawed lifetime maximums, but this bill reinstates that
    lifetime maximum provision.

    Why does that matter?

    Take me for example. My health insurance policy is charged more than
    $100,000 a year for my cost of care. Of that $100,000 a year, $81,600
    of that goes to pay for my disease-modifying drug, whose sole purpose
    is to slow and delay the ability for MS to destroy my central nervous
    system. If you are unfamiliar with the disease, I should tell you that
    the unpredictable way this disease attacks makes it very complicated
    for me to plan my future. This disease in its progression will
    deteriorate my brain and spinal cord, potentially causing paralysis and
    a whole host of other disabilities. Without my medication, MS would
    attack my body at will, and I would be a prisoner in my own body. And,
    if you used $100,000 as an annual benchmark, I would exceed my
    insurance benefits in 10 years, when I will be just 42-years old.

    At that time, my insurance company will be allowed drop me. That would
    force me to look for a new insurance plan. Because I have a pre-
    existing condition, insurance companies could deny me coverage outright
    or they would be able to charge me unaffordable insurance premiums,
    forcing me to go without. So, to those of you who roll your eyes when
    you hear someone on the news saying that there are people who might die
    without the Affordable Care Act: please, remember this story. MS does
    not provide a quick death, instead causing a slow breakdown of function
    and body processes that is both heartbreaking to watch and agonizing to
    experience.

    In addition to removing protections for pre-existing conditions, this
    bill strips what are considered ``essential health benefits,'' which
    means that my insurance carrier wouldn't have to cover any of my
    doctor's visits, lab tests, MRIs, or prescription drugs that are
    critical to my care.

    You see, my life is all about numbers. I am now part of an exclusive
    club; just one of the tens of millions of Americans who could lose
    their insurance coverage if you pass this disastrous legislation.

    How a country cares for its most vulnerable population says a lot about
    who we are as a nation, about our character. The healthcare debate has
    always been about something more than politics. It's about doing what's
    right for the people who don't have a voice. I choose to speak out
    about healthcare not to point out how sick I am, but to illustrate how
    sick I am not, and that is in large part thanks to the Affordable Care
    Act.

    Since I was a very little girl, I have had a tremendous and
    overwhelming love for my country. I believe that while our union is not
    perfect, when we gather to debate, we bear witness to the enduring
    strength of our constitution. We affirm the promise of democracy. We
    are celebrating that our nation is truly an idea that is unique;
    carefully thought out and a masterpiece in the making. It demonstrates
    that what makes this country exceptional is our allegiance to an idea,
    a constitution, which our founders articulated many centuries ago. Our
    government was carefully designed as a government for, by, and of the
    people. It is all our call to duty to bridge the meaning of the words
    written as a Declaration of Independence with the realities of our
    time; for history tells us that while these truths may be self-evident,
    they've never been self-executing.

    I am among the 32 million Americans who will be hurt by this bill.
    Because I live in Washington, DC, I do not have a Senator to call. I
    don't have representation in my own government; someone to plead my
    case to. Instead, I am writing you a letter, to be submitted into the
    record of a hearing that I am not allowed to attend, much less testify
    in person.

    I have a face. I am a person. I am someone's daughter, sister, grand-
    daughter, niece, aunt, significant other, and friend. I want to live a
    full and prosperous life. I want to grow old. I want to feel the sun on
    my face and breathe a sigh of relief that the Congress in which I have
    no say in electing, is somehow remembering that I am a person too.
    Someone whose health hangs in the balance of this hearing, this vote,
    and this Congress.

    I respectfully ask that this bill be pulled from consideration and that
    both parties work together to fix the flaws in the Affordable Care Act.

    In good health,

    Emily Todebush
    Washington, DC, by way of the great State of Michigan

                                     ______

                           Trust for America's Health

                          1730 M Street, NW, Suite 900

                              Washington, DC 20036

                                (t) 202-223-9870

                                (f) 202-223-9871

                            www.healthyamericans.org

    September 22, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Building
    Washington, DC 20510-6200

           RE: Hearing to consider the Graham-Cassidy-Heller-Johnson
    proposal, September 25, 2017

    Dear Chairman Hatch and Ranking Member Wyden:

    On behalf of Trust for America's Health, a non-profit, non-partisan
    organization dedicated to improving the health of every American, I am
    writing to voice our strong opposition to the Graham-Cassidy-Heller-
    Johnson amendment (#1030) to the American Health Care Act (H.R. 1628)
    and to any legislation that would eliminate the Prevention and Public
    Health Fund (Prevention Fund). We urge Senators to work together in a
    bipartisan manner to ensure that Americans have access to high quality,
    affordable health care, including clinical preventive services, and to
    strengthen the public health system so that illnesses, injuries and
    needless deaths can be avoided.

    Although we do not yet have a score from the Congressional Budget
    Office (CBO), the Graham-Cassidy proposal would dramatically increase
    the number of uninsured Americans by an estimated 32 million Americans,
    according to an analysis by the Center on Budget and Policy Priorities.
    It also would eliminate $15.1 billion in current and future public
    health funding (FY19-FY28). This will threaten the ability of the
    Center for Disease Control and Prevention (CDC) to protect Americans'
    health and slash lifesaving investments in states by more than $3
    billion over 5 years alone. The result will be American people becoming
    sicker and poorer. It will impede our ability to respond to and recover
    from natural disasters such as Hurricanes Harvey and Irma. We will
    likely see more opioid overdoses, increases in infant mortality and
    innumerable other preventable health issues, all of which add up to
    elevated healthcare costs.

    We are particularly concerned about the impact on those covered under
    Medicaid. The same analysis indicates that this proposal would cut
    Medicaid funding for all but 12 states, with those states with Medicaid
    expansion populations being particularly disadvantaged. Reductions in
    Medicaid enrollment would severely restrict access to health care
    services, especially for those with limited incomes. By eliminating
    protections for those with pre-existing conditions, Americans who have
    faced or are currently facing illness will be particularly prone to
    higher premiums and subsequently higher rates of uninsured. Without
    affordable insurance coverage, we will see increased rates of
    preventable illnesses, injuries and deaths.

    Coverage is crucially important, but we also want to highlight the
    consequences of repealing the Prevention Fund, which makes up 12
    percent of the CDC budget. Of that investment, $625 million directly
    supports state and local public health efforts. This legislation would
    eliminate the Prevention Fund as of October 2018 (FY19). This would
    devastate the CDC budget and would wreak havoc on our efforts to reduce
    chronic disease rates, immunize our children and prepare the public
    health system to address infectious disease outbreaks and other
    threats.

    The United States spends more than $3 trillion annually on health care,
    but directs just 3 percent of that toward preventing illness in the
    first place. Public health funding is already insufficient to meet
    existing needs, and public health departments struggle every time a new
    epidemic emerges, as we saw last year with the emergence of the Zika
    virus. This leaves Americans unnecessarily vulnerable to preventable
    health problems, ranging from major disease outbreaks and bioterrorism
    threats to diabetes and opioid misuse.

    We don't know where or when the next outbreak will come and we can't
    wait until a crisis hits to begin investing in public health. Keeping
    Americans healthier would significantly drive down trips to the
    doctor's office or emergency room, safeguard Americans against
    epidemics, and reduce healthcare costs. Finally, we have attached below
    for your consideration a letter addressed to Senate leadership dated
    June 26, 2017 and signed by over 580 organizations, expressing their
    opposition to repealing the Prevention and Public Health Fund. We urge
    you to oppose this legislation. Thank you for your consideration.

    Sincerely,

    John Auerbach
    President and CEO

                                     ______

    June 26, 2017

    The Honorable Mitch McConnell
    Senate Majority Leader
    U.S. Senate
    Washington, DC 20510

    The Honorable Charles Schumer
    Senate Minority Leader
    U.S. Senate
    Washington, DC 20510

    Dear Majority Leader McConnell and Minority Leader Schumer:

    On behalf of the more than 580 undersigned organizations, we are
    writing to warn of the dire consequences of repealing the Prevention
    and Public Health Fund (the Prevention Fund), which is repealed by the
    Better Care Reconciliation Act (H.R. 1628) at the start of FY 2018.
    Repealing the Prevention Fund without a corresponding increase in the
    allocation for the Labor-Health and Human Services-Education
    appropriations bill would leave a funding gap for essential public
    health programs, and could also foretell substantial cuts for other
    critical programs funded in the bill. As the Senate continues work on
    its version of health reform, we urge you to leave the Prevention and
    Public Health Fund in place.

    Today, more than 12 percent of the Centers for Disease Control and
    Prevention (CDC) budget is supplied through Prevention Fund
    investments. This includes core public health programs that provide
    essential funds to help states keep communities healthy and safe, such
    as the 317 immunization program, epidemiology and laboratory capacity
    grants, the entire Preventive Health and Health Services (Prevent)
    Block Grant program, cancer screenings, chronic disease prevention and
    other critically important programs. For example, the Prevent Block
    Grant provides all 50 states, the District of Columbia, 2 American
    Indian tribes, and 8 U.S. territories with flexible funding to address
    their unique public health issues at the state and community level.

    Despite the growing and geographically disparate burden of largely
    preventable diseases, health threats such as the opioid epidemic, and
    emerging infectious disease outbreaks such as the Zika virus, federal
    disease prevention and public health programs remain critically
    underfunded. Public health spending is still below pre-
    recession levels, having remained relatively flat for years. The CDC's
    budget authority has actually decreased by 11.4 percent since FY 2010
    adjusted for inflation, and the Prevention Fund has helped to make up
    the difference.

    Discretionary programs, including public health, education, and job
    training programs funded through the Labor-Health and Human Services-
    Education (LHHS) appropriations spending bill have been cut
    dramatically and disproportionately in recent years as lawmakers have
    worked to reduce the deficit, even though experts across the political
    spectrum agree these programs are not a driving factor behind our
    nation's mid- and long-term fiscal challenges. Eliminating the
    Prevention Fund would be disastrous to the CDC budget and programs, and
    to the LHHS bill as a whole, leaving a nearly $1 billion budget hole
    which would be impossible to fill under current discretionary spending
    caps.

    Funding prevention not only saves lives but it saves money. A
    comprehensive study of evidence based prevention programs found that
    every dollar invested yields $5.60 in savings. There are many
    provisions of the Affordable Care Act aimed at promoting health and
    prevention, but the Prevention Fund is particularly important--a
    dedicated investment in prevention and public health activities to
    counteract the much larger bill--$3.2 trillion and growing--we pay
    every year as a country to treat illness and disease.

    We urge you to maintain funding made possible by the Prevention and
    Public Health Fund and safeguard funding for the CDC and other programs
    under the Labor-HHS-Education spending bill.

    Sincerely,

    2Morrow, Inc.                       American College of Cardiology
    1,000 Days                          American College of Clinical
                                        Pharmacy
    1965                                American College of Occupational
                                        and Environmental Medicine
    Ability360                          American College of Preventive
                                        Medicine
    Academy of Geriatric Physical
    Therapy                             American College of Sports Medicine
    Academy of Nutrition and Dietetics  American Council on Exercise
    Action for Healthy Kids (AFHK)      American Diabetes Association
    Active Living By Design             American Federation of State,
                                        County, and Municipal Employees
    Active Transportation Alliance      American Federation of Teachers
    Ad Hoc Group for Medical Research   American Foundation for Suicide
                                        Prevention
    ADAP Advocacy Association (aaa+)    American Heart Association
    Addiction Connections Resource      American Immunization Registry
                                        Association
    Adult Congenital Heart Association  American Indian/Alaska Native/
                                        Native Hawaiian APHA Caucus
    Advancement Project California      The American Academy of HIV
                                        Medicine
    Advocate Good Shepherd Hospital     American College of Occupational
                                        and Environmental Medicine
    Advocates for Better Children's
    Diets                               American Lung Association
    African American Health Alliance    American Medical Student
                                        Association
    AIDS Alliance for Women, Infants,
    Children, Youth, and Families       American Organization of Nurse
                                        Executives
    The AIDS Institute                  American Psychological Association
    AIDS Research Consortium of Atlanta  American Public Health Association
    AIDS United                         American School Health Association
    Alabaster                           American Sexual Health Association
    Allamakee County Public Health      American Society for Nutrition
    American Academy of HIV Medicine    American Society of Hematology
    American Academy of Pediatrics      American Society of Tropical
                                        Medicine and Hygiene
    American Association for Dental
    Research                            American STD Association
    American Association for the Study
    of Liver Diseases                   American Thoracic Society
    American Association of Colleges of
    Nursing                             Ann and Robert H. Lurie Foundation
    American Association of Colleges of
    Pharmacy                            APICAT for Healthy Communities
    American Association of
    Naturopathic Physicians             APLA Health
    American Association of
    Neuromuscular and Electrodiagnostic
    Medicine                            The Arc
    American Association on Health and
    Disability                          Arizona Center for Law in the
                                        Public Interest
    American Cancer Society Cancer
    Action Network                      The Bronx Health Link
    Arizona Health Care Association     Bronx Health REACH
    Arizona Medical Association         California Food Policy Advocates
    The Arizona Partnership for
    Immunization                        California Pan-Ethnic Health
                                        Network
    Arizona Public Health Association   California Public Health
                                        Association-North
    Arizona Rural Health Association    California State Association of
                                        Counties
    Arkansas Public Health Association  California WIC Association
    Asian and Pacific Islander American
    Health Forum                        Cambridge Health Alliance
    Asian Services In Action            Campaign for Tobacco-Free Kids
    Association for Clinical and
    Translational Science               Camptonville Community Partnership
    Association for Prevention Teaching
    and Research                        Canary Health
    Association for Professionals in
    Infection Control and Epidemiology  Cancer Council of the Pacific
                                        Islands
    Association of Accredited
    Naturopathic Medical Colleges       Cancer Prevention and Treatment
                                        Fund
    Association of Accredited Public
    Health Programs                     Canyon Ranch Center for Prevention
                                        and Health Promotion
    Association of American Cancer
    Institutes                          The Cave Institute
    Association of American Medical
    Colleges                            Cedar County Public Health
    Association of Community Health
    Nursing Educators                   Center for Behavioral Epidemiology
                                        and Community Health
    Association of Maternal and Child
    Health Programs                     Center for Health and Learning
    Association of Montana Public
    Health Officials                    Center for Health Promotion and
                                        Disease Prevention
    Association of Public Health
    Laboratories                        Center for Science in the Public
                                        Interest
    Association of Public Health Nurses Center in the Park
    Association of Reproductive Health
    Professionals                       Center for Popular Democracy
    Association of Schools and Programs
    of Public Health                    Central California Asthma
                                        Collaborative
    Association of State and
    Territorial Health Officials        Central Jersey Family Health
                                        Consortium
    Association of State Public Health
    Nutritionists                       Central Michigan District Health
                                        Department
    Association of University Centers
    on Disabilities                     Central Michigan Regional Rural
                                        Health Network
    Asthma and Allergy Foundation of
    America                             Centralina Area Agency on Aging
    Atrius Health                       Centro Multicultural La Familia
    Authority Health                    Cerro Gordo County Department of
                                        Public Health
    B'more Mobile                       Chalk Talk Science Project
    Barnes ON THE MOVE Partnership      ChangeLab Solutions
    Behavioral Health Leadership
    Institute                           Chautauqua County Department of
                                        Health and Human Services
    Benzie Leelanau District Health
    Department                          Chicago Commons
    Berean Wellness and Community
    Support Center                      Childhood Obesity Prevention
                                        Coalition of Washington State
    Big Cities Health Coalition         Children and Adults with Attention
                                        Deficit Hyperactivity Disorder
                                        (CHADD)
    Black Women's Health Imperative     Children's Action Alliance
    Boston Alliance for Community
    Health                              Children's Environmental Health
                                        Network
    Boston Public Health Commission     Children's Health Fund
    Boston Senior Home Care             Children's Mental Health Network
    Boston University School of Public
    Health                              City-County Health District
    Boulder County (CO) Public Health   Clinica Sierra Vista
    Boys and Girls Clubs of America     Clinical Research Forum
    Coalition for Healthy School Food   Coalition for Clinical and
                                        Translational Science
    Coconino County Public Health
    Services District                   Coalition for Health Funding
    College of Public Health and Human
    Sciences                            District Health Department 2 and 4
                                        (West Branch, MI)
    Oregon State University             Diversified Resources Group
    Colorado Association of Local
    Public Health Officials             Doctors for America
    Colorado Association of School
    Nurses                              Dorchester County Health Department
    Colorado Children's Immunization
    Coalition                           Duxbury Council on Aging
    Colorado Public Health Association  Dystonia Medical Research
                                        Foundation
    Columbia County (NY) Health
    Department                          Early Impact Virginia
    Commissioned Officers Association
    of the U.S. Public Health Service,
    Inc. (COA)                          East Bay Agency for Children
    CommonHealth ACTION                 Edna Bennett Pierce Prevention
                                        Center, Penn State University
    Community Access National Network
    (CANN)                              Ehrens Consulting
    Community Catalyst                  Elder Options
    Community Clinic Consortium         Elder Services of the Merrimack
                                        Valley, Inc.
    Community Health Councils           Elder Services of Worcester Area,
                                        Inc.
    Community Health Initiative Napa
    County (CA)                         Element Health, Inc.
    Community Health Improvement
    Partners                            Emory University
    Connecticut Directors of Health
    Association                         Endocrine Society
    Connecticut Public Health
    Association                         Enhance Asian Community on Health
    Conrad House, Inc.                  Eradicating the School-to-Prison
                                        Pipeline Foundation, Inc.
    The Consortium                      Essential Access Health
    Contact Wellness Foundation         Essex County (NY) Health Department
    Cook County (IL) Department of
    Public Health                       ETA Sigma Gamma
    Cooley's Anemia Foundation          Evidence-Based Leadership Council
    COPD Foundation                     Fairhill Partners
    Council for Diabetes Prevention     Family Services Agency of Santa
                                        Barbara (CA) County
    Council of Mexican Federations in
    North America                       The Family Van: Harvard Medical
                                        School
    Council of State and Territorial
    Epidemiologists                     Fathers and Families of San Joaquin
    Council on Aging--Chicopee, MA      Fayette County Health Department
    County Health Executives
    Association of California           Feeling Good MN
    County of San Diego Health and
    Human Services Agency               First in Families of North Carolina
    The Crohn's and Colitis Foundation
    of America                          Florida Breastfeeding Coalition
    Cultiva La Salud                    The Food Trust
    Delaware Academy of Medicine/
    Delaware Public Health Association  Forest Grove Public Schools Region
                                        6 Regional Prevention Coordinators
    Delaware County Office for the
    Aging                               Foundation for Healthy Generations
    Delaware Public Health Association  Fund for Public Health in New York
                                        City
    Denver Public Health                Futures Without Violence
    Des Ahrens Lactation Consulting     Gallatin City-County Health
                                        Department
    Detroit Public Health STD Clinic    Gay and Lesbian Medical Association
    Diabetes Center for Improvement     GBS/CIDP Foundation International
    Digestive Disease National
    Coalition                           George Washington University Cancer
                                        Center
    Dignity Health                      Georgia Society for Public Health
                                        Education
    Directors of Health Promotion and
    Education                            Global Liver Institute
    District Health Department #10
    (Tampa, FL)                         Grand Traverse County Health
                                        Department Greater Holyoke YMCA
    Healing Touch Massage               The Greenlining Institute
    Health Care Foundation of Greater
    Kansas City                         Harrison County (IA)
    Health Connect of South Dakota      Home and Public Health
    Health Department of Northwest
    Michigan                            Hawaii Public Health Association
    Healthy Living Collaborative of
    Southwest Washington                Hawaii Public Health Institute
    Health Promotion Council of
    Southeastern Pennsylvania, Inc.     Interstitial Cystitis Foundation
    Health Resources in Action          Inter-Tribal Council of Michigan
    Healthcare Ready                    Iowa Public Health Association
    Healthy Communities Coalition       Jefferson County Public Health
    Healthy Living Cape Cod             Jeffrey Modell Foundation
    Healthy Oxford Hills                John Peter Smith Health Network
    Healthy Schools Campaign            Johns Hopkins Center for Health
                                        Security
    Healthy Teen Network                Johns Hopkins University Institute
                                        for Health and Productivity Studies
    Healthy Weight Partnership          Joy-Southfield Community
                                        Development Corp
    Hemophilia Council of California    Kalusugan Community Services
    Hemophilia Foundation of Southern
    California                          Kansas Breastfeeding Coalition
    Hepatitis B Foundation              Kentucky Voices for Health
    Hepatitis Foundation International  Khmer Health Advocates
    Heritage Health and Housing         KL Startups
    Hispanic Health Initiatives, Inc.   Kossuth County Public Health
    HIV Medicine Association            La Alianza Hispana
    HLN Consulting, LLC                 Lake County Health Department and
                                        Community Health Center
    Hogg Foundation for Mental Health   Lakeshore Foundation
    Home Care Alliance of MA            Latino Coalition for a Healthy
                                        California
    Human Impact Partners               The Latino Health Insurance
                                        Program, Inc.
    Human Rights Campaign               Latino Public Health Network at
                                        Hopkins
    Idaho Immunization Coalition        Laurie M. Tisch Center for Food,
                                        Education, and Policy, Teachers
                                        College, Columbia University
    Idaho Public Health Association     Lawrence-Douglas County Health
                                        Department
    Idaho Walk Bike Alliance            League of American Bicyclists
    Illinois Public Health Institute    Levine Senior Center
    Immunize Nevada                     LISC New York City
    Impetus--Let's Get Started, LLC     LiveWell Longmont
    Indiana Public Health Association    LiveWell Luzerne
    Infectious Diseases Society of
    America                             Liver Health Initiative
    Institute for Community and
    Collaborative Health                Local Public Health Association of
                                        Minnesota
    Institute for Health and
    Productivity Studies, Johns Hopkins
    Bloomberg School of Public Health   Los Angeles County Department of
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    Institute for Public Health
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    Institute of Social Medicine and
    Community Health                    Louisiana Public Health Association
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    Consulting, LLC                     Louisiana Public Health Institute
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    International Foundation for
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    Meharry Medical College             Maricopa County Department of
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    Men's Health Caucus                 Maricopa Integrated Health System
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    Minneapolis Health Department       National Center for Health Care
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    Minnesota Public Health Association The National Commission for Health
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    Mississippi Public Health
    Association                         National Coalition for Promoting
                                        Physical Activity
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    MJH Grant Consulting                National Coalition on Health Care
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    Montana Primary Care Association    The National Consumer Voice for
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    Montana Public Health Association   National Consumers League Long-Term
                                        Care
    Montgomery County Health Department National Council for Behavioral
                                        Health
    Montrose County School District     National Council on Aging
    Morehouse School of Medicine        National Environmental Health
                                        Association
    Mother and Child Health Coalition   National Family Planning and
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    Multicultural Family Center         National Forum for Heart Disease
                                        and Stroke Prevention
    My Brother's Keeper, Inc.           National Foundation for Infectious
                                        Diseases
    NAATPN, Inc.                        National Health Care for the
                                        Homeless Council
    NAPHSIS: National Association for
    Public Health Statistics and
    Information Systems                 National Healthy Start Association
    Nashville CARES                     National Hemophilia Foundation
    National AHEC Organization          National Hispanic Medical
                                        Association
    National Alliance on Mental Illness National Institute for Children's
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    National Alliance of State and
    Territorial AIDS Directors          National Latino Network of Casa de
                                        Esperanza
    National Alopecia Areata Foundation National Physician's Alliance
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    Network                              Nebraska Association of Local
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    National Birth Equity Collaborative Nemours Children's Health System
    National Black Justice Coalition    NephCure Kidney International
    NICHQ (National Institute for
    Children's Health Quality)          NETWORK Lobby for Catholic Social
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    NIRSA: Leaders in Collegiate
    Recreation                          Nevada Public Health Association
    NJSOPHE                             New England Wellness Foundation
    NJ YMCA State Alliance              New Jersey Public Health
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    North American Quitline Consortium  The New York Academy of Medicine
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                                        Center
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    OASIS Institute                     Pulmonary Hypertension Association
    Ohio Public Health Association      PureView Health Center
    Oklahoma Public Health Association  Quality Home Care Services
    Olympic Area Agency on Aging        Racial and Ethnic Health
                                        Disparities Coalition
    ON THE MOVE, a Community Public
    Health Partnership                  Rails-to-Trails Conservancy
    Ontario County (NY) Public Health   Raising Women's Voices for the
                                        Health Care We Need
    Oregon Public Health Association    Redstone Global Center for
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    Oregon State University             Region 9 Education Cooperative
    Origins FTD, Inc.                   Research!America
    Out2Enroll                          Respiratory Health Association
    Partners for a Healthier Community  Retrofit
    Partners in Care Foundation         RiverStone Health
    PATHS Education Worldwide           Rural AIDS Action Network
    Peer Health Exchange                Rural Center for AIDS/STD
                                        Prevention at the IU School of
                                        Public Health Bloomington
    Peggy Lillis Foundation             S2AY Rural Health Network, Inc.
    Personal Assistance Services
    Council                             Sacramento Black Child Development
                                        Institute
    Philly Breastfeeds                  Safe and Healthy Communities
    Planned Parenthood Federation of
    America                             Safe Kids Worldwide
    Polk County (WI) Health Department  Safe Routes to School National
                                        Partnership
    Presence Mercy Medical Center
    Health Institute                    Safe States Alliance
    Prevent Blindness                   Saint Anthony Hospital
    Prevent Cancer Foundation           Salud de Paloma
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    Preventive Cardiovascular Nurses
    Association                         Sarah Samuels Center for Public
                                        Health Research and Evaluation
    Primary Care Development
    Corporation                         Self-Management Resource Center
    Primary Care Medicine and Public
    Health Synergy                      School-Based Health Alliance
    Prism Health North Texas            Scleroderma Foundation
    Project Inform                      SCP Partners
    Project Mend-A-House                Second Harvest Food Bank Santa Cruz
                                        County
    Promoting Healthy                   Self-Management Resource Center
    Protecting Arizona's Family
    Coalition                           Senior Citizen Services of Greater
                                        Tarrant County Inc.
    Public Health Advocates             Senior Resources--Agency on Aging
    Public Health Association of
    Nebraska                            Senior Services of Snohomish County
    Public Health Association of New
    York City                           Senior Services of Southeastern
                                        Virginia
    Public Health Delta and Menominee
    Counties                            SeniorsPlus
    The Society for Healthcare
    Epidemiology of America             Sexuality Information and Education
                                        Council of the U.S.
    Society for Public Health Education Shelby County Schools Coordinated
                                        School Health
    Society for the Advancement of
    Violence and Injury Research
    (SAVIR)                             Shoals Community Clinic
    Society of Behavioral Medicine      Sickle Cell Disease Association/
                                        PDVC
    The Society for Healthcare
    Epidemiology of America             Sigma Xi, The Scientific Research
                                        Honor Society
    Society of State Leaders of Health
    and Physical Education              Sleep Research Society
    South Alabama Regional Planning
    Commission                          Virginia Public Health Association
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    Collaborative                       Walk San Francisco
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    Coalition                           WalkBoston
    Southern AIDS Coalition             The Wall Las Memorias Project
    Southern California Public Health
    Association                         Washington State Association of
                                        Local Public Health Officials
                                        (WSALPHO)
    Southern California Society for
    Public Health Education             Washington State Public Health
                                        Association
    Southern HIV/AIDS Strategy
    Initiative (SASI)                   Wayne State University Center for
                                        Health and Community Impact
    Southwest Human Development, Inc.   Wellco
    SparksInitiatives                    WellGiG
    Spina Bifida Association            Wellness Institute of Greater
                                        Buffalo
    Spokane Shrinking Violet Society    West Valley Neighborhoods Coalition
    St. Clair County Health Department  Western Illinois Area Agency on
                                        Aging
    Street Level Health Project         Western North Carolina AIDS Project
    Stewart Memorial Community Hospital Wholesome Wave
    Susan G. Komen                      Wilkes-Barre Family YMCA
    Tacoma-Pierce County (WA) Health
    Department                          Winnesehiek County Board of Health
    Tennessee Public Health Association Wisconsin Institute for Healthy
                                        Aging
    Think Bicycles of Johnson County    Wisconsin Public Health Association
    Three Rivers District Home Health   WithinReach
    Thrive At Life: Working Solutions   Wolfson Wellness
    Tomorrow Matters!                   WomenHeart: The National Coalition
                                        for Women with Heart Disease
    Training Resources Network, Inc.    The Women's Caucus
    Treatment Action Group              Worksite Wellness LA
    Tri County Health Department
    (Greenwood Village, CO)             YCat Yoga Therapy and Jnani
                                        Chapman's Integrative Medicine
                                        Service
    Trust for America's Health          Yolo County (CA) Children's
                                        Alliance
    Tuscola County Health Department     Youngstown State University
    Union for Reform Judaism            YOUR Center
    U.S. Hereditary Angioedema
    Association                         Zero Breast Cancer
    United States Breastfeeding
    Committee
    United Way of Tarrant County, TX
    Universal Health Care Action
    Network of Ohio
    The University of Texas M.D.
    Anderson Cancer Center
    Utah Public Health Association
    Valley Program for Aging Services
    Vermont Public Health Association
    VillageCare
    Village Connect

                                     ______

                                    UnidosUS

                            Raul Yzaguirre Building

                        1126 16th Street, NW, Suite 600

                           Washington, DC 20036-4845

    Introduction

    UnidosUS, formerly the National Council of LaRaza, is the largest
    national Hispanic * civil rights and advocacy organization
    in the United States. For nearly 50 years, we have worked to advance
    opportunities for middle- and working-class Latino children and
    families, including immigrant and mixed-status households, to achieve
    the highest level of health possible. In this capacity, UnidosUS and
    its Affiliate Network of nearly 300 Affiliates have worked to ensure
    that all people-regardless of who they are or where they are from--have
    access to affordable, quality health care.
    ---------------------------------------------------------------------------
        * The terms ``Hispanic'' and ``Latino'' are used
    interchangeably by the U.S. Census Bureau and throughout this document
    to refer to persons of Mexican, Puerto Rican, Cuban, Central American,
    Dominican, Spanish, and other Hispanic descent; they may be of any
    race.

    Advancing health equity is crucial for all Americans, including Latinos
    who are still more likely to be uninsured than other Americans. The
    Affordable Care Act (ACA) has helped drive us closer to health equity.
    Since the implementation of this law, more than 4 million Latinos
    gained coverage and the rate of uninsured Latinos plummeted to a record
    low--from 43.2% in 2010 to 24.8% in 2016.\1\ Still, this progress is
    fragile. While the number of uninsured Latinos has fallen dramatically
    because of the ACA, in 2016, 40% of uninsured adults were Latino.\2\
    Proposals that we have seen to repeal and replace the ACA would reverse
    course on these historic gains and put millions of people one medical
    emergency away from financial devastation.
    ---------------------------------------------------------------------------
        \1\ The Commonwealth Fund, ``Millions More Latino Adults Are
    Insured Under the Affordable Care Act'' (Washington, DC, The
    Commonwealth Fund, 2017), http://www.commonwealthfund.
    org/publications/blog/2017/jan/more-latino-adults-insured.
        \2\ Ibid.

    As evidence of our commitment to improving access to health care,
    UnidosUS has published several reports on coverage gains and what the
    ---------------------------------------------------------------------------
    ACA means to the Latino community:

          ``Latino Children's Coverage Reaches Historic High, But Too Many
    Remain Uninsured,'' published by UnidosUS and the Georgetown Center for
    Children and Families (December 2016).
          ``Historic Gains in Health Coverage for Hispanic Children in the
    Affordable Care Act's First Year,'' published by UnidosUS and the
    Georgetown Center for Children and Families (January 2016).
          ``Latino Health at Risk: What the American Health Care Act Means
    for Latinos''--separate publications for Arizona, Colorado, Florida,
    and Nevada, published by UnidosUS and FamilesUSA (June 2017).

    UnidosUS strongly opposes the Graham-Cassidy-Heller-Johnson bill
    (Graham-Cassidy), the latest in a long string of attempts to repeal and
    replace the ACA. By some estimates, this bill would lead to at least 30
    million people losing coverage, deep cuts and restructuring of the
    Medicaid program, weakening or eliminating protections for people with
    preexisting conditions, and skyrocket out-of-pocket costs for
    consumers. It is not surprising that so many stakeholders have publicly
    expressed their opposition to the bill, including a bipartisan group of
    governors, all 50 state Medicaid directors, the American Academy of
    Pediatrics, and America's Health Insurance Plans (AHIP). Hardworking
    Americans, including Latinos, cannot afford the implications of this
    bill.

    This written statement will focus on the importance of the ACA program
    to the Latino community, concerns with the Graham-Cassidy proposal, and
    recommendations for strengthening the ACA by stabilizing the
    marketplace.

    The ACA Has Led to Historic Gains for Latino Coverage

    Overall, the ACA has made health coverage a reality for 20 million
    Americans, including 4 million nonelderly Latino adults.\3\ Since the
    provisions went into effect in 2013, the positive effects have been
    clear:
    ---------------------------------------------------------------------------
        \3\ Assistant Secretary for Planning and Evaluation, ``Health
    Insurance Coverage and the Affordable Care Act,'' Washington, DC, 2015.

          Over 4 million Latinos, including children and young adults,
    have benefited from the ACA's provisions. The ACA has provided coverage
    to mostly nonelderly adults--4.2 million. It is important to note that
    figure includes over 900,000 Latino young adults between the ages of 19
    and 26. These young Latinos would otherwise be uninsured; but have
    coverage under their parents' plan because of the ACA.\4\ Additionally,
    over 600,000 Latino children have gained coverage since 2013 because of
    health coverage expansions, including the ACA.\5\
    ---------------------------------------------------------------------------
        \4\ Assistant Secretary for Planning and Evaluation, ``Report Shows
    Affordable Care Act Has Expanded Insurance Coverage Among Young Adults
    of All Races and Ethnicities,'' Washington, DC, 2012.
        \5\ Ibid.

          The ACA has brought the Latino uninsured rate down to historic
    lows. Between 2013 and 2015, the overall Latino uninsured rate declined
    to 16.2%, the lowest rate ever recorded.\6\ This dramatic reduction is
    due, in large part, to the ACA. This law is also thought to have
    influenced a similar decline in the Latino child uninsured rate--with
    the largest 2-year decline on record between 2013 and 2015 (11.5%-
    7.5%).\7\ This decline also brought the uninsurance rate for Latino
    children to a record low.
    ---------------------------------------------------------------------------
        \6\ U.S. Census Bureau, ``Health Insurance Coverage in the United
    States: 2015,'' Current Population Reports, Washington, DC, 2016.
        \7\ Georgetown Center for Children and Families and NCLR, ``Latino
    Children's Coverage Reaches Historic High, But Too Many Remain
    Uninsured'' (Washington, DC: Georgetown Center for Children and
    Families and NCLR, 2016), http://publications.nclr.org/handle/
    123456789/1672 (accessed January 2017).

          States that expanded Medicaid under the ACA have experienced the
    largest decline in the uninsured rate for nonelderly Latino adults. In
    these states, the average uninsured rate for elderly Latino adults was
    22%, compared to 36% in states that elected not to expand.\8\
    California, which expanded its Medicaid program, experienced the
    largest percentage point decline in the nonelderly Latino adult
    uninsured rate of any state (38%-20%).\9\
    ---------------------------------------------------------------------------
        \8\ Ibid.
        \9\ Ibid.

          Most Latinos know that the ACA is working. Nationwide, nearly
    three out of four Latino voters (71%) believe that the ACA is working
    well or mostly working well, and should remain in place.\10\ Moreover,
    the August 2017 Kaiser Health Tracking Poll found that overall, most
    adults (60%) thought it was a good thing that Republicans did not
    repeal the ACA.
    ---------------------------------------------------------------------------
        \10\ National Council of La Raza and Latino Decisions, Health
    Policy Survey: October 12-19, 2016 (Washington, DC: NCLR and Latino
    Decisions, 2016).
    ---------------------------------------------------------------------------

    Concerns With Graham-Cassidy Bill

    The Graham-Cassidy bill, the latest effort from Senate Republicans to
    repeal and replace the ACA, makes one thing clear: the health and well-
    being of the American people is not a priority. Instead, this bill
    makes harsh cuts to fundamental health care programs like Medicaid,
    while making it more difficult for working- and
    middle-class Americans to access health insurance. In this spirit,
    Graham-Cassidy includes the most injurious parts of previous repeal-
    and-replace bills and adds other provisions that will do even more
    harm. While a full score from the Congressional Budget Office (CBO)
    does not exist, the CBO score of previous repeal attempts can serve as
    a useful proxy of the effect this bill would have on health coverage in
    2027 when all block grant funding to the states is cut off.\11\
    Specifically, for the Obamacare Repeal Reconciliation Act, the CBO
    estimated that 32 million people would lose coverage if funding for
    state Medicaid expansion programs and premium subsidies were eliminated
    by 2027. In fact, it is likely that coverage loss would be even greater
    due to the addition of Medicaid per capita caps this bill imposes on
    our children, seniors, and the disabled.
    ---------------------------------------------------------------------------
        \11\ Congressional Budget Office, ``H.R. 1628 Obamacare Repeal
    Reconciliation Act of 2017,'' Washington, DC, 2017, https://
    www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/52939-
    hr1628amendment.pdf (accessed August 2017).

    The Graham-Cassidy bill threatens the well-being of millions of
    Americans, but stands to have a greater negative effect on the Latino
    community. This bill puts everyone with Medicaid coverage, or receiving
    premium subsidies in the ACA marketplace, at risk of losing access to
    health coverage, or being forced to pay more for it. However, Latinos
    will be disproportionately harmed by this proposal, because they are
    more likely to count on the federal programs, like Medicaid and ACA
    premium subsidies, which are singled out for major cuts. UnidosUS has
    ---------------------------------------------------------------------------
    four key concerns with this harmful proposal from Senate Republicans.

          The Medicaid program as we know it would end. Like other repeal
    and replace bills, Graham-Cassidy would restructure and cut funding for
    the rest of Medicaid, outside of the ACA's Medicaid expansion. The
    proposal caps the amount of federal funding available for traditional
    Medicaid beneficiaries like children, people with disabilities, and
    low-income seniors. Between 2020 and 2026, Medicaid spending for the
    traditional Medicaid Population will be cut by an estimated $175
    billion, including by $39 billion in 2026 alone.\12\ These cuts will
    force states to cut benefits, cap the number of enrollees, or both.
    ---------------------------------------------------------------------------
        \12\ Jacob Leibenluft et al., ``Like Other ACA Repeal Bills,
    Cassidy-Graham Plan Would Add Millions to Uninsured, Destabilize
    Individual Market'' (Washington, DC: Center on Budget and Policy
    Priorities, 2017).
    ---------------------------------------------------------------------------
              A cap on Medicaid spending would hit Latinos the
    hardest, as one-third of Latinos, including over half of all children,
    count on Medicaid for health coverage.\13\
    ---------------------------------------------------------------------------
        \13\ Kaiser Family Foundation, ``Distribution of the Nonelderly
    With Medicaid by Race/
    Ethnicity'' (Washington, DC: Kaiser Family Foundation, 2015), http://
    kff.org/medicaid/state-indicator/distribution-by-raceethnicity-4/
    ?currentTimeframe=O; (accessed May 2017); and Center for American
    Progress, ``Hispanic Children Receiving Health Insurance Through
    Medicaid by State, 2015'' (data table, Center for American Progress,
    2017).
    ---------------------------------------------------------------------------
              Latino children, who are part of the traditional
    Medicaid population, account for a majority of Medicaid/CHIP enrollees.
    Over half of Latino children count on Medicaid for coverage and would
    see their benefits or enrollment affected by drastic cuts.\14\
    ---------------------------------------------------------------------------
        \14\ Annie E. Casey Foundation, ``Children who have health
    insurance by health insurance type and by race and ethnicity''
    (Baltimore, MD: Annie E. Casey, 2016); and Joan Alker, Tara Mancini,
    and Martha Heberlein, ``Snapshot of Children's Coverage by Race and
    Ethnicity'' (Washington, DC: Georgetown CCF, 2017).

          The Medicaid expansion provision under the ACA and marketplace
    subsidies would end. Graham-Cassidy would eliminate the ACA's Medicaid
    expansion and marketplace subsidies starting in 2020. The proposal
    includes cutting federal funding for state Medicaid expansion and
    premium subsidies by $236 billion from 2020 to 2026 and offers smaller
    and insufficient block grants. States would not be required to spend
    block grant funds on lowering health care costs for low- and moderate-
    income children and families; they could spend this money virtually any
    way they please. Losing both provisions would leave millions of
    Americans vulnerable to a coverage loss.
              Eleven million Americans, including 3 million
    Latinos, who gained Medicaid coverage because of state expansions,
    would be at risk of losing coverage.\15\
    ---------------------------------------------------------------------------
        \15\ National Council of La Raza analysis of U.S. Census Bureau,
    ``2015-2016 Annual Social and Economic Supplement, Current Population
    Survey,'' Washington, DC, 2016, https://www.census.gov/programs-
    surveys/cps/data-detail.html, with assistance from the Center on Budget
    and Policy Priorities (CBPP); and Centers for Medicare and Medicaid
    Services, ``Total Medicaid Enrollees--VIII Group Break Out Report''
    (Washington, DC: U.S. Department of Health and Human Services, 2016),
    https://www.medicaid.gov/medicaid/program-information/downloads/cms-64-
    enrollment-report-jan-mar-2016.pdf.
    ---------------------------------------------------------------------------
              Nearly 9 million Americans, including most
    Latinos, who use premium subsidies to purchase individual marketplace
    coverage, would be at risk of losing coverage.\16\
    ---------------------------------------------------------------------------
        \16\ CMS, ``2017 Marketplace State-Level Open Enrollment Public Use
    File,'' downloaded from https://www.cms.gov/Research-Statistics-Data-
    and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/
    Plan_Selection_ZIP.html (accessed June 2017).

          Graham-Cassidy shifts federal funds from Medicaid expansion
    states to nonexpansion states. Under the proposed block grant
    structure, overall funding for Medicaid expansion and subsidies will be
    cut, but in 2021, reduced federal funding would be redistributed across
    states. The allotment would be based on their share of low-income
    residents rather than actual spending. This means that over time,
    states that expanded Medicaid and effectively enrolled citizens in the
    ACA's health insurance marketplace would be punished, including states
    with large Latino populations, like California, Florida, and New
    York.\17\ While all states will see reductions over time, at least
    initially, states that did not expand or work to enroll low-income
    people would see less damaging cuts or even increased funding
    initially. In all, 36 states, plus DC, would face net federal funding
    cuts in 2021. In the long run, every state will face net funding cuts
    when block grant funding ends after 2026.\18\
    ---------------------------------------------------------------------------
        \17\ Jacob Leibenluft et al., ``Like Other ACA Repeal Bills,
    Cassidy-Graham Plan Would Add Millions to Uninsured, Destabilize
    Individual Market'' (Washington, DC: Center on Budget and Policy
    Priorities, 2017).
        \18\ Ibid.

    States that lose the most federal funds for Medicaid and premium
    subsidies include states with significant Latino populations like
    Arizona, California, Colorado, Florida, New York, and Nevada.
              A total of 9.2 million Latinos are enrolled in
    Medicaid coverage in these states.\19\
    ---------------------------------------------------------------------------
        \19\ Kaiser Family Foundation, ``Distribution of the Nonelderly
    With Medicaid by Race/
    Ethnicity'' (Washington, DC: Kaiser Family Foundation, 2015), http://
    kff.org/medicaid/state-indicator/distribution-by-raceethnicity-4/
    ?currentTimeframe=O; (accessed May 2017).
    ---------------------------------------------------------------------------
              California stands to lose the most with a $27.8
    billion cut in federal funding for health care costs and covering low-
    and moderate-income people by 2026. Other states will face
    significantly reduced funding as well: New York by $18.9 billion,
    Florida by $2.7 billion, Arizona by $1.6 billion, Colorado by $823
    million, and Nevada by $639 million.\20\
    ---------------------------------------------------------------------------
        \20\ Jacob Leibenluft et al., ``Like Other ACA Repeal Bills,
    Cassidy-Graham Plan Would Add Millions to Uninsured, Destabilize
    Individual Market'' (Washington, DC: Center on Budget and Policy
    Priorities, 2017).

          Graham-Cassidy weakens consumer protections under the ACA,
    including those for people with preexisting conditions. This bill would
    allow states to waive the ACA's prohibition against charging higher
    premiums based on the existence of health conditions or health status.
    The U.S. Department of Health and Human Services estimates that up to
    133 million nonelderly Americans may have a preexisting condition.\21\
    States applying for a waiver would only be asked to explain how they
    intend to maintain access for people with pre-existing conditions; they
    would not need to submit any proof that their plan would accomplish
    that. Furthermore, this bill also ends the requirement that insurers
    cover essential health benefits including hospitalization, maternity
    care, and prescription drugs.
    ---------------------------------------------------------------------------
        \21\ Office of the Assistant Secretary for Planning and Evaluation,
    ``Health Insurance Coverage for Americans with Pre-Existing Conditions:
    The Impact of the Affordable Care Act,'' U.S. Department of Health and
    Human Services, Washington, DC, 2017.
    ---------------------------------------------------------------------------

    Strengthen Existing Law via Bipartisan Solutions

    Congress has the power and responsibility to prioritize the health and
    economic security of the American people. I urge you to reject efforts
    to strip health care away from those who need it most and instead focus
    on taking bipartisan legislative action to reduce uncertainty in the
    health insurance marketplace, hold down premiums, and bolster access to
    health coverage for more Americans. While the opportunity to improve
    the law for the coming year may slip past amid efforts to repeal, work
    must be done to strengthen the law in the future. An important starting
    point would be to continue work on bipartisan legislation to stabilize
    the marketplace that prioritizes the following:

          Make the cost-sharing reduction (CSR) payments permanent.
    Congress should create a permanent funding stream for CSR payments.
    Sixty percent of people with marketplace coverage use CSR payments to
    significantly reduce their out-of-pocket health care costs. The
    Congressional Budget Office estimates that terminating these payments
    would cause benchmark silver plan premiums to increase by an average of
    20% and cause 1 million people to lose coverage.

          Reinstate and fund the ACA's reinsurance program. Congress
    should reinstate and make permanent the reinsurance program to
    facilitate increased insurer participation in the marketplace and lower
    costs. When it was funded, the ACA's reinsurance program resulted in
    lower premiums for consumers. In 2014, the reinsurance program reduced
    premiums by 10-14%. Similar savings would help more Americans attain
    coverage this open enrollment period.

          Prioritize 2018 Latino open enrollment outreach and enrollment
    efforts. Congress should appropriate funds and instruct the Department
    of Health and Human Services (HHS) to provide enrollment resources and
    assistance for all consumers. Congress should also direct HHS to
    prioritize communities of color, those with limited English proficiency
    (LEP), immigrant and mixed-status families, as well as the LGBTQ
    community. These communities historically have had lower coverage rates
    and are more likely to be new to our health care system than other
    consumers. Our work with Affiliates over four open enrollment periods
    demonstrates that in-person, in-language, and culturally competent
    consumer outreach and assistance is the most effective way to engage
    the Latino community, including LEP and immigrant families. These
    resources are critical this year, given the compressed open enrollment
    period and the uncertainty surrounding the administration's enforcement
    of the ACA.

    Conclusion

    While the ACA is not perfect, the historic impact of the law cannot be
    denied. It has proven to be successful in expanding coverage, improving
    health outcomes, and increasing financial security to 20 million
    American people. Despite that, this law is under attack again. With
    each proposal purporting to strengthen the ACA, the stakes for the
    American people are raised and it becomes clearer that positioning
    people and families for better health and greater economic security is
    not a priority for this Congress. We strongly oppose any plan--
    including the Graham-Cassidy bill--that undermines tens of millions of
    Americans who have finally been able to obtain quality, affordable
    health insurance and that asks the sickest and poorest among us to bear
    the brunt of health care costs. These proposals are just cruel. Every
    senator who is considering voting for the Graham-Cassidy bill must
    realize they are voting to jeopardize the lives and financial stability
    of working families back home. You can, and must, do better. Any
    national health reform proposal should focus on giving more people, not
    fewer, the opportunity for quality, affordable, and accessible health
    care. The health and economic security of our country demand it and the
    American people deserve no less.

                                     ______

                       Letter Submitted by Laura Wallace

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Building
    Washington, DC 20510-6200

    Re: Statement for the record for Graham-Cassidy bill hearing, September
    25, 2017

    September 22, 2017

    Dear Senators:

    I am concerned that the Graham-Cassidy bill, if passed, would imperil
    access to healthcare for millions of Americans, including myself and my
    family. I am particularly concerned about how the bill would affect
    premium prices for people with pre-existing conditions. I urge the
    Senate to reject any bill that could lead to price discrimination based
    on pre-existing conditions.

    Before the Affordable Care Act became law, my family struggled to
    qualify for comprehensive coverage on the private individual market due
    to pre-existing conditions. Once the Affordable Care Act became law, I
    was able to purchase a comprehensive plan on the private individual
    market. I do not receive a subsidy; I pay the full cost of the premium.
    It's not cheap, but before the Affordable Care Act, this type of
    comprehensive coverage wasn't available to me on the private individual
    market at all; the premiums for what was available were astronomical
    because people with pre-existing conditions were charged more.

    I am very concerned that if Graham-Cassidy passes, comprehensive
    coverage will become either unavailable or unaffordable for me. Graham-
    Cassidy would let states decide whether or not they keep various rules
    that are currently required at the federal level under the Affordable
    Care Act, such those that prevent insurance companies from charging
    more for pre-existing conditions, implementing lifetime caps on
    coverage, or offering non-comprehensive plans that don't cover
    essential health benefits. If my state did not keep those requirements,
    my premium would likely go up substantially because of pre-existing
    conditions--and any plan might no longer offer such comprehensive
    coverage.

    I am also concerned that premiums are likely to go up in general if the
    individual mandate is repealed, because that would change the risk
    pool.

    Please reject any bill, including Graham-Cassidy, that could allow
    insurers to charge more for pre-existing conditions, implement lifetime
    or annual caps, or charge extra for things that are currently
    considered essential health benefits (such as prenatal and maternity
    care, checkups, lab tests, prescription medication, substance abuse
    treatment, etc).

    Best regards,

    Laura Wallace

    CC: Senator Dianne Feinstein, Senator Kamala Harris

                                     ______

           Wisconsin Board for People With Developmental Disabilities
    September 22, 2017

    Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
    September 25, 2017

    U.S. Senate
    Committee on Finance,
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Dear Chairman Hatch and members of the Senate Finance Committee:

    The Wisconsin Board for People with Developmental Disabilities (BPDD)
    is charged under the federal Developmental Disabilities Assistance and
    Bill of Rights Act (DD Act) with advocacy, capacity building, and
    systems change to improve self-determination, independence,
    productivity, and integration and inclusion in all facets of community
    life for people with developmental disabilities.

    We agree with the 75 national disability groups opposed to the Graham-
    Cassidy-Heller-Johnson (GCHJ) bill that this legislation puts people
    with disabilities at risk and actively undermines the improvements the
    DD Act is working to achieve for people with Intellectual and
    Developmental Disabilities (I/DD) and their families. Many provisions
    within the bill will disproportionately harm people with disabilities,
    and threaten Wisconsin's innovative, cost-effective Medicaid programs
    that have successfully reduced costs and kept people out of expensive
    institutions.

    The Graham-Cassidy-Heller-Johnson bill (GCHJ) contains the same ideas
    as previous ACA repeal bills including cuts and per capita caps to
    Medicaid, weakening of consumer protections, and no controls on rising
    health care, prescription, and other increasing costs--and would have
    the same negative effects on people with disabilities, people with pre-
    existing conditions, and their families.

    BPDD hears from Wisconsin people with disabilities and their families
    across the state. Their opposition to this bill has been universal.

    Medicaid Critical to Wisconsin People With Disabilities and Their
                        Families

    Medicaid pays for the Forward HealthCard and almost 20 Wisconsin
    programs--including Family Care, IRIS, Children's Long Term Support,
    BadgerCare, intensive autism services, etc.--that help older adults,
    people with disabilities, families with children, and low income
    working adults.

    Fifty percent of people with disabilities in Wisconsin rely on
    Medicaid, and people with I/DD participate in all Wisconsin's 20 state
    Medicaid programs to stay healthy, become employed, and remain in their
    homes.

    Medicaid provides essential therapies, equipment, special education
    services, and equipment from physical therapists to feeding tubes, and
    many other services critical to people with disabilities. Medicaid
    funded supports and services often makes the difference between
    caregivers being able to keep their jobs or leaving the workforce--
    jeopardizing their own financial futures--to care for family members.

    Per Capita Caps Threaten Services, Increase Risk for Expensive
                        Institutionalization

    People with disabilities will be disproportionally harmed by Medicaid
    cuts and per capita caps. Care for people with disabilities makes up a
    significant part of state Medicaid budgets due to their long-term care
    needs.
    Reduced Federal Funding Threatens Wisconsin Investment and Flexibility
    The block grants and per capita caps included in the GCHJ bill do not
    provide states with additional flexibility. Current Medicaid law
    provides states with tremendous flexibility through waivers to custom
    design their state's Medicaid programs. In fact, no two state Medicaid
    programs operate the same way, a testament to the Medicaid innovation
    and experimentation states have undertaken the past 52 years.

    Wisconsin state government has made extensive use of federal waivers
    (e.g., BadgerCare Plus, Family Care, Partnership, SeniorCare, IRIS, and
    Children's Long-Term Support etc.) to shape and design programs to
    specifically meet the health and long-term care needs of the people of
    Wisconsin. Because Wisconsin has been able to leverage these
    flexibilities, it is the only state in the nation that has eliminated
    waiting lists for adults, according to the Kaiser Family Foundation,
    and a proposal to do the same for children has been included in this
    state budget. Waitlists for long-term care services have ended while
    also cutting Medicaid costs by hundreds of millions of dollars and
    keeping administrative costs constrained at 2%.

    The GCHJ bill will force states to make large and continued cuts to
    Medicaid each state budget cycle as the federal funding contribution
    continues to decline and costs continue to rise. The Medicaid block
    grant and per capita caps proposed in the bill will result in
    dramatically reduced funding for Wisconsin, and will force the state to
    reduce services, cut optional services, restrict eligibility, and
    increase waiting lists.

    Early analysis projects Wisconsin may not lose funding immediately, but
    projections show a $562M loss of federal funds for Wisconsin's 20
    Medicaid programs and ForwardHealth card by 2026. By 2027 Wisconsin
    stands to lose $3 billion in federal Medicaid funds. Per capita caps
    continue to deepen cuts over time (Avalere predicts $29B reduction to
    traditional Wisconsin Medicaid by 2036).
    Per Capita Caps and Funding Reductions Put People With Disabilities at
            Risk for Institutionalization
    Federal Medicaid law currently mandates states to pay for high-cost
    institutional facilities (such as nursing homes, and state centers for
    the developmentally disabled if states have chosen not to close them).
    Wisconsin has dramatically reduced Medicaid costs by keeping people in
    the community, progress that this bill threatens to reverse. The home
    and community based services (HCBS) on which people with disabilities
    rely to live and participate in their communities are especially at
    risk because they are optional and could be completely eliminated.

    Wisconsin has valued and invested in home and community based (HCBS)
    services as a mechanism to maximize people's independence and lower
    overall Medicaid spending by keeping people out of expensive
    institutions. For more than 20 years, Wisconsin has been expanding the
    Medicaid funded long-term care programs Family Care and IRIS; these
    programs have dramatically reduced high-cost institutional spending and
    kept people in their homes, jobs, and communities.

    Since 2002, Family Care and IRIS have reduced overall spending on
    Medicaid long term care by 10%, reduced the amount of long term care
    Medicaid dollars spent on institutions by 50%, and decreased the number
    of people in nursing homes paid for by Medicaid by 35%. Seventy percent
    of Wisconsin's long-term care enrollees live in a home or community-
    based setting, which are typically 30-40% less expensive than
    institutional care. Wisconsin is poised to become one of the only
    states in the nation to have no waiting lists for kids and adults
    needing home and community based supports.

    Per capita caps and the funding reductions that go with them could take
    Wisconsin backwards 25 years to the days where people waited years (and
    sometimes died waiting) for needed supports or could force people back
    into more expensive institutions because they can no longer wait for
    home-based supports.

    Uncertainty for People With Disabilities With Pre-Existing Conditions

    Most people with disabilities have one or more care needs that could be
    considered a pre-existing condition. Prior to the ACA, many people with
    disabilities faced discrimination, high premium, coverage limits, and
    challenges to accessing care from insurers.

    The GCHJ bill allows states to choose not to cover Essential Health
    Benefits, effectively ending pre existing conditions protections.
    States could roll back the 10 essential health benefits (including
    hospitalization, prescription drugs, habilitative and rehabilitative
    services etc.) currently required to be a part of all insurance plans,
    and to permit insurers to charge higher premiums to people with pre-
    existing conditions, which means insurers could once again discriminate
    based against people based on their medical history. The bill does not
    define what ``adequate and affordable'' care means. Without these
    protections, experts warn that coverage could become unattainable and/
    or unaffordable for many.

    The inclusion of high risk pools will provide little protection for
    people with pre-
    existing conditions. Experts on both sides of the aisle have clearly
    warned that high risk pools lead to higher costs, fewer benefits and
    waiting lists rationing care for those with pre-existing conditions.

    BPPD strongly opposes the GCHJ bill because of these negative impacts
    on people with disabilities and urges Congress to work with the
    disability community on any changes to both the Affordable Care Act and
    existing Medicaid programs.

    Sincerely,

    Beth Swedeen
    Executive Director

                                     ______

                             Wisconsin Family Ties

                          16 N. Carroll St., Suite 230

                               Madison, WI 53703

                          608-267-6800 or 800-422-7145

                         https://www.wifamilyties.org/

    Wisconsin Family Ties is a statewide, parent-run non-profit
    organization serving families in that include children and youth with
    social, emotional, behavioral or mental health challenges. We are
    writing to urge you to oppose the Graham-
    Cassidy-Heller-Johnson proposal, which represents a grave threat to the
    Medicaid funding upon which so many Wisconsin children and youth with
    mental health challenges and their families rely.

    According to national estimates, about one in five children have a
    diagnosable mental health issue, and the prevalence of childhood severe
    emotional disturbance approaches one in 10. According to a 2011 report
    from the Kaiser Family Foundation, Medicaid is the single largest
    funder of behavioral health treatment nationwide; Kaiser also reports
    that in Wisconsin, one in three children is covered by Medicaid/CHIP.
    Medicaid is absolutely crucial to the mental health and well-being of
    Wisconsin's children and their families.

    By instituting per-capita caps on federal Medicaid funding, the Graham-
    Cassidy-Heller-Johnson proposal would be devastating to children and
    adults with disabilities. The cuts would threaten numerous areas in
    which Medicaid programs support children's mental health in Wisconsin,
    jeopardizing our state's efforts to make a better future for our
    children and youth. The following elements of Medicaid are of
    particular concern:

    EPSDT (Early Periodic Screening, Diagnosis, and Treatment)

    The Medicaid EPSDT benefit, known in Wisconsin as HealthCheck, is the
    child health component of Medicaid that allows children and youth to
    access comprehensive and preventive health and behavioral health care.
    Behavioral health treatment for autism and serious emotional
    disturbance falls under the EPSDT benefit. Capping Medicaid will make
    it virtually inevitable that states will be unable to maintain the
    comprehensive nature of EPSDT, putting the children and youth who need
    behavioral therapies at risk.

    School Based Services

    Medicaid is a critical funding stream for school districts to increase
    the number of students who receive mental health services. In
    Wisconsin, schools and districts have increasingly sought ways to
    partner with community-based mental health providers. The 2017-2019
    Wisconsin state budget, which will soon be signed by Governor Scott
    Walker, includes grants for comprehensive integration of school/
    community mental health partnerships, but the effort will be severely
    compromised if the Medicaid funding mechanism for the clinical
    therapies is undermined by the Graham-Cassidy-Heller-Johnson proposal.

    Children's Long Term Support (CLTS)

    Wisconsin has made innovative use of existing flexibilities via the
    Children's Long Term Support waiver, covering children and youth with
    severe emotional disturbances as well as with physical and
    developmental disabilities. The supports provided through this program
    help keep children where they belong--in their homes with their
    families. Recent research has indicated that parents in families
    receiving long-term support services are also more likely to remain
    employed, contributing not only to the economy but to their own mental
    well-being. The 2017-2019 Wisconsin state budget includes eliminating
    the CLTS waiver waiting list, which has grown to 2,200 children (around
    a quarter of whom qualify with severe emotional disturbance). Under the
    Graham-Cassidy-Heller-Johnson proposal, per capita caps threaten once
    again to leave families waiting for assistance that they desperately
    need.

    Comprehensive Community Services

    Finally, the Medicaid caps would also threaten the Medicaid-funded
    Comprehensive Community Services (CCS) program, a cornerstone of recent
    Wisconsin initiatives to improve mental health care for children and
    adults in our state. CCS serves individuals of all ages, including
    children and youth, who need ongoing services for mental illness or
    substance use disorders. A team of service providers works with each
    individual based on that person's individual needs and goals. The CCS
    program helps children and youth be more successful at home, at school,
    and in the community. The Graham-Cassidy-Heller-Johnson proposal would
    set this program, too, at risk.

    At a time when so many of Wisconsin's children and youth, and their
    families, are facing mental health challenges of crisis-level
    proportions, we should not even be considering inflicting such
    structural damage on the Medicaid system that supports them. Wisconsin
    Family Ties urges the Senate Committee on Finance to reject the Graham-
    Cassidy-Heller-Johnson proposal and focus instead on transparent, bi-
    partisan negotiations toward strengthening the Affordable Care Act.

    Thank you for the opportunity to submit this testimony. Please do not
    hesitate to contact me for further information: joanne@wifamilyties.org
    or by phone at (608) 261-0532.

    Joanne Juhnke
    Policy Director

                                     ______

                      Letter Submitted by Deanna Wurzbach

    September 20, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Building
    Washington, DC 20510-6200

    Re: Graham-Cassidy-Heller-Johnson bill

    Dear Committee:

    I am writing to tell you about how this bill will adversely affect the
    life of my daughter and that of so many others who rely on Medicaid.

    My daughter just turned 44 yesterday and ever since the age of 21, she
    has been able to hold a part-time job, volunteer in the community and
    have the health and pharmaceutical services she needs. She has epilepsy
    and brain damage so she is functioning around the age of six
    cognitively and has developed a lot of life skills thanks to her
    support system. She has job coaches to help her complete her job
    cleaning a church successfully and with volunteering at a local
    hospital and at a nursing home as well. If this bill comes to fruition,
    she will not be able to live as productive a life nor will she be able
    to live at home with us as she has done all her life. The loss of all
    of these things would result in chaos and heartache in her life. She is
    very proud of her abilities, and we are as well. I find it disgraceful
    that the most vulnerable of our population is the faction to suffer so
    that others can enjoy wealth and power.

    I am equally upset that this bill will affect so many others so
    adversely. Healthcare and living a life of dignity is a human right not
    a luxury or the whim of those in power.

    Sincerely,

    Deanna Wurzbach

                                     ______

                  Letter Submitted by Miles J. Zaremski, Esq.

    September 25, 2017

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Building
    Washington, DC 20510-6200

    Re:  Statement for the September 25, 2017 hearing on H.R. 1628, as
    revised,
    a/k/a/ Graham-Cassidy health care bill

    Dear Committee Members:

    I submit this letter in a non-representative capacity for inclusion in
    the official committee record as part of its September 25, 2017 hearing
    on the Graham-Cassidy health care bill, H.R. 1628, revised as of
    September 24, 2017. I also realize that it will probably not reach the
    record before the Senate votes by September 30th, but I consider its
    contents important enough to be made part of the official record.

    First, and painting with an extremely broad brush, I am a health care
    attorney of some 44 years now, with a substantial portion of that time
    involved in health care policy, extending back to when the HCQIA
    (Health Care Quality Improvement Act) was being developed in the 1980s
    and, most recently, being called upon to advise Members of Congress as
    the Affordable Care was being crafted in 2009/2010. I have also written
    and spoken extensively, nationally as well as on the international
    stage, on areas affecting the nation's health care and health care law.
    This has included law faculty positions and as an invited speaker at
    the University of Chicago, Case Western Reserve, Stetson Law School
    (professor, adjunct), and as far away as the Macquarie School of Law in
    Sydney, Australia. I have, as well, been the longest serving chair (5
    years) of the American Bar Association's Standing Committee on Medical
    Professional Liability, and the first non MD-JD president of the
    American College of Legal Medicine.

    My remarks follow viewing a substantial portion of the committee's
    hearing this afternoon on C-SPAN 2.

    Besides everything that has been said pro and con on Graham-Cassidy,
    one viewpoint that has not been clearly articulated is that this
    proposed legislation, if passed, will be a denial of equal protection
    for all Americans.

    The core of H.R. 1628, as revised, is to give health care back to each
    state to administer for its own residents, with the assistance of
    government block grants. In so doing, each state will have the
    discretion to divvy up those funds as each state's budget allows,
    including allowing for more leniency in granting waivers to insurers
    for what medical conditions will be covered by them and to what
    financial extent such conditions will be paid by them. This certainly
    impacts all those with pre-
    existing conditions. But what has not been clearly stated is that every
    American, generally speaking, is the same physiologically as is the
    illness or disease that afflicts each such individual, regardless of
    the state, or U.S. commonwealth or territory in which he or she
    resides. So, if any one of us contracts a cancer, a pneumonia,
    undergoes a joint replacement, or even for females, becomes pregnant,
    depending upon where we live, we might obtain better, or worse, health
    care through insurance than someone in a neighboring state or across
    the country is able to acquire through a state-administered program
    under Graham-Cassidy. This, in other words, would be a denial of equal
    protection for the same human being that has contracted the same
    disease or medical condition. The ACA, while imperfect and requiring a
    bipartisan fix for its shortcomings, at least provides uniformity in
    mandated health care insurance protections across state lines for all
    Americans.

    As well, the ``sweeteners'' now being offered to states like Alaska,
    Maine, Arizona, and Kentucky (no doubt to attract their senators' votes
    on the bill), effectively will provide more benefits to residents in
    those states than residents of every other state. And we cannot forget
    Graham-Cassidy's redistribution of Medicaid funds from those states
    that accepted the expansion under the ACA to those states that rejected
    the expended funds.

    These three examples constitute, as if in microcosm, a perspective of
    denying equal (health care) protection for the citizens of all states
    never really addressed in your hearing today, but is an essential one
    to be recorded and made part of your committee's record of today's
    hearing.

    Thank you for allowing me to put forth the above views.

    Sincerely,

    Miles J. Zaremski

                                     ______

                       Letter Submitted by Ginger Zarske

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Re: Hearing to consider the Graham-Cassidy-Heller-Johnson proposal,
    September 25, 2017

    Senator Hatch and members of the Senate Finance Committee:

    I am writing to give my perspectives on the Graham-Cassidy-Heller-
    Johnson bill.

    First, let me say that you are being churlish and childish in your
    commitment to repeal the ACA. President Obama knew it wasn't perfect.
    He worked hard to appease everyone, including the Health Care industry,
    and he always said that any improvements would be welcomed. You should
    be working to negotiate with the Health Care industry and the states to
    create a better, more robust plan. Instead, you are systematically
    breaking it up and creating nothing but chaos.

    It is your fault that insurance carriers are pulling out of states. It
    is your fault that some states refuse to expand Medicaid so that low
    income families and children can have a decent shot at a life, and it
    will be your fault when thousands of people die because they didn't
    have adequate health care.

    I hope you can't sleep.

    Sincerely,

    Ginger Zarske

                                     ______

                   Letter Submitted by Miriam and Neil Zusman

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Dear Members of the Senate Finance Committee,

    Despite claims to the contrary, the proposed amendment known as the the
    Graham-Cassidy-Heller-Johnson proposal, S. Amdt. 1030 to H.R. 1628, The
    American Health Care Act of 2017, scheduled for the Senate Committee on
    Finance meeting September 25th, is a plan that the Republicans are
    presenting as just another Patient Protection and Affordable Care Act
    (2010) repeal bill that would have the same devastating effects as the
    previous repeal bills they tried to get passed, causing at least 15
    million people to become uninsured and driving up premiums by 20%!
    Eleven governors, including five Republicans and a pivotal Alaskan
    independent, as well as the Executive Directors of the American
    Association of Retired Persons and the Executive Director of the
    American Public Health Association have urged the Senate this past
    Tuesday to reject this last-ditch push to dismantle the Patient
    Protection and Affordable Care Act (2010).

    The plan would completely eliminate the ACA's expansion of Medicaid,
    which has extended coverage to 11 million people: low income families
    and people with disabilities and children.

    It would also completely eliminate the ACA's marketplace subsidies,
    which currently help almost 9 million people afford coverage.

    It would provide $239 billion less in federal support for Medicaid
    coverage between 2020 and 2026, and END completely after 2026. New York
    State could lose more than $33 billion by 2027 under the Graham-Cassidy
    amendment.

    On top of these cuts, the plan would also cap and cut Medicaid for
    seniors, people with disabilities, and families with children, cutting
    funding outside expansion by about $175 billion between 2020 and 2026.

    I believe in quality, affordable healthcare for ALL Americans! I
    believe that health care ought to be an American right. A human right
    to health means that everyone has the right to the highest attainable
    standard of physical and mental health, which includes access to all
    medical services, sanitation, adequate food, decent housing, healthy
    working conditions, and a clean environment. Please warrant that the
    people you represent will have the ability to be productive and healthy
    citizens, regardless of their current income, by having affordable
    high-quality health care.

    Respectfully,

    Miriam and Neil Zusman