[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 [email protected] 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
[email protected] (202) 591-5319
Stephen Goewey, Vice President Communications
[email protected] (202) 246-1619

                                 ______
                                 
                         ALS Association et al.

Contact: [email protected]
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 [email protected] 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 
[email protected].

                                 ______
                                 
                           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 [email protected] 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, [email protected] 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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29. Sommers BD, Baicker K, Epstein AM. Mortality and access to care 
among adults after state Medicaid expansions. N Engl J Med. 
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30. Sommers BD. State Medicaid expansions and mortality, revisited: a 
cost-
benefit analysis. Am J Health Econ. 2017. doi:10.1162/AJHE_a_00080

31. Sommers BD, Long SK, Baicker K. Changes in mortality after 
Massachusetts health care reform: a quasi-experimental study. Ann 
Intern Med. 2014;
160:585-93. [PMID: 24798521] doi:10.7326/M13-2275

32. McWilliams JM, Zaslavsky AM, Meara E, Ayanian JZ. Health insurance 
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33. Baker DW, Sudano JJ, Durazo-Arvizu R, Feinglass J, Witt WP, 
Thompson J. Health insurance coverage and the risk of decline in 
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34. Hadley J, Waidmann T. Health insurance and health at age 65: 
implications for medical care spending on new Medicare beneficiaries. 
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of health insurance on near-elderly health and mortality. Am J Health 
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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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World Report. March 8, 2017 (http://www.usnews.com/opinion/thomas-
jefferson-street/articles/2017-03-08/the-gops-obamacare-repeal-has-a-
health-care-coverage-problem).

2. Watson K. GOP congressman: ``Nobody dies because they don't have 
access to health care.'' CBS News. May 6, 2017 (http://www.cbsnews.com/
news/gop-congressman-nobody-dies-because-they-dont-have-access-to-
health-care/).

3. McWilliams JM. Health consequences of uninsurance among adults in 
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4. Baicker K, Taubman SL, Allen HL, et al. The Oregon experiment--
effects of Medicaid on clinical outcomes. N Engl J Med 2013;368:1713-
22.

5. Hu L, Kaestner R, Mazumder B, Miller S, Wong A. The effect of the 
Patient Protection and Affordable Care Act Medicaid expansions on 
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Research, 2016.

6. Chua KP, Sommers BD. Changes in health and medical spending among 
young adults under health reform. JAMA 2014;311:2437-9.

7. Mazumder B, Miller S. The effects of the Massachusetts Health Reform 
on household financial distress. Am Econ J Econ Policy 2016;8:284-313.

8. Finkelstein A, Taubman S, Wright B, et al. The Oregon Health 
Insurance Experiment: evidence from the first year. Q J Econ 
2012;127:1057-106.

9. Sommers BD, Long SK, Baicker K. Changes in mortality after 
Massachusetts health care reform: a quasi-experimental study. Ann 
Intern Med 2014;160:585-93.

10. Simon K, Soni A, Cawley J. The impact of health insurance on 
preventive care and health behaviors: evidence from the first two years 
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11. Sommers BD, Blendon RJ, Orav EJ, Epstein AM. Changes in utilization 
and health among low-income adults after Medicaid expansion or expanded 
private insurance. JAMA Intern Med 2016;176:1501-9.

12. Ghosh A, Simon K, Sommers BD. The effect of state Medicaid 
expansions on prescription drug use: evidence from the Affordable Care 
Act. Cambridge, MA: National Bureau of Economic Research, 2017.

13. Taubman SL, Allen HL, Wright BJ, Bakker K, Finkelstein AN. Medicaid 
increases emergency-department use: evidence from Oregon's Health 
Insurance Experiment. Science 2014;343:263-8.

14. Akosa Antwi Y, Mariya AS, Simon K, Sommers BD. Changes in emergency 
department use among young adults after the Patient Protection and 
Affordable Care Act's Dependent Coverage Provision. Ann Emerg Med 
2015;65(6):664-672.e2.

15. Miller S. The effect of insurance on emergency room visits: an 
analysis of the 2006 Massachusetts health reform. J Public Econ 
2012;96:893-908.

16. Scott JW, Rose JA, Tsai TC, et al. Impact of ACA insurance coverage 
expansion on perforated appendix rates among young adults. Med Care 
2016;54:818-26.

17. Loehrer AP, Song Z, Haynes AB, Chang DC, Hutter MM, Mullen JT. 
Impact of health insurance expansion on the treatment of colorectal 
cancer. J Clin Oncol 2016;34:4110-5.

18. Wherry LR, Miller S. Early coverage, access, utilization, and 
health effects associated with the Affordable Care Act Medicaid 
expansions: a quasi-experimental study. Ann Intern Med 2016;164:795-
803.

19. Sommers BD, Maylone B, Blendon RJ, Orav EJ, Epstein AM. Three-year 
impacts of the Affordable Care Act: improved medical care and health 
among low-
income adults. Health Aff (Millwood) 2017;36:1119-28.

20. Keating NL, Kouri EM, He Y, West DW, Winer EP. Effect of 
Massachusetts health insurance reform on mammography use and breast 
cancer stage at diagnosis. Cancer 2013;119:250-8.

21. Robbins AS, Han X, Ward EM, Simard EP, Zheng Z, Jemal A. 
Association between the Affordable Care Act dependent coverage 
expansion and cervical cancer stage and treatment in young women. JAMA 
2015;314:2189-91.

22. Sommers BD, Baicker K, Epstein AM. Mortality and access to care 
among adults after state Medicaid expansions. N Engl J Med 
2012;367:1025-34.

23. Van Der Wees PJ, Zaslavsky AM, Ayanian JZ. Improvements in health 
status after Massachusetts health care reform. Milbank Q 2013;91:663-
89.

24. Sommers BD, Gunja MZ, Finegold K, Musco T. Changes in self-reported 
insurance coverage, access to care, and health under the Affordable 
Care Act. JAMA 2015;314:366-74.

25. Courtemanche C, Marton J, Ukert B, Yelowitz A, Zapata D. Early 
effects of the Affordable Care Act on health care access, risky health 
behaviors, and self-assessed health. Cambridge, MA: National Bureau of 
Economic Research, 2017.

26. Miller S, Wherry LR. Health and access to care during the first 2 
years of the ACA Medicaid expansions. N Engl Med 2017;376:947-56.

27. Kronick R. Health insurance coverage and mortality revisited. 
Health Serv Res 2009;44:1211-31.

28. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, 
Himmelstein DU. Health insurance and mortality in U.S. adults. Am J 
Public Health 2009;
99:2289-95.

29. Sommers BD. State Medicaid expansions and mortality, revisited: a 
cost-benefit analysis. Am J Health Econ 2017 May 17th (Epub ahead of 
print).

30. Torres H, Poorman E, Tadepalli U, et al. Coverage and access for 
Americans with chronic disease under the Affordable Care Act: a quasi-
experimental study. Ann Intern Med 2017;166:472-9.

31. Allen H, Baicker K, Finkelstein A, Taubman S, Wright BJ. What the 
Oregon Health Study can tell us about expanding Medicaid. Health Aff 
(Millwood) 2010;29:1498-506.

32. Shartzer A, Long SK, Anderson N. Access to care and affordability 
have improved following Affordable Care Act implementation; problems 
remain. Health Aff (Millwood) 2016;35:161-8.

33. Collins SR, Gunja M, Doty MM, Beutel S. Americans' experiences with 
ACA Marketplace and Medicaid coverage: access to care and satisfaction. 
New York: The Commonwealth Fund, 2016.

34. Starfield B, Shi L, Macinko J. Contribution of primary care to 
health systems and health. Milbank Q 2005;83:457-502.

35. Sommers BD, Simon K. Health insurance and emergency department 
use--a complex relationship. N Engl J Med 2017;376:1708-11.

36. Cannon MF. Oregon study throws a stop sign in front of ObamaCare's 
Medicaid expansion. Washington, DC: Cato Institute, 2013.

37. Kaufman HW, Chen Z, Fonseca VA, McPhaul MJ. Surge in newly 
identified diabetes among Medicaid patients in 2014 within Medicaid 
expansion states under the Affordable Care Act. Diabetes Care 
2015;38:833-7.

38. Cole MB, Galarraga O, Wilson IB, Wright B, Trivedi AN. At federally 
funded health centers, Medicaid expansion was associated with improved 
quality of care. Health Aff (Millwood) 2017;36:40-8.

39. Murray CJ, Atkinson C, Bhalla K, et al. The state of U.S. health, 
1990-2010: burden of diseases, injuries, and risk factors. JAMA 
2013;310:591-608.

40. 10 leading causes of death by age group, United States--2015. 
Atlanta: Centers for Disease Control and Prevention (http://
www.cdc.gov/injury/images/lc-charts/
leading_causes_of_death_age_group_2015_1050w740h.gif).

41. Cancer treatment and survivorship: facts and figures: 2016-2017. 
Atlanta: American Cancer Society, 2016 (http://www.cancer.org/content/
dam/cancer-org/research/cancer-facts-and-statistics/cancer-treatment-
and-survivorship-facts-and-figures/cancer-treatment-and-survivorship-
facts-and-figures-2016-2017.pdf).

42. Miilunpalo S, Vuori I, Oja P, Pasanen M, Urponen H. Self-rated 
health status as a health measure: the predictive value of self-
reported health status on the use of physician services and on 
mortality in the working-age population. J Clin Epidemiol 1997;50:517-
28.

43. DeSalvo KB, Bloser N, Reynolds K, He J, Muntner P. Mortality 
prediction with a single general self-rated health question: a meta-
analysis. J Gen Intern Med 2006;21:267-75.

44. Care without coverage: too little, too late. Washington, DC: 
Institute of Medicine, 2002.

45. Krieger N. Epidemiology and the people's health: theory and 
context. Oxford, United Kingdom: Oxford University Press, 2013.

46. Roy A. Romneycare improved health outcomes, thanks to private-
sector coverage. Forbes. May 7, 2014 (https://www.forbes.com/sites/
theapothecary/2014/05/07/romneycare-improved-health-outcomes-thanks-to-
private-sector-coverage/#6bcbd7flde55).

47. Epstein AM, Sommers BD, Kuznetsov Y, Blendon RJ. Low-income 
residents in three states view Medicaid as equal to or better than 
private coverage, support expansion. Health Aff (Millwood) 
2014;33:2041-7.

48. McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Health of 
previously uninsured adults after acquiring Medicare coverage. JAMA 
2007;298:2886-94.

49. Card D, Dobkin C, Maestas N. Does Medicare save lives? Q J Econ 
2009;
124:597-636.

50. Finkelstein A, McKnight R. What did Medicare do? The initial impact 
of Medicare on mortality and out of pocket medical spending. J Public 
Econ 2008;92:1644-68.

51. Gawande A. The heroism of incremental care. The New Yorker. January 
23, 2017 (http://www.newyorker.com/magazine/2017/01/23/the-heroism-of-
incremental-care).

52. Sommers BD, Maylone B, Nguyen KH, Blendon RJ, Epstein AM. The 
impact of state policies on ACA applications and enrollment among low-
income adults in Arkansas, Kentucky, and Texas. Health Aff (Millwood) 
2015;34:1010-8.

53. Garthwaite C, Graves JA. Success and failure in the insurance 
exchanges. N Engl J Med 2017;376:907-10.

54. Robinson LA. How U.S. government agencies value mortality risk 
reductions. Rev Environ Econ Policy 2007;1:283-99.

                                 ______
                                 
                             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 
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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,[email protected].

                                 ______
                                 
                  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 
[email protected] 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: [email protected]

               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: [email protected]       Email: [email protected]

                                 ______
                                 
                   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 
                                    Public Health
Institute for Public Health 
Innovation                          The Los Angeles Trust for 
                                    Children's Health
Institute of Social Medicine and 
Community Health                    Louisiana Public Health Association
Intermountain Public Health 
Consulting, LLC                     Louisiana Public Health Institute
International Board of Lactation 
Consultant Examiners                Lung Cancer Alliance
International Certification and 
Reciprocity Consortium              Madera Coalition for Community 
                                    Justice
International Foundation for 
Functional Gastrointestinal 
Disorders                           Maine Public Health Association
International Society for Disease 
Surveillance                        MaineHealth
International Valley Health 
Institute                           March of Dimes
Medicines360                        The Marfan Foundation
Meharry Medical College             Maricopa County Department of 
                                    Public Health
Men's Health Caucus                 Maricopa Integrated Health System
Mennin Consulting and Associates    Maryland Partnership for Prevention
Mental Health America of Arizona    Maryland Public Health Organization
METAvivor                           Massachusetts Public Health 
                                    Association
Metropolitan Area Planning Council  Master Trainer
Metropolitan Chicago Breast Cancer 
Task Force                          Matter of Balance
Michigan Association for Local 
Public Health                       Meals on Wheels
Michigan Breastfeeding Network      National Blood Clot Alliance
MIKE Program                        National Center for Disaster 
                                    Preparedness
Minneapolis Health Department       National Center for Health Care
Minnesota Academy of Nutrition and 
Dietetics                           National Center for Transgender 
                                    Equality
Minnesota Public Health Association The National Commission for Health 
                                    Education Credentialing, Inc.
Mississippi Public Health 
Association                         National Coalition for Promoting 
                                    Physical Activity
Missouri Association of Area 
Agencies on Aging                   National Coalition of STD Directors
MJH Grant Consulting                National Coalition on Health Care
Monona County Public Health         National Collaborative for Health 
                                    Equity
Montana Primary Care Association    The National Consumer Voice for 
                                    Quality
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 
                                    Reproductive Health Association
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 
                                    Health Quality
National Alliance of State and 
Territorial AIDS Directors          National Latino Network of Casa de 
                                    Esperanza
National Alopecia Areata Foundation National Physician's Alliance
National Association for Health and 
Fitness                             National Network of Public Health 
                                    Institutes
National Association of Area 
Agencies on Aging                   National Prevention Science 
                                    Coalition
National Association of Chronic 
Disease Directors                   National Recreation and Park 
                                    Association
National Association of Counties    National Resource Center on 
                                    Domestic Violence
National Association of County and 
City Health Officials               The National Viral Hepatitis 
                                    Roundtable
National Association of Perinatal 
Social Workers                      National WIC Association
National Association of School 
Nurses                              National Women's Health Network
National Association of Social 
Workers                             Native Health
National Association of State 
Alcohol and Drug Abuse Directors    NC SOPHE Advocacy Committee
National Birth Defects Prevention 
Network                              Nebraska Association of Local 
                                    Health Directors
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 
                                    Justice
NIRSA: Leaders in Collegiate 
Recreation                          Nevada Public Health Association
NJSOPHE                             New England Wellness Foundation
NJ YMCA State Alliance              New Jersey Public Health 
                                    Association
NMAC                                New Mexico Public Health 
                                    Association
North American Quitline Consortium  The New York Academy of Medicine
North Carolina Alliance for Health  New York State Association of 
                                    County Health Officials
North Carolina Citizens for Public 
Health                              Newington Senior and Disabled 
                                    Center
North Dakota Public Health 
Association                         Public Health Foundation
Northern Illinois Public Health 
Consortium                          Public Health Institute
Nurses of South Carolina            Public Health Solutions
Nursing Students for Sexual and 
Reproductive Health                 Pulmonary Fibrosis Advocates
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 
                                    Prevention and Wellness
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
Prevention Institute                San Francisco AIDS Foundation
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
South Carolina Tobacco-Free 
Collaborative                       Walk San Francisco
Southeast Ohio Breastfeeding 
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: [email protected] 
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

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