[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


                      EXAMINING THREATS TO WORKERS
                      WITH PREEXISTING CONDITIONS

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

                                HEARING

                               BEFORE THE

                         COMMITTEE ON EDUCATION
                               AND LABOR
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

            HEARING HELD IN WASHINGTON, DC, FEBRUARY 6, 2019

                               __________

                            Serial No. 116-1

                               __________

      Printed for the use of the Committee on Education and Labor
      
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                    COMMITTEE ON EDUCATION AND LABOR

             ROBERT C. ``BOBBY'' SCOTT, Virginia, Chairman

Susan A. Davis, California           Virginia Foxx, North Carolina,
Raul M. Grijalva, Arizona            Ranking Member
Joe Courtney, Connecticut            David P. Roe, Tennessee
Marcia L. Fudge, Ohio                Glenn Thompson, Pennsylvania
Gregorio Kilili Camacho Sablan,      Tim Walberg, Michigan
  Northern Mariana Islands           Brett Guthrie, Kentucky
Frederica S. Wilson, Florida         Bradley Byrne, Alabama
Suzanne Bonamici, Oregon             Glenn Grothman, Wisconsin
Mark Takano, California              Elise M. Stefanik, New York
Alma S. Adams, North Carolina        Rick W. Allen, Georgia
Mark DeSaulnier, California          Francis Rooney, Florida
Donald Norcross, New Jersey          Lloyd Smucker, Pennsylvania
Pramila Jayapal, Washington          Jim Banks, Indiana
Joseph D. Morelle, New York          Mark Walker, North Carolina
Susan Wild, Pennsylvania             James Comer, Kentucky
Josh Harder, California              Ben Cline, Virginia
Lucy McBath, Georgia                 Russ Fulcher, Idaho
Kim Schrier, Washington              Van Taylor, Texas
Lauren Underwood, Illinois           Steve Watkins, Kansas
Jahana Hayes, Connecticut            Ron Wright, Texas
Donna E. Shalala, Florida            Daniel Meuser, Pennsylvania
Andy Levin, Michigan*                William R. Timmons, IV, South 
Ilhan Omar, Minnesota                    Carolina
David J. Trone, Maryland             Dusty Johnson, South Dakota
Haley M. Stevens, Michigan
Susie Lee, Nevada
Lori Trahan, Massachusetts
Joaquin Castro, Texas
* Vice-Chair

                   Veronique Pluviose, Staff Director
                 Brandon Renz, Minority Staff Director
                                
                                
                                ------                                
                            
                            
                            C O N T E N T S

                              ----------                              
                                                                   Page

Hearing held on February 6, 2019.................................     1

Statement of Members:
    Scott, Hon. Robert C. ``Bobby'', Chairman, Committee on 
      Education and Labor........................................     1
        Prepared statement of....................................     4
    Foxx, Hon. Virginia, Ranking Member, Committee on Education 
      and Labor..................................................     5
        Prepared statement of....................................     7

Statement of Witnesses:
    Corlette, Ms. Sabrina, Research Professor, Center on Health 
      Insurance Reforms, Georgetown University Health Policy 
      Institute..................................................     9
        Prepared statement of....................................    11
    Gupta, Dr. Rahul, Senior Vice President and Chief Medical and 
      Health Officer, March of Dimes.............................    42
        Prepared statement of....................................    44
    Riedy, Mr. Chad, Resident, Alexandria, VA....................    23
        Prepared statement of....................................    25
    Turner, Ms. Grace-Marie, President, Galen Institute..........    30
        Prepared statement of....................................    32

Additional Submissions:
    Adams, Hon. Alma S., a Representative in Congress from the 
      State of North Carolina:
        Article: House Health Bill Would Lead To Less Coverage, 
          Higher Patient Costs...................................   108
        Prepared statement from MomsRising.......................   110
        Article: National Disability Rights Network Opposes 
          American Health Care Act...............................   112
    Jayapal, Hon. Pramila, a Representative in Congress from the 
      State of Washington:
        Prepared statement from Asian and Pacific Islander 
          American Health Forum (APIAHF).........................   113
    Underwood, Hon. Lauren, a Representative in Congress from the 
      State of Illinois:
        Article: Final Rule on Short-term Insurance plans will 
          leave Patients With High costs, Less Coverage..........   118
    Questions submitted for the record by:
        Guthrie, Hon. Brett, a Representative in Congress from 
          the State of Kentucky..................................   121
        Smucker, Hon. Lloyd K., a Representative in Congress from 
          the State of Pennsylvania..............................   121
    Ms. Turner's response to questions submitted for the record..   122

 
        EXAMINING THREATS TO WORKERS WITH PREEXISTING CONDITIONS

                              ----------                              


                      Wednesday, February 6, 2019

                        House of Representatives

                   Committee on Education and Labor,

                            Washington, DC.

                              ----------                              

    The committee met, pursuant to notice, at 10:15 a.m., in 
room 2175, Rayburn House Office Building. Hon. Robert C. 
``Bobby'' Scott (chairman of the committee) presiding.
    Present: Representatives Scott, Davis, Courtney, Sablan, 
Bonamici, Takano, Adams, Norcross, Jayapal, Morelle, Harder, 
McBath, Schrier, Underwood, Hayes, Shalala, Levin, Omar, Trone, 
Stevens, Lee, Trahan, Castro, Foxx, Roe, Thompson, Walberg, 
Guthrie, Byrne, Grothman, Stefanik, Allen, Smucker, Banks, 
Walker, Comer, Cline, Fulcher, Taylor, Watkins, Wright, Meuser, 
Timmons, and Johnson.
    Staff present: Tylease Alli, Chief Clerk; Nekea Brown, 
Deputy Clerk; Ilana Brunner, General Counsel; David Dailey, 
Senior Counsel; Daniel Foster, Health and Labor Counsel; 
Mishawn Freeman, Staff Assistant; Alison Hart, Professional 
Staff; Carrie Hughes, Director of Health and Human Services; 
Eli Hovland, Staff Assistant; Eunice Ikene, Labor Policy 
Advisor; Ariel Jona, Staff Assistant; Kimberly Knackstedt, 
Disability Policy Advisor; Stephanie Lalle, Deputy 
Communications Director; Andre Lindsay, Staff Assistant; Max 
Moore, Office Aide; Merrick Nelson, Digital Manager; Udochi 
Onwubiko, Labor Policy Counsel; Veronique Pluviose, Staff 
Director; Banyon Vassar, Deputy Director of Information 
Technology; Joshua Weisz, Communications Director; Cyrus Artz, 
Minority Parliamentarian; Marty Boughton, Minority Press 
Secretary; Courtney Butcher, Minority Coalitions and Member 
Services Coordinator; Rob Green, Minority Director of Workforce 
Policy; John Martin, Minority Workforce Policy Counsel; Sarah 
Martin, Minority Professional Staff Member; Hannah Matesic, 
Minority Legislative Operations Manager; Kelley McNabb, 
Minority Communications Director; Alexis Murray, Minority 
Professional Staff Member; Brandon Renz, Minority Staff 
Director; Ben Ridder, Minority Legislative Assistant; Meredith 
Schellin, Minority Deputy Press Secretary and Digital Advisor; 
Heather Wadyka, Minority Staff Assistant; and Lauren Williams, 
Minority Professional Staff Member.
    Chairman Scott. The Committee on Education and Labor will 
come to order, and I want to welcome everyone to the hearing. I 
note that a quorum is present. The Committee is meeting today 
to hear testimony on examining threats to workers with 
preexisting conditions.
    Pursuant to committee rule 7(c) opening statements are 
limited to the chair and the ranking member. This allows us to 
hear from our witnesses a lot sooner and provides all members 
with adequate time to ask questions.
    I recognize myself now for the purpose of making an opening 
Statement.
    Today we are here to examine the threats to affordable 
healthcare for workers with preexisting conditions. I want to 
welcome our distinguished witnesses for agreeing to be here 
today and to testify on an issue that affects roughly 133 
million Americans across the country.
    On March 23, 2010, President Barack Obama signed the 
Patient Protection and Affordable Care Act into law. Over the 
last 9 years, this historic legislation has improved the lives 
of countless Americans by making insurance more affordable and 
more accessible, while strengthening the quality of health 
coverage and enacting lifesaving consumer protections.
    The Affordable Care Act's success is even more remarkable 
in the context of the persistent attempts to repeal and 
sabotage the law. Since it was passed the House Republicans 
called more than 70 votes to repeal all or parts of the ACA. 
Those efforts were punctuated by the American Health Care Act, 
a bill passed by House Republicans in 2017, which gutted 
protections for patients with preexisting conditions. According 
to the CBO, the repeal bill would have resulted in 23 million 
fewer Americans with health coverage, would have raised 
premiums by 20 percent the first year while providing less 
comprehensive benefits, and would have jeopardized many of the 
consumer protections found in the ACA.
    The Trump Administration has taken an equally aggressive 
approach to undermining the law. For example, the 
Administration has expanded the use of junk plans that roll 
back consumer protections, raise the costs for most consumers, 
and have a troubling record of fraud and abuse.
    On June 19, 2018, the Department of Labor finalized a rule 
to expand association health plans. Under the rule, 
associations can sell coverage to small businesses and self-
employed individuals without meeting certain ACA standards that 
would otherwise apply, such as: the requirement to cover 
essential benefits, the prohibition against charging higher 
premiums based on factors such as gender or occupation, and the 
age rating limit, which prevents insurers from charging 
unaffordable premiums to older people.
    Extensive research has shown that association health plans 
create a few winners and a lot of losers. A report published by 
the Government Accountability Office in 2000 found that they 
are likely to increase costs for most workers who are not in 
association plans and make it harder for older, sicker workers 
to get affordable care. The prevalence of fraud in these plans 
is equally concerning. A 2004 Congressional Budget Office 
report identified 144 ``unauthorized or bogus'' plans from 2000 
to 2002. Those plans covered at least 15,000 employers and more 
than 200,000 policyholders, and left unpaid medical bills over 
$252 million.
    On August 3, 2018, the Departments of Health and Human 
Services, Labor, and Treasury jointly moved to expand the use 
of short-term health plans. The Departments issued a final rule 
to extend the allowable duration of short-term plans from 3 
months to up to 12 months, with renewability up to 36 months. 
Under the rule the short-term plans do not have include Federal 
consumer protections, including protections for patients with 
preexisting conditions. Because of the risk of confusion and 
overall lack of consumer safeguards, not one single group 
representing patients, physicians, nurses or hospitals voiced 
support for the rule expanding the use of short-term plans.
    The Administration's final and most dangerous attack on the 
ACA is its unusual decision to side with a group of Republican 
attorneys general in a lawsuit against the Federal Government 
seeking to strike the ACA in court. So the Trump Administration 
is effectively arguing that the ACA's consumer protections 
should be invalidated, along with the rest of the law.
    If this ultimately prevails, as it did in the district 
court in Texas, the result would be catastrophic. All 
Americans, whether insured through the ACA marketplace or 
through their employers, would lose the consumer protections we 
all take for granted, including elimination of lifetime and 
annual caps. The prohibition on lifetime and annual coverage 
limits, which protects workers from incurring unreasonable out-
of-pocket expenses. Before the ACA, more than 90 percent of 
non-group plans had annual or lifetime caps on coverage, and a 
majority of the employer-provided plans imposed lifetime 
limits.
    Cost-sharing protections, the requirement that plans offer 
to limit out-of-pocket costs to an affordable percentage of a 
worker's income, elimination of preexisting health condition 
exclusions, the requirement that all health plans cover 
patients with preexisting conditions at the standard rate. Last 
night I was pleased to hear the President's comment that he 
wants to protect patients with preexisting conditions and end 
the spread of AIDS. As I said, the actions of the 
Administration have jeopardized those protections and people 
with HIV or AIDS who would be excluded from coverage based on 
preexisting conditions if those initiatives succeed. Preventive 
services without cost-sharing, the protection that allows 
workers and families to access vital preventive care without 
paying out-of-pocket expenses. That protection would be 
eliminated.
    While I appreciate that my Republican colleagues are now 
voicing support for many of these protections, their words have 
not translated into actions. On January 9, Democrats voted on a 
resolution to empower the House counsel to intervene in the 
Texas case to defend the ACA and protect people with 
preexisting conditions. Only three House Republicans voted to 
support the resolution.
    There many different views within the Democratic Party and 
across the political spectrum regarding the best path forward 
to further expand affordable care. But we must all commit, both 
with our words and deeds, to maintaining the lifesaving 
consumer protections enacted in the ACA and we must refuse to 
go backward.
    Until efforts to repeal and sabotage this historic 
legislation cease, workers with preexisting conditions will be 
at risk of losing access to the care they need to live healthy 
and fulfilling lives.
    I now recognize the distinguished ranking member for the 
purpose of an opening statement.
    [The statement of Chairman Scott follows:]

    Prepared Statement of Hon. Robert C. ``Bobby'' Scott, Chairman, 
                    Committee on Education and Labor

    Today, we are here to examine the threats to affordable health care 
for workers with pre-existing conditions. I want to welcome and thank 
our distinguished witnesses for agreeing to be here and testify today 
on an issue that effects roughly 133 million Americans across this 
country.
    On March 23, 2010, President Barack Obama signed the Patient 
Protection and Affordable Care Act into law. Over the past 9 years, 
this historic legislation has improved the lives of countless Americans 
by making insurance more affordable and more accessible, while also 
strengthening the quality of health coverage and enacting lifesaving 
consumer protections.
    Prior to the ACA, Federal law allowed insurers to deny people 
coverage for certain pre-existing conditions, including recently 
treated substance use disorder, pregnancy, and cancer. Prior to the 
ACA, insurers in the individual market could exclude these individuals 
from coverage, charge higher premiums, or put annual or lifetime caps 
of health care coverage.
    According to a 2007 Commonwealth Fund survey, 36 percent of adults 
who attempted to purchase coverage in the individual market reported 
being turned down or charged a higher price because of their medical 
history. The ACA guaranteed access to affordable care for the roughly 
133 million Americans with pre-existing conditions at the standard 
rate.
    By any objective measure, the Affordable Care Act has been a 
success. The uninsured rate, which was 16.7 percent in 2009, fell to 
just 8.8 percent in 2017.
    The ACA's success is even more remarkable in the context of the 
persistent attempts to repeal and sabotage the law. Since it was 
passed, House Republicans have voted more than 70 times to repeal all 
or parts of the ACA. Those efforts were punctuated by the American 
Health Care Act, a bill passed by House Republicans in 2017, which 
gutted protections for patients with pre-existing conditions. According 
to the CBO, the repeal bill would have resulted in 23 million fewer 
Americans with health coverage and would have raised premiums by 20 
percent in the first year while providing less comprehensive benefits.
    The Trump Administration has taken an equally aggressive approach 
to undermining the law. For example, the Administration has expanded 
the use of junk health plans that rollback consumer protections, raise 
costs for all consumers, and have a troubling record of fraud and 
abuse.
    On June 19th, 2018, the Department of Labor finalized a rule to 
expand association health plans. Under the rule, associations can sell 
coverage to small businesses and self-employed individuals without 
meeting certain ACA standards that would otherwise apply, such as: 1) 
the requirement to cover essential health benefits; 2) the prohibition 
against charging higher premiums based on factors such as gender or 
occupation; and 3) the age rating limit, which prevents insurers from 
charging unaffordable premiums to older people.
    Extensive research has shown that association health plans create 
winners and losers. A report published by the Government Accountability 
Office in 2000, found that they are likely to increase costs to some 
workers and make it harder for older, sicker workers to get affordable 
care. The prevalence of fraud in these plans is equally concerning. A 
2004 Congressional Budget Office identified 144 ``unauthorized or 
bogus'' plans from 2000 to 2002, covering at least 15,000 employers and 
more than 200,000 policyholders, leaving $252 million in unpaid medical 
claims.
    On August 3rd, 2018, the Departments of Health and Human Services, 
Labor, and the Treasury jointly moved to expand the use of short-term 
health plans. The Departments issued a final rule to extend the 
allowable duration of short-term health plans from 3 months to up to 12 
months, with plans renewable for up to 36 months. Under the rule, 
short-term plans do not have include Federal consumer protections, 
including protections for patients with pre-existing conditions.
    Because of the risk of confusion and the overall lack of consumer 
safeguards, not one single group representing patients, physicians, 
nurses or hospitals voiced support for the rule expanding the use of 
short-term plans.
    The Administration's final and most dangerous attack on the ACA is 
its unusual decision to side with a group of Republican Attorneys 
General in a lawsuit against the Federal Government seeking to strike 
down the law in court. Specifically, the Trump Administration is 
arguing that the ACA's consumer protections should be invalidated.
    If it ultimately prevails, as it did in a District Court in Texas, 
the result would be catastrophic. All Americans, whether insured 
through an ACA marketplace or through their employer, would lose the 
consumer protections we all take for granted, including:
    Elimination of Lifetime and Annual Caps: The prohibition on 
lifetime and annual coverage limits, which protects workers from 
incurring unreasonable out-of-pocket expenses. Before the ACA, more 
than 90 percent of nongroup plans had annual or lifetime caps on 
coverage, and a majority of employer-provided plans imposed lifetime 
limits.
    Cost-Sharing Protections: The requirement that plans limit out-of-
pocket costs to an affordable percentage of a worker's income.
    Elimination of Preexisting Health Condition Exclusions: The 
requirement that all health plans cover patients' pre-existing 
conditions.
    Preventive Services without Cost-sharing: The protection that 
allows workers and families to access vital preventive care without 
paying out-of-pocket.
    While I appreciate that my Republican colleagues are now voicing 
support for many of these protections, their words have not translated 
into actions. On January 9, House Democrats voted on a resolution to 
empower the House counsel to intervene in the Texas case to defend the 
ACA and protect people with pre-existing conditions. Only three House 
Republicans votes to support the resolution.
    There many different views both within the Democratic Party and 
across the political spectrum regarding the best path forward to 
further expand access to affordable care. But we must all commit both 
with our words and our actions to maintaining the lifesaving consumer 
protections enacted in the ACA and refusing to go backward.
    Until efforts to repeal and sabotage this historic legislation 
cease, workers with pre-existing conditions will be at risk of losing 
access to the care they need to live healthy and fulfilling lives.
    Thank you and I now yield to the Ranking Member, Dr. Foxx.
                                 ______
                                 
    Mrs. Foxx. Thank you, Mr. Chairman. Americans with 
preexisting conditions need health insurance. This is a fact 
and a value that Congress and the President have affirmed 
countless times. It is also the law. Insurance companies are 
prohibited from denying or not renewing health coverage due to 
a preexisting condition. Insurance companies are banned from 
rescinding coverage based on a preexisting condition. Insurance 
companies are banned from excluding benefits based on a 
preexisting condition. Insurance companies are prevented from 
raising premiums on individuals with preexisting conditions who 
maintain continuous coverage.
    So it is perplexing why Committee Democrats are even 
holding this hearing. And by doing so, they are making it about 
threats. Instead, this hearing should focus on how the strong 
economy, with its extraordinary job growth, is increasing the 
number of workers with employer-sponsored health coverage.
    This committee's work on--employer-based health care 
options dates back to when the cost of health care began to 
rise several decades ago. The status quo was not sustainable, 
then and in 2010, the tide took a radical turn for the worse 
with the Affordable Care Act, which decimated options for 
employers earnestly seeking to provide competitive benefits 
packages to recruit and retain workers and sent individual 
premium costs on an even faster upward trajectory. Workers paid 
the price, employers paid the price.
    But, after 8 years of Republican leadership in the House of 
Representatives and the election of President Trump, the U.S. 
economy and job markets are thriving. With consistent wage 
growth and greater availability of highly competitive jobs, 
smart employers are continuing to ensure that they offer 
competitive benefits packages--including sponsored health care 
plans--to recruit and retain workers. And their efforts are 
working.
    According to the Kaiser Family Foundation, 152 million 
Americans--including many who have preexisting conditions--are 
insured through plans offered by their employer. That is the 
majority of the American work force and more than the 
individual market, Medicare, or Medicaid. Since 2013, 7 million 
more Americans have gained employer-sponsored health care 
coverage, with 2.6 million gaining coverage since President 
Trump took office. The plans employers offer are on average 
higher quality and provide better value than what can be found 
on the individual market.
    In 2017, the average premium for individual and family 
employer-sponsored coverage increased by a modest 3 and 5 
percent respectively. In contrast, the average exchange 
premium, Obamacare, went up by roughly 30 percent.
    So, if we are going to have this hearing at all, we welcome 
it as an opportunity to talk once more about the importance of 
making sure American workers have more options, more 
flexibility, and more freedom.
    Last Congress, the Republican-led House of Representatives 
passed the American Health Care Act. The legislation would 
restore stability to the health care marketplace and deliver 
lower costs to consumers. Ensuring protections for individuals 
with preexisting conditions was a central piece of the bill. It 
was Section 137 of the legislation stating: ``Nothing in this 
Act shall be construed as permitting health insurance insurers 
to limit access to health coverage for individuals with 
preexisting conditions.'' So, people may have an opinion, but 
they cannot argue with the facts. The facts are written in this 
legislation--Section 137.
    Republicans on this committee also led the passage of the 
Small Business Health Fairness Act. That legislation would 
empower small businesses to band together through association 
health plans, AHPs, to negotiate for lower health insurance 
costs on behalf of their employees. And last summer, the 
Department of Labor finalized a rule expanding access to AHPs.
    During the 115th Congress, House Republicans also passed 
the Competitive Health Insurance Reform Act and the Committee-
led Self Insurance Protection Act. What all of these bills have 
in common is their goal to expand coverage, lower health care 
costs for all Americans, and again, give freedom to Americans.
    Committee Republicans welcome this opportunity once again 
to assure Americans with preexisting conditions that their 
coverage is protected.
    House Republicans will continue to champion legislative 
solutions to combat some of the most pressing problems facing 
our healthcare system, including skyrocketing costs, the high 
prices of certain drugs, the industry's lack of cost 
transparency, and the looming threat of a single payer system. 
These are the factors that pose the real threat to Americans 
having options to work for them.
    I yield back, Mr. Chairman.
    [The statement of Mrs. Foxx follows:]

Prepared Statement of Hon. Virginia Foxx, Ranking Member, Committee on 
                          Education and Labor

    Americans with pre-existing conditions need health insurance. This 
is a fact, and a value that Congress and the President have affirmed 
countless times. It's also the law. Insurance companies are prohibited 
from denying or not renewing health coverage due to a pre-existing 
condition. Insurance companies are banned from rescinding coverage 
based on a pre-existing condition. Insurance companies are banned from 
excluding benefits based on a pre-existing condition. Insurance 
companies are prevented from raising premiums on individuals with pre-
existing conditions who maintain continuous coverage.
    So it's perplexing why Committee Democrats are even holding this 
hearing, and by doing so they are trying to make it about threats. 
Instead, this hearing should focus on how the strong economy with its 
extraordinary job growth is increasing the number of workers with 
employer-sponsored health coverage.
    This committee's work on employer-based health care options dates 
back to when the costs of health care began to rise several decades 
ago. The status quo was not sustainable then, and in 2010 the tide took 
a radical turn for the worse with the Affordable Care Act, which 
decimated options for employers earnestly seeking to provide 
competitive benefits packages to recruit and retain workers and sent 
individual premium costs on an even faster upward trajectory.
    Workers paid the price. Employers paid the price.
    But, after 8 years of Republican leadership in the House of 
Representatives, and the election of President Trump, the U.S. economy 
and job markets are thriving. With consistent wage growth and greater 
availability of highly competitive jobs, smart employers are continuing 
to ensure that they offer competitive benefits packages including 
sponsored health care plans to recruit and retain workers.
    And their efforts are working. According to the Kaiser Family 
Foundation,
    152 million Americans--including many who have pre-existing 
conditions--are insured through plans offered by their employer. That's 
the majority of the American work force, and more than the individual 
market, Medicare, or Medicaid.
    Since 2013, 7 million more Americans have gained employer-sponsored 
health care coverage, with 2.6 million gaining coverage since President 
Trump took office. The plans employers offer are, on average, higher 
quality and provide better value than what can be found on the 
individual market.
    In 2017, the average premium for individual and family employer-
sponsored coverage increased by a modest 3 and 5 percent, respectively. 
In contrast, the average Exchange premium Obamacare went up by roughly 
30 percent.
    So, if we are going to have this hearing at all, we welcome it as 
an opportunity to talk once more about the importance of making sure 
American workers have more options, more flexibility, and more freedom.
    Last Congress, the Republican-led House of Representatives passed 
the American Health Care Act. The legislation would restore stability 
to the health care marketplace and deliver lower costs to consumers. 
Ensuring protections for individuals with pre-existing conditions was a 
central piece of the bill with Section 137 of the legislation stating: 
``Nothing in this Act shall be construed as permitting health insurance 
issuers to limit access to health coverage for individuals with 
preexisting conditions.''
    So, people may have an opinion, but they cannot argue with the 
facts, and the facts are written in this legislation. Section 137.
    Republicans on this committee also led the passage of the Small 
Business
    Health Fairness Act. That legislation would empower small 
businesses to band together through association health plans (AHPs) to 
negotiate for lower health insurance costs on behalf of their 
employees, and last summer, the Department of Labor finalized a rule 
expanding access to AHPs.
    During the 115th Congress, House Republicans also passed the 
Competitive Health Insurance Reform Act and the committee-led Self-
Insurance Protection Act. What all of these bills have in common is 
their goal to expand coverage, lower health care costs for all 
Americans, and again, give freedom to Americans.
    Committee Republicans welcome this opportunity once again to assure 
Americans with pre-existing conditions that their coverage is 
protected. House Republicans will continue to champion legislative 
solutions to combat some of the most pressing problems facing our 
health care system, including skyrocketing costs, the high prices of 
certain drugs, the industry's lack of cost transparency, and the 
looming threat of a single-payer system. These are the factors that 
pose the real threat to Americans having options that work for them.
                                 ______
                                 
    Chairman Scott. Thank you. Without objection, all the 
members who wish to insert written statements to the record 
should do so by submitting them to the committee clerk 
electronically in Microsoft Word format by 5 p.m. February 19, 
2019.
    I will now introduce our witnesses.
    Our first witness will be Sabrina Corlette, a research 
professor at the Center on Health Insurance Reforms at 
Georgetown University's McCourt School of Public Policy where 
she directs research on private health insurance and market 
research. Prior to joining Georgetown faculty she was the 
director of health policy programs at the National Partnership 
for Women and Families where she focused on insurance market 
reform, benefit design, and the quality and affordability of 
healthcare. She is a member of the Washington, DC Bar 
Association.
    Chad Riedy is 37 years old, has cystic fibrosis. He lives 
in Alexandria, Virginia with his wife, Julie, and two sons. In 
addition to volunteering for the Cystic Fibrosis Foundation he 
has spent the last 13 year working in the real estate industry.
    Grace-Marie Turner is president of Galen Institute, a 
public policy research organization she founded in 1995 to 
promote free market ideas for health reform. She has served as 
a member of the Long-term Care Commission, the Medicaid 
Commission, the National Advisory Board for the Agency for 
Healthcare Research and Quality. Prior to founding the Galen 
Institute she served as executive director for the National 
Commission on Economic Growth and Tax Reform.
    Dr. Rahul Gupta is the senior vice president and chief 
medical and health officer for the March of Dimes. He is one of 
the world's leading health experts. In his role Dr. Gupta 
provides strategic oversight for the March of Dimes' medical 
and public health efforts to improve healthcare for moms and 
babies. Prior to joining the March of Dimes he served under two 
Governors as West Virginia's health commissioner, and as the 
chief health officer he led the State's opioid crisis response 
efforts and several public health initiatives.
    We appreciate all of the witnesses for being here today and 
look forward to your testimony. Let me remind the witnesses 
that we have read your written statements and they will appear 
in full in the hearing record. Pursuant to committee rule 7(d), 
the committee, and committee practice, each of you will be 
asked to limit your oral presentation to a 5-minute summary of 
your written Statement.
    Let me remind the witnesses that pursuant to Title 18 of 
the U.S. Code Section 1, it is illegal to knowingly and 
willfully falsify a Statement, representation, writing 
document, or material fact presented to Congress or otherwise 
conceal or cover up a material fact.
    Before you begin your testimony please remember to press 
the button on your microphone in front of you so that it will 
be turned on and the members can hear you. As you begin to 
speak the light in front of you will turn green, after 4 
minutes the light will turn yellow to signal you have 1 minute 
remaining. When the light turns red we ask you to summarize and 
end your testimony.
    We will then let the entire panel make their presentations 
before we move to member questions. When answering a question 
please remember once again to turn your microphone on.
    I will first recognize Ms. Corlette.

 TESTIMONY OF SABRINA CORLETTE, RESEARCH PROFESSOR, CENTER ON 
 HEALTH INSURANCE REFORMS, GEORGETOWN UNIVERSITY HEALTH POLICY 
                           INSTITUTE

    Ms. Corlette. Thank you, Mr. Chairman. Ranking Member Foxx, 
members of this committee, it is really an honor to be here 
with you today and to discuss the need for affordable, adequate 
insurance coverage, particularly for those with preexisting 
conditions.
    In my testimony I will focus on some of the challenges 
faced by people with preexisting conditions before the ACA was 
enacted and how current threats to the ACA could have 
disproportionately harmful effects on these individuals and 
workers.
    Before the ACA was enacted roughly 48 million people lacked 
health insurance and an estimated 22,000 died prematurely each 
year due to being uninsured. 60 percent of the uninsured 
reported having problems with medical debt. The high number of 
uninsured was costing providers an estimated $1,000 per person 
in uncompensated care costs. The lack of affordable adequate 
coverage also led to a phenomenon called ``job lock'', where 
workers are reluctant to leave the guarantee of subsidized 
employer-based coverage for the uncertainty of the individual 
market. And for many people with health issues job-based 
coverage could also be spotty or include barriers to enrolling.
    Prior to the ACA, in most States, people seeking health 
insurance could be denied a policy or charged more because of 
their health status, age, or gender, or have the services 
needed to treat their condition excluded from their benefit 
package. Indeed, a 2011 GAO study found that insurance 
companies denied applicants a policy close to 20 percent of the 
time. Under the ACA these practices are prohibited.
    Prior to the ACA coverage also could come with significant 
gaps, such as for prescription drugs, mental health, and 
substance use services and maternity care. Under the ACA 
insurers must cover a basic set of essential benefits.
    Extremely high deductibles and annual or lifetime limits on 
benefits were also common before the ACA. The law protects 
people from both by capping the annual amount paid out-of-
pocket each year and prohibiting insurers from placing 
arbitrary caps on coverage.
    Members of this committee are aware that the ACA is now 
under threat of being overturned due to pending litigation in 
Federal court. If the plaintiffs' argument prevails it would be 
tantamount to repealing the ACA without any public policy to 
replace it. And this is a scenario that Congress rejected in 
multiple votes in 2017. Congress rejected it because repealing 
the ACA without replacing it would result in 32 million 
Americans losing insurance, double premiums for people in the 
individual insurance market, leave an estimated three-quarters 
of the Nation's population in areas without any insurer, cause 
a significant financial harm for hospitals and other providers 
due to uncompensated care costs, cause the loss of an estimated 
2.6 million jobs around the country, and importantly for this 
committee, result in harm to people with job-based covered, 
including the loss of coverage for preventative service without 
cost-sharing, such as vaccines, well visits, and contraception, 
the return to preexisting condition exclusions, young adults no 
longer allowed to stay on their parents health plans, and 
insecurity due to crippling out-of-pocket costs for people with 
high cost conditions.
    This Administration has also instituted regulatory changes 
that have resulted in higher premiums for people in the 
individual market. These include the decision to cut off a key 
ACA subsidy, the dramatic reduction in outreach and consumer 
enrollment assistance, and the introduction of junk insurance 
policies that are permitted to discriminate against people with 
preexisting conditions. The zeroing out of the mandate penalty 
has also increased premiums.
    While the bulk of the negative effects of these policies 
are felt by people in the individual market, these negative 
effects spill over into the job-based market. The ACA is by no 
means perfect. Even its most ardent supporters argue that more 
could be done to expand Medicaid and improve affordability for 
middle class families. There are a range of policy options that 
this committee and others can explore to strengthen the law's 
foundation while also building on its remarkable achievements.
    Thank you for providing this forum and I look forward to 
the discussion.
    [The statement of Ms. Corlette follows:]
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    Chairman Scott. Thank you. Mr. Riedy?

    TESTIMONY OF CHAD RIEDY, RESIDENT, ALEXANDRIA, VIRGINIA

    Mr. Riedy. Good morning. Thank you, Chairman Scott, Ranking 
Member Foxx, and distinguished members of the committee for 
inviting me to testify today.
    I would also like to thank my wife, Julie, and my parents 
for being here today and for their support.
    My name is Chad Riedy and I have cystic fibrosis. I would 
like to share my story of what living with CF is like and what 
the protections in the ACA mean to me and millions of other 
Americans living with chronic health conditions. CF is a rare 
genetic disease that affects about 30,000 people in the U.S. 
and causes a thick, sticky mucus to buildup in the airways 
causing infections. There is no cure for CF.
    When I was diagnosed in 1984 at 3 years old, my parents 
were told that they should not expect me to live to age 12. 
Today I sit here at 37. I have been married for 12 years and a 
father of our 2 boys, Liam, who is 8, and Tate, who just turned 
7.
    Let me tell you what it is like to live with CF. Every day 
I take 30 pills to help me breathe, digest food, and reduce 
inflammation in my lungs. I also take inhaled medicines and use 
a vest that shakes loose mucus in my lungs. Four times a year I 
go through a lengthy evaluation process with a team of doctors 
at Johns Hopkins. I do this to keep my lungs well enough to 
keep me alive. But I will never have the lung capacity of any 
of you sitting here today.
    When I was 26 I got really sick for the first time. My wife 
and I had just returned from our honeymoon when I started to 
notice that I was having a hard time breathing performing 
normal, routine activities, like walking up stairs or talking 
on the phone. After a visit to my care team I was admitted 
immediately to the hospital, where I stayed for 7 days 
receiving intravenous antibiotics, chest physical therapy, and 
other procedures to stabilize my health. While my healthcare 
was covered under my employer-based insurance plan, when I 
returned home I received constant reminders about how close I 
was to hitting my lifetime and annual caps. Before the ACA 
banned these practices I would stay awake wondering would I 
exceed my limits or be denied coverage, then what, how would I 
pay for these things?
    The next time, in 2014, when I got very sick again, over 8 
months my lung function, which had been stable for 7 years, 
declined dramatically. I was so sick that not only was I 
missing work, I could not walk 10 feet across our living room 
floor without having to stop and catch my breath. I struggled 
to carry my kids, who at the time were four and one. Things 
progressed to the point where we started to have conversations 
about needing a lung transplant just to stay alive. Thankfully, 
because the ACA was in place, I could focus on making a strong 
recovery instead of the financial hardships from all these 
medical bills.
    In January 2018 I started on a drug that has changed my 
life called SYMDEKO. It treats the underlying cause of my CF, 
not just the symptoms. It has brought more stability to my lung 
function, but most importantly it has allowed me to be a better 
husband, father, and friend. I no longer worry when carrying 
laundry up a couple flights of steps from the basement. And 
when my boys are tired and want a piggyback ride or need extra 
love, daddy is there for them.
    My treatments and care help me breathe a little easier and 
stay healthy so that I can work to help provide for my family, 
but they are expensive. In 2018 the total cost of all my 
medicines was about $450,000. This does not include my care 
team, visits to them, or other procedures. While we spend a lot 
out of pocket, I am thankful that our insurance covers most of 
these.
    This is my story and there are so many more like it across 
the country. For people battling rare and chronic disease, the 
policies we are discussing today are a matter of life and 
death. If the Judge's ruling against the ACA stands and 
insurance companies are allowed to implement annual and 
lifetime caps I would reach them in a matter of years and be on 
the hook for unimaginable financial costs. In addition, the cap 
on out-of-pocket sharing is vital for someone like me.
    I am grateful that I have coverage that allows me to access 
a great team of doctors and cutting-edge medicines that help me 
fight this disease. Because of this I have hope, hope for a 
future where I grow old with my wife, see my kids grow up, 
graduate college, get married, and start families of their own.
    I am not asking for you to take care of me, I do that 
myself. I also understand that the ACA is not perfect, but the 
protections it contains are critical to me and millions of 
other Americans with preexisting conditions.
    I thank the committee for giving me the opportunity to 
share my story and I ask that you are to keep our hope alive as 
you consider legislation this Congress.
    Thank you.
    [The statement of Mr. Riedy follows:]
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    Chairman Scott. Thank you, Mr. Riedy. Ms. Turner?

  TESTIMONY OF GRACE-MARIE TURNER, PRESIDENT, GALEN INSTITUTE

    Ms. Turner. Thank you, Chairman Scott, Ranking Member Foxx, 
and members of the Committee for inviting me to testify today.
    At the Galen Institute we focus on ways to ensure 
affordable health coverage to all Americans, particularly 
protection for the most vulnerable. I am really pleased to be 
on the panel with Mr. Riedy, and thank you for so bravely 
sharing your story. I am thankful for the health care system 
that supports your care and for continued innovations so new 
treatments can be available.
    Today in my testimony I am going to discuss the centralrole 
that the employer health insurance market plays in our health 
sector, new opportunities to reduce costs and expand access to 
coverage, and bipartisan support for preexisting condition 
protections, and the need for further improvements.
    Nine out of ten workers are employed in the U.S. by 
companies that offer health insurance. These benefits are tax 
free, both to workers and companies, a generous benefit but one 
that leverages nearly $3 in private employer spending for every 
$1 in Federal tax revenue losses. Employers and employees want 
the best value for their health care dollar and often work very 
hard to balance cost and quality.
    Long before the ACA, employers offered preventative 
services because they know that addressing health issues before 
they become a crisis can lead to better outcomes and minimize 
costs. These employers also play a vital role in supporting our 
health sector. Physicians and hospitals are paid much less 
under Medicare and Medicaid than under employer plans, and 
because private insurance pays more, they provide the margins 
that allow many hospitals and providers to stay in business. 
Leading proposals to expand Medicare coverage to all Americans 
would extend these public disbursement rates universally, 
diminishing quality and access to care.
    The Trump administration is offering several options 
through its regulatory authority to help individuals and 
employees with more affordable coverage. The Chairman mentioned 
one of them, including association health plans. They allow 
small firms to group together to get some of the same benefits 
that large employers have. A Washington Post story just 
reported on a new study showing that AHP benefits are 
comparable to most workplace plans and plans are not 
discriminating on patients with preexisting conditions. They 
also have new flexibility under Section 1332 of the ACA to 
lower costs through risk mitigation programs. They separately 
subsidize patients with the highest cost, lowering premiums for 
others, and leading to increased enrollment. In Alaska, 
premiums for the lowest-cost bronze plan fell by 39 percent in 
2018 and Maryland is seeing an even larger drop this year.
    Putting the sickest people in the same pool with others 
means that their premiums are higher. Virginia Senator Bryce 
Reeves talked with one of his constituents recently who said he 
makes a good living, provides for his family, but he said his 
health insurance premiums are $4,000 a month. And he said that 
is more than my mortgage, and really pleading for help. 
Unfortunately, many healthy people are dropping out of the 
market because costs are so high.
    There is strong bipartisan support for preexisting 
condition protections. The ACA assures people cannot be turned 
down or have their policies canceled because of their health 
status, and these protections are still in place. Legislation 
passed by the House of Representatives maintained preexisting 
condition protection. But they do not work for everyone. 
Janet--did not use her last name--reported that she was 
diagnosed in 1999 with Hepatitis C. She lives in Colorado and 
applied for coverage in the State's high-risk pool. Her 
premiums in 2010 were $275 a month. Then her liver failed. She 
needed a transplant. The $600,000 bill was covered 100 percent 
with only $2,500 out-of-pocket. Colorado's high-risk pools 
closed when the ACA started in 2014. Her premiums rose to $450. 
By 2018 they were $1,100 a month. The deductible was $6,300. 
But her anti-rejection medications were not covered. She said 
almost everything I needed was denied, which threw me into a 
world of having to appeal to get the care I needed. She said 
those of us who are self-employed and are not eligible for tax 
credits wind up footing way too much of the bill. She said her 
costs are $19,000 a year before insurance pays and she has to 
pay extras for her medication. She keeps her insurance because 
if something else happened, and her liver failed and she needed 
another transplant, she said it would bankrupt my family.
    I hope to work with you to achieve the goals of better 
access to more affordable coverage and better protection with 
those with preexisting conditions.
    Thank you for the opportunity to testify today.
    [The statement of Ms. Turner follows:]
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    Chairman Scott. Thank you. Dr. Gupta, before you start I 
think I need to give full disclosure. I have been an active 
member of the--volunteer for the March of Dimes for several 
decades. So I appreciate your testimony.

   TESTIMONY OF RAHUL GUPTA, SENIOR VICE PRESIDENT AND CHIEF 
           MEDICAL AND HEALTH OFFICER, MARCH OF DIMES

    Dr. Gupta. Thank you for being an active member, Mr. 
Chairman, and thank you, along with Ranking Member Foxx and 
members of the committee, for the opportunity to testify today.
    My name is Rahul Gupta, I am the senior vice president and 
chief medical and health officer at the March of Dimes. In 
addition to my role representing the March of Dimes I also 
bring perspective from my experience as a practicing physician 
and as a former State health commissioner and a local health 
officer.
    As a primary care physician, it was not uncommon for me to 
treat women who were struggling with high costs of employer-
based health insurance or priced out of coverage altogether due 
to their preexisting conditions. These women were in the 
impossible condition of having to make choices between getting 
the care they needed and affording their families' basic 
necessities, such as food and prescription medications. 
Preexisting conditions are common among Americans. Six in every 
ten American adults in the U.S. has a chronic disease, and four 
in ten have two or more.
    Chronic conditions, such as high blood pressure, diabetes, 
heart disease, and obesity can have tragic consequences for 
women during pregnancy. Each day in the United States more than 
two women die of pregnancy-related causes, and more than 50,000 
have severe pregnancy complications. More American women are 
dying of pregnancy-related complications than any other 
developed country in the world, and it is not getting any 
better.
    As pregnancy or childbirth are also widely considered 
preexisting conditions the prevalence of at least one 
preexisting condition in this population is almost universal. 
If conditions like preterm birth, birth defects, or neonatal 
abstinence syndrome, are considered tens of millions of 
children could be subject to insurance discrimination 
throughout their lives. The Affordable Care Act contains a 
range of provisions to help ensure comprehensive, meaningful, 
and affordable coverage for women, children, and their 
families. Amongst its most important popular provisions is the 
requirement that health plans cover all individuals regardless 
of preexisting conditions. The law ensures that all American 
can obtain coverage without worrying that they will be subject 
to discrimination, whether outright denial of coverage, or 
carve-outs of the benefits they need the most.
    It is difficult for me to overstate the importance of ACA's 
requirements that all plans cover the 10 essential health 
benefits, including maternity care.
    The ACA has also addressed a range of issues related to 
affordability of coverage. Cost has historically been and 
remains one of the greatest barriers to care. If people are 
unable to afford coverage, healthcare becomes all but 
inaccessible. Under the ACA, policies sold on the individual 
and small group markets are prohibited from charging women high 
premiums. Health plans can no longer impose annual or lifetime 
caps. In the case of maternal and childbirth and child health, 
these caps could be financially devastating.
    A woman, for example, with a high-risk pregnancy and 
delivery could easily exceed an annual cap, leaving her unable 
to obtain needed care for the rest of the year. Worse, a baby 
born extremely preterm, who needs months of care in the 
neonatal ICU, could exhaust a lifetime cap before even coming 
home.
    This triad of preexisting condition protections, essential 
health benefits, and affordability provisions represent a 
three-legged stool that supports access to comprehensive 
quality and affordable coverage for all Americans. All three of 
these legs must be maintained to protect and promote our 
Nation's health, especially the health of women, children, and 
families.
    March of Dimes is deeply troubled by Texas v. U.S. This 
lawsuit appears to have been undertaken as a legal exercise 
divorced from any real appreciation of its ramification for 
millions of Americans and their health and wellbeing. With the 
recent decision of the Federal court judge to declare ACA 
unconstitutional in its entirety, the plaintiffs appear to be 
in a classic situation of the dog that caught the car. They 
were caught off guard by their own victory and now are unsure 
how to explain that they have argued for an action that will 
cost millions of Americans their health coverage and 
potentially even their lives.
    In addition, we are deeply concerned about efforts by the 
Administration to promote access to short-term, limited 
duration insurance plans. These plans are not required to cover 
essential health benefits, including maternity care, mental 
health, and substance use treatment, and could again exclude or 
charge patients more based on their preexisting conditions. 
Whatever changes may be undertaken to our Nation's health laws 
and systems, they must be made with the express goal of 
improving access to coverage and care that is accessible, 
comprehensive, and affordable.
    In essence, this concept is no different than when I am 
seeing a patient in my office. I endeavor to provide her with 
the highest quality care in a compassionate manner, keeping in 
mind that she should not have to sacrifice her next trip to the 
grocery store in exchange. I sincerely hope that we can provide 
the same guarantee to all Americans.
    Thank you for holding this meeting, and I look forward to 
any questions.
    [The statement of Dr. Gupta follows:]
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    Chairman Scott. Thank you, thank you. And now we will have 
our members ask questions. First, I am going to defer on my 
side, and the gentleman from Connecticut, Mr. Courtney.
    Mr. Courtney. Thank you, Mr. Chairman. And, again, I want 
to applaud the fact that we are holding this hearing in this 
committee. Back in 2009 and 2010, when the Affordable Care Act 
was crafted with three different committees, it was our 
committee which led the way in terms of preexisting conditions 
and all the patient protections, because we have jurisdiction 
over ERISA. So, again, we actually were the place where the law 
was written that was, in my opinion, you know, one of the great 
steps forward of our Nation in terms of social and civil 
rights.
    You know, again, Ms. Corlette talked about what the 
landscape looked like back in 2009 and 2010. I brought along a 
flyer that was being sold to a lot of businesses, which again, 
brings back the bad old days. Again, it is a health plan where 
it is touted as great news for people who buy their own health 
insurance, a flexible health plan, affordable. However, if you 
flip to the back, it had sort of in the smaller print the fact 
that they may not be able to cover people who have ever had 
treatment for the following, AIDS, alcohol or drug dependence, 
cancer, COPD, connective tissue disorder, Crohn's disease, 
diabetes, emphysema, heart attack or stroke, hepatitis, 
inpatient emotional or mental illness, organ or tissue 
transplant, or colitis. So if you are like an episode of 
survivor and you are not in that category, however, you are 
still not out of the woods yet because it also says that other 
individuals who are obese, underweight, have undergone 
diagnostic tests for a whole variety of different illnesses, as 
well as expectant parents or children less than 2 months old 
are also not going not be able to take advantage of that 
policy. And, last, it says this list is not all inclusive. 
Other conditions may apply.
    So, I mean that is what health insurance looked like until 
President Obama signed the Affordable Care Act in March 2010, 
which once and for all abolished this whole type of medical 
underwriting practice. And, again, it was also architecture 
that was built around it to make that meaningful, such as 
essential health benefits, the lifetime caps, which Mr. Riedy 
so powerfully testified to, adjusted community rating so that 
older people can't be charged more than three times a younger 
individual.
    So, again, regarding the Texas case, as Dr. Gupta said, I 
mean there is absolutely no question that the Justice 
Department, which participated with the plaintiffs and did not 
defend the Department of Health and Human Services, if that 
ruling were to stand, again, that would just take a wrecking 
ball to the whole architecture, again, that was built. Is that 
correct, Ms. Corlette?
    Ms. Corlette. That is correct. For the plaintiff States, if 
their position prevails the entire law would be invalidated.
    Mr. Courtney. And in terms of some of the other changes 
that they have made through the regulatory process, the 
association health plans, which, again, on surface sounds 
great, that small businesses can team together in different 
sectors and go out and buy collectively. By the way, that was 
totally legal prior to the Trump Administration's ruling and 
there were about 600 association health plans across the 
country. What the ruling really did was it basically allowed 
those plans to avoid, again, a lot of these patient 
protections, such as essential health benefits, which were 
painstakingly designed with the Institute of Medicine in terms 
of what is healthcare and what should health insurance be, and 
lifetime caps, et cetera.
    So, again, I just wonder if you could sort of focus on that 
point, that the Administration, again, is in fact undermining 
preexisting conditions and preexisting condition protections 
with those types of regulatory actions.
    Ms. Corlette. That is absolutely correct. Groups of 
employers have always been able to join an association and 
offer benefits if they choose to do so. What the Administration 
is encouraging is arrangements that essentially are allowed to 
cherry pick the healthiest and youngest employer groups out of 
the regulated market and thereby gain a pricing advantage.
    Mr. Courtney. And the short-term plans, Dr. Gupta, you 
mentioned, again, it is the same story, that it is really a 
device to avoid again the protections that were built into the 
Affordable Care Act.
    Dr. Gupta. That is very true. And along with that, the 
other part of this is the medical loss ratio that was built 
into the ACA and that is not subject to in the short-term 
plans. So they can have as much as 50 percent medical loss 
ratio and actually profit disproportionately out of--
    Mr. Courtney. And the short-terms plans are really not that 
short. Again, when the prior Administration allowed for a very 
short, short-term plan, these now almost are basically going to 
be sold for an entire year. Isn't that correct?
    Dr. Gupta. Correct. They could be sold for about 364 days 
and then renewable afterwards.
    Mr. Courtney. So, I mean it is basically a whole new 
product. And, again, we would see the bad old days in terms of, 
you know, this type of laundry list of fine print where people 
are going to have a rude awakening when they thought they had 
insurance and in fact it was totally useless and meaningless.
    I yield back.
    Chairman Scott. Dr. Foxx.
    Mrs. Foxx. Thank you, Mr. Chairman. Ms. Turner, people 
living with preexisting conditions, such as cancer, diabetes, 
or other illnesses face an incredibly difficult battle each and 
every day. And, in particular, I commend Mr. Riedy for his 
strength and courage to share his story with us today. People 
should not worry about having their coverage denied because of 
a medical condition when they should be focused on getting well 
and managing their quality of life. That is why congressional 
Republicans have voted time and time again to protect 
preexisting condition protections.
    Ms. Turner, are these protections under current law 
sufficient to protect access to coverage for the most 
vulnerable healthcare consumers, and do you agree that these 
protections should be maintained?
    Ms. Turner. The protections absolutely should be 
maintained. But I do believe that we do have to address the 
issue of cost because many people who need coverage are not 
able to afford it and then are completely, completely exposed. 
So I believe that the preexisting conditions that are in law 
today and that the House of Representatives supported in the 
American Health Care Act were important, will continue to be 
important. I see the strong support, both in Congress and with 
the American people, to maintain those protections.
    Mrs. Foxx. Thank you, Ms. Turner. Because of policies 
enacted by the previous House Republican majority and 
regulatory actions taken the by Trump administration our 
economy is thriving. As I mentioned, the economy added 304,000 
jobs last month, almost double what economists were expecting. 
As a result, the number of individuals with employer sponsored 
coverage has grown by nearly 7 million since 2013, with 2.6 
million gaining coverage since President Trump took office. How 
does strong economic growth contribute to more workers gaining 
health insurance from their employers?
    Ms. Turner. Virtually all employers want to offer health 
insurance to their employees, but many smaller businesses, in 
particular, just can't afford it, both because of the 
regulatory burdens as well as the cost. The Trump 
administration is giving them some new options, both with 
association health plans and with health reimbursement 
arrangements. For those that have employer coverage, it is such 
a valued benefit and employers and employees work together to 
balance cost and quality and comprehensiveness of benefits. And 
as a result, employer-sponsored health insurance is certainly 
the most popular benefit offered by employers. And I am pleased 
to say that is not only continuing but being enhanced by the 
strong economy.
    Mrs. Foxx. Thank you. Ms. Turner, when I travel around my 
district in North Carolina, I hear stories from so many people 
who struggle with the high and sometimes unpredictable costs 
that they face when taking care of themselves and their 
families. Out-of-control drug prices, surprise medical bills 
are two topics that President Trump has recently identified as 
places for reform and areas where I believe we can find 
bipartisan agreement.
    In addition to these issues, what other areas do you think 
that Republicans and Democrats can move forward and work on 
together to find a solution that benefits patients, workers, 
and families?
    Ms. Turner. I do work with a number of people in the policy 
community and it is surprising to see how much agreement there 
is on really trying to help people. I think we need to 
strengthen the system for the most vulnerable. I was on a panel 
yesterday--on Monday at the Academy of Health with several 
people from center-left and we talked about the importance of 
thinking of the whole person, of comprehensiveness of care, of 
allowing people to not only have coverage for health care, but 
housing support and food support and transportation support. 
Thinking of the whole person I think is really crucial and 
devolving more power and authority to the States and localities 
that have the understanding of their markets and resources I 
think is really crucial. But I also think addressing the cost 
of health coverage is so important.
    Between 2017 and 2018 we lost 2 million people in the 
individual health insurance market. They dropped out because of 
cost. So we have got to address the cost for people who want 
health insurance, who currently are healthy, but know they need 
protection. And we need to make sure that we are strengthening 
the system for the most vulnerable.
    Mrs. Foxx. Thank you, Ms. Turner. I yield back, Mr. 
Chairman.
    Chairman Scott. Thank you. The gentlelady from Oregon, Ms. 
Bonamici.
    Ms. Bonamici. Thank you, Mr. Chairman, and thank you to all 
of our witnesses.
    Last week there was a hearing in the Ways and Means 
Committee here in the House about preexisting conditions and 
one of the witnesses was the insurance commissioner from my 
home State of Oregon, Andrew Stolfi. And he talked about how in 
Oregon since the ACA we now have more than 3.7 million 
Oregonians, which is about 94 percent of our population, with 
health insurance coverage. And since the ACA that has been a 
significant improvement, significantly reducing the number of 
people without insurance. And before the ACA insurers had 
offered limited coverage or excluded so many people who 
applied. In fact, before the ACA the denial rate was about 30 
percent, 30 percent of people who applied were denied. And in 
Commissioner Stolfi's words, he said the ACA has helped change 
all of this, pregnant mothers know they can get the care they 
need and their babies need, children with developmental 
disabilities can get all of the essential physician-recommended 
physical, occupational, and behavioral therapy they need to 
grow to their fullest potential.
    So, the ACA is now protecting millions of people in Oregon 
who have preexisting medical conditions. Lisa from Beaverton is 
26 years old, she received a diagnosis when she was 23, stage 4 
lymphoma. I am happy to report that her cancer is now in 
remission and she is pursuing a master's degree, but she is 
pretty worried, frankly, when she hears all the conversations 
about repealing the ACA, this Texas lawsuit. She said ``I have 
hopefully a lot of life ahead of me and it frustrates me that 
my history of cancer could limit my access to healthcare.''
    Mr. Riedy, thank you so much for sharing your story. I have 
an advocate in the district I represent, Ella, a young woman 
with CF, and she comes to the Capitol when she can to advocate 
for more research and funding. And her family shares your 
concern about lifetime caps.
    How is the last couple of years--how have you personally 
felt when you hear all these conversations about repealing the 
Affordable Care Act? And when you hear about this lawsuit that 
might repeal the Act?
    Mr. Riedy. Thank you. It is scary to think, especially like 
I testified earlier, with the cost of my care currently, having 
caps or potentially being able to be denied coverage is a scary 
thought. Knowing that there is access to drugs that are 
changing my life and that there is more medicine coming down 
the pike that will ultimately, I fully believe, one day cure 
cystic fibrosis. But that will come at a cost. And it is hard 
to think or sort of comprehend that those treatments may be 
there and because of a lifetime cap or because of being denied 
access, that I will not be able to get those medicines, or your 
constituent's daughter would not be able to get those medicines 
that could potentially save or prolong her life.
    Ms. Bonamici. Thank you so much. And you made an excellent 
point, that access does not mean affordability. And if there is 
not the prohibition against discrimination for people with 
preexisting conditions, if the companies are saying well, we 
offer insurance to people with preexisting conditions, it just 
costs a fortune, it is not meaningful access.
    I have another question to Dr. Corlette. I have another 
constituent, Diane, who is a small business owner and for a 
long time she--she has a son with autism and a small business--
for a long time she could not afford insurance before the ACA. 
She almost lost her home and business during the financial 
collapse. She went several years without coverage and she was 
uninsurable because she had preexisting conditions.
    So, she was not able to manage her arthritis, made it 
difficult for her to work. So, under the ACA she was able to 
get coverage, she could see a doctor, she eventually had hip 
replacement surgery, she is now able to work, has rebuilt her 
business. So, a really positive story largely because of that 
access to marketplace coverage.
    So, Professor Corlette, if the ACA protections we have 
discussed are undermined, what might that mean for Diane and 
other small business owners who do look to provide coverage for 
themselves, their families, and their employees?
    Ms. Corlette. Sure. So, if the ACA is invalidated in a 
Texas court it will wipe away some of the protections that your 
constituent has benefited from. So, for example, in the group 
market, if she is buying as a small business owner she could--
her employees could face what are called preexisting condition 
exclusions where the insurance company excludes from your 
benefit package those services that would actually treat your 
condition, for which you actually need services, for up to a 
year. The insurance company would not be required to cover 
essential health benefits, which is a list of benefits that the 
Institute of Medicine and others have said should be in a basic 
benefit package, it could impose lifetime annual limits, there 
may not be a cap on the annual amount that she or her employees 
would pay out-of-pocket. So, there are a number of critical 
protections that people in job-based coverage would lose.
    Ms. Bonamici. Thank you very much and I see my time has 
expired. I yield back. Thank you, Mr. Chairman.
    Chairman Scott. Thank you. Dr. Roe.
    Dr. Roe. Thank you, Mr. Chairman. And, Mr. Riedy, I want to 
start with you.
    First of all, the easiest vote I have made here in the U.S. 
Congress was for the 21st Century Cures Act. To Dr. Collins, 
Francis Collins, the director of the NIH, it is very easy for 
me to vote to increase his budget to $39 billion. When I was a 
medical student, the first pediatric rotation I had in Memphis 
was St. Jude's Children's Hospital. Eighty percent of those 
children died in 1969 when I rotated there, today 80 percent of 
them live. If you have a rare condition, it is 100 percent for 
you. So I think there is a cure out there in the way and I 
think your future is very optimistic. And thank you for being 
here today.
    Look, we could all agree that we want to increase coverage 
and access and lower costs. That is exactly what we wanted to 
do with the ACA. Everyone can agree to that. And we agreed that 
we wanted to discuss preexisting conditions. And I want to go 
over very quickly, so everybody understands, that if you have 
health-based insurance, which I provide in my office for my 
employees, everyone--you cannot discriminate based on a 
preexisting condition. No. 2, if you have Medicaid or Medicare, 
you cannot discriminate versus on a preexisting condition. It 
is only in the small group and individual market where this 
occurred. And people feared if they lost their job and they 
ended up in the small group or individual market that they 
couldn't do that.
    I have a bill that I am dropping today, a very simple bill. 
It has one paragraph, it is three pages long, that essentially 
provides ERISA coverage to the small group and individual 
market. It treats them--me--as an individual--and I have been 
on the individual market--exactly like a large corporation. And 
that solves the problem and everyone in here--no matter what 
the Court does--if the Court rules whatever they rule. If they 
rule and it takes apart this, we have covered everybody and 
treated each individual exactly the same as a big company. This 
should be simple to do, it is one paragraph.
    And let me also say, Dr. Gupta, to you, let me share some 
experiences in Tennessee. We were promised the costs were going 
to go down. Our costs went up 175 percent and we lowered the 
number of plans out there that we could have. In my district, 
where I live, three-fourths as many people paid the penalty as 
actually get a subsidy. And what is happening in the real world 
is with these out-of-pockets and co-pays, if the hospital were 
our practice for 30 years, over 60 percent of the uncollectible 
debt are people with the insurance, not without insurance, but 
with insurance. And what happens is a patient will come to my 
office and if they had a condition, one of the 10 essential 
health benefits, they got their screening procedure done, that 
was fine, that was ``free''. If I found anything wrong with 
them and I had to send them down to the hospital for a test, 
they then have to meet their out-of-pocket and co-pay, which 
can be $3-4-5,000--and my family is $10,000. And so what 
happens, the hospitals, the providers, end up eating that. That 
is what his happening in the real world. Or people don't get 
the second test that they need, and that is what we have to 
look at.
    I also want to say to you all that I have a preexisting 
condition. I was treated 17-18 months ago for proState cancer. 
So I am in that pool of preexisting conditions and I don't want 
to be excluded either, nor do I want my patients excluded. And 
that is why I think we should all support this bill right here.
    And, Miss Turner, if you would, I would like for you to 
comment a little bit about my suggestion, about just applying 
these ERISA rules to me or to any individual out there.
    Ms. Turner. As we said, employers so highly value their 
employer coverage, and one of the reasons is because someone is 
negotiating on their behalf for a quality health plan. And 
health plans in the workplace are basically community rated. 
You may have different plan options, but everybody is basically 
paying the same amount for premiums. And HIPAA, of course, 
protections say that if you have group coverage through an 
employer and you move from one employer to another, that next 
employer must cover you at the same rate. So you can't then be 
basically underwritten. So there are a lot of existing 
protections in law.
    And I am very intrigued with your very creative legislation 
to basically extend those protections. I think it is important 
to note that if the Supreme Court--and I don't know anyone who 
knows what the Supreme Court is going to do--were to strike 
down the law, Congress is absolutely determined to fix it and 
to maybe improve the ACA in the process.
    Dr. Roe. I agree. And one of the things that I think is out 
there in the group market, in the self insured market--and we 
did this when I was on the City Commission in my hometown--is 
you can have disease management--Dr. Gupta knows this very 
well. And I have seen those cases where I have a friend of mine 
who has a large company with 15,000 employees, had a 1 percent 
increase in their premium per year for the last 5 years. And we 
can do that in the small group and individual market if we work 
together.
    Mr. Chairman, thank you. I yield back.
    Chairman Scott. Thank you. Gentleman from California, Mr. 
Takano.
    Mr. Takano. Thank you, Mr. Chairman. Let me begin by saying 
that my home district in Riverside, California, we cut--the 
Affordable Care Act enabled us to cut our uninsured rate by 
more than half because of expanded Medicaid and because of 
Covered California, which is the name of our exchange. I have 
personally spoken to older people in my district who have not 
reached Medicare age, but at an age when if there were no ACA 
they would not get any cost-sharing subsidies and they could 
not have afforded the insurance. They were very grateful that 
they got the cost-sharing subsidies so that they could reduce 
their exposure to a major medical incident.
    So, the majority offers these really false solutions of 
association plans and short-terms plans. Ms. Corlette, could 
you--you know, I think these plans are really evasions around 
minimum benefits. Is that correct?
    Ms. Corlette. That is right. So short-term plans are exempt 
from all of the Affordable Care Act rules, so they don't have 
to enroll people who have health issues, they don't have to 
cover the essential health benefits, and quite commonly with 
these plans, if you do get diagnosed with something after you 
enroll, they will do what is called post-claims underwriting 
and drop you from the plan to avoid paying your medical bills. 
So, if you do have an unexpected medical event or diagnosis, 
you might find yourself uncovered.
    The concern is that they will siphon away healthy people 
from the Affordable Care Act marketplaces and result in higher 
premiums for those who are not perfectly healthy and have to 
buy one of these ACA plans.
    Mr. Takano. So, the same for association plans, which were 
available, but the way the Administration has structured them, 
a similar sort of result.
    Ms. Corlette. Association health plans are similar but not 
exactly the same. They do have to comply with some of the ACA 
rules, but not all. And so they can use essentially the rating 
advantage they have, because they can charge higher rates based 
on age and other factors to cherry pick healthier employer 
groups from the ACA market.
    Mr. Takano. And there goes, you know, any affordability 
gain by the ACA. So, these are really ways to undermine the ACA 
and to undermine by extension protections for people with 
preexisting conditions, is that right?
    Ms. Corlette. That is right. If you have a preexisting 
condition or you simply want comprehensive coverage, like 
maternity care or other things that you feel are important, you 
would be buying in the ACA market, and if healthy people are 
siphoned away the ACA market risk pool will be smaller and it 
will be sicker, and insurers will price higher as a result.
    Mr. Takano. So, I would say that attempts to undermine the 
pools, undermine enrollment periods--so if we look at slashing 
funding for outreach and enrollment activities, that means less 
people enroll and makes these insurance pools less viable. That 
is also hurting people with preexisting conditions.
    Ms. Corlette. That is right. There is no question that 
research shows that advertising, marketing, outreach, 
education, consumer assistance, those all work to get healthy 
people into the pool.
    Mr. Takano. And this Administration has, you know, really 
refused to spend the outreach to get people to sign up for 
insurance, which then creates the premium dollar pool to make 
insurance viable and actually keep the cost down.
    Ms. Corlette. That is right. This Administration has 
slashed outreach and marketing by about 80 percent. So it is 
hard to bring healthy people in if they are not aware that the 
coverage opportunity exists.
    Mr. Takano. It was hard for me to square this President 
wanting to protect people with preexisting conditions knowing 
that his Administration intentionally did that.
    So also shortening the enrollment period, making it less--
giving people less time to enroll into these insurance plans 
also has the same result.
    Ms. Corlette. That is right. And a number of the State-
based marketplaces that can choose their own open enrollment 
periods have extended them to give people more time to enroll, 
and that has been a successful strategy.
    Mr. Takano. Well, and the Administration has also engaged 
in undermining the stability of the markets through ending the 
cost-sharing reduction payments for lower-income consumers. 
Would prevent people from being able to buy insurance because 
they don't have these subsidies.
    Ms. Corlette. It is absolutely the case that the decision 
by this Administration to cut the cost-sharing reduction 
subsidy led to an increase in premiums in the individual market 
significantly. I think 20 percent.
    Mr. Takano. Well, this intentional undermining in at least 
the three ways that I have spoken about, I mean certainly 
reduces the viability of these healthcare exchanges and also 
really makes meaningless any statement that this President 
wants to protect people with preexisting conditions and their 
ability to get insurance.
    I yield back, Mr. Chairman.
    Chairman Scott. Thank you. Gentleman from Pennsylvania, Mr. 
Thompson.
    Mr. Thompson. Chairman, thank you for hosting this hearing. 
Incredibly important topic. As someone who practiced healthcare 
for 28 years as a therapist, rehabilitation services manager, 
licensed nursing home administrator, I mean this is an 
important topic and preexisting conditions is a serious issue, 
an incredibly important issue. I have been disappointed over 
the past couple of years where, you know, with preexisting 
conditions individuals living with preexisting conditions 
obviously need confidence in their lives that they are going to 
be able to purchase insurance that they need to cover that 
condition, for treatment, rehabilitation. But quite frankly, 
what I have been disappointed in is how--there are people with 
preexisting conditions--need that health care professionals who 
are compassionate and dedicated, they want to provide those 
service, they want to access--they want those patients to be 
able to access those services. Well, we have got a lot of 
politicians that have been weaponizing preexisting conditions 
for political purposes. And whenever we do that, you know, my 
experience--I have only been here--this is my 11th year. I was 
here in 2009-2010. It doesn't serve anyone well.
    And so also my background, I used to get very frustrated 
advocating for my patients, whether it was in a nursing home, 
comprehensive inpatient, rehab, acute care, you know, going to 
battle with insurance companies. The people with some of the 
more chronic conditions are the ones that are facing those 
lifetime benefits. So I certainly support those improvements.
    But that said, let us--you know, I really want to clarify 
here, Ms. Turner, you know, protections for individuals with 
preexisting conditions has been a consistent area of agreement 
for both Republicans and Democrats. You Stated that protections 
for people with preexisting conditions are currently the law of 
the land and under the American Health Care Act, passed by the 
House last Congress, would the current law's legal protections 
for individuals with preexisting conditions be retained?
    Ms. Turner. If the Supreme Court were to invalidate the ACA 
and find the individual mandate unconstitutional and non-
severable, which I think is unlikely, but if it would, it would 
certainly give several years of transition time before it went 
into effect to give Congress ample time to figure out how to 
back up these protections. And as you said, the Congress at 
the--whoever has been in control of the Congress has been a 
strong support of protection for preexisting conditions. Even 
if people don't have them now, they think they could get them 
in the future and they know someone has chronic conditions. So 
those protections need to be in place, but they need to be in a 
place in a way that actually allows the market to continue to 
work and doesn't drive out the healthy people because the costs 
are so high.
    Mr. Thompson. I mean there are a lot of things that impact. 
I think people getting into the pool, so to speak, that was 
mentioned by my friend from California, but the folks that have 
gotten out of the pool, I think there is a significant number 
who have gotten out because of post ACA, the cost, the 
escalating cost. And people with preexisting conditions that 
have--that were pleased that they could get it, the insurance 
but their costs have escalated. So we can't be complacent with 
the law as it is now, whether--we have to take measures.
    One final question for you, Ms. Turner. We constantly hear 
about the challenges that small employers face when dealing 
with costs and compliance burdens in providing health insurance 
coverage to their employees. While some small businesses are 
able to offer health coverage, many simply can't afford to do 
so. And one option, among others, which was passed by this 
committee, is for the small employers to band together to 
provide economies of scale for purchasing health insurance 
through association health plans.
    Now, what are other alternatives that encourage and enable 
employers, both small and large, to preserve and expand quality 
health coverage for their employees?
    Ms. Turner. Well, I do think it is important to focus on 
association health plans because this recent study by a very 
well respected analyst, Kev Coleman, said that he did not see 
that the plans that these new association health plans, which 
are offered in 13 States, just in the 7-months since the rule 
was finalized, and offering more than two dozen plans, that 
they really do provide an option for employers.
    I have been in seminars with H.R. directors of Fortune 500 
companies and talked with innumerable small businesses. They 
want to negotiate benefits that their employees want and they 
listen to their employees. And they are as comprehensive of 
benefits as they can afford and offer that coverage. So I think 
that it is important to give respect to the people purchasing 
these policies, that they will find a way to make sure people 
have coverage that is as good as they can afford, rather than 
no coverage at all, which is where too many people are without 
these options.
    Mr. Thompson. Thank you, Ms. Turner. Thank you, Chairman.
    Chairman Scott. Thank you. The gentlelady from Washington, 
Ms. Jayapal.
    Ms. Jayapal. Thank you, Mr. Chairman. On October 31 of last 
year, conveniently just a few days before the midterm election, 
President Trump tweeted, and I quote, ``Republicans will 
protect people with preexisting conditions far better than 
Democrats.'' That was a pretty big flip-flop given that the 
President and Republicans in Congress, including many on this 
very committee, spent most of last Congress voting to try to 
kill the Affordable Care Act and its protections for 
individuals with preexisting conditions. In fact, I think I am 
right about this, the only Republican members of this committee 
who did not vote for the horrible Trump Care bill last Congress 
were the eight new members who had not yet been elected.
    Now, this Administration is backing a lawsuit that could 
strip coverage for more than 133 million Americans with 
preexisting conditions with absolutely no plan to replace that 
coverage. And if this ruling takes effect more than 17 million 
people would lose coverage in the first year alone.
    So, to my Republican colleagues, which one is it? Do the 
American people deserve coverage for preexisting conditions or 
don't they?
    Let me also point out that overturning preexisting 
conditions protections would disproportionately harm racial and 
ethnic minorities. And, Mr. Chairman, I seek unanimous consent 
to enter a written Statement from the Asian and Pacific 
Islander American Health Forum into the record.
    Chairman Scott. Without objection. And I want to remind our 
colleagues that pursuant to committee practice, materials must 
be submitted to the committee clerk within 14 days following 
the last day of the hearing, preferably in a Microsoft Word 
format. The materials submitted must address the subject matter 
of the hearing. And only a member of the committee or an 
invited witness may submit the materials for inclusion in the 
record.
    Documents are limited to 50 pages. Documents longer than 50 
pages will be incorporated into the record by way of an 
internet link, so that you must provide the committee clerk 
with that in the timeframe, but recognize that years from now 
that link may no longer work.
    And I will give you a couple of seconds at the end.
    Thank you.
    Ms. Jayapal. Thank you, Mr. Chairman. And noted for the 
future.
    So let me start with my first question for Ms. Corlette. 
Thank you for your testimony. In your professional opinion as a 
research professor at the Center on Health Insurance Reforms, 
let us go back a little bit, why did it take an act of Congress 
to require insurance companies to insure people with 
preexisting conditions?
    Ms. Corlette. Well, before the ACA insurance companies, in 
order to make money, the business strategy was to enroll as 
many healthy people as you could, bring in their premiums, and 
pay out as little as possible in claims. So, to do that they 
engaged in what was called medical underwriting, which required 
people when they applied for coverage to submit health forms. 
They had lists of up to 400 different conditions that would 
cause you to be excluded from coverage. But, essentially that 
was the business strategy.
    What the ACA tried to do was change the business strategy 
away from risk avoidance to risk management.
    Ms. Jayapal. Thank you. So, just to be frank, insurance 
companies wouldn't cover people with preexisting conditions 
because they are too expensive, correct?
    Ms. Corlette. Yes.
    Ms. Jayapal. OK. So, Ms. Corlette, you also said in your 
testimony that the Affordable Care Act was enacted in part to 
correct serious deficiencies in health insurance markets that 
left millions uninsured and millions more with inadequate 
coverage. The reality is that the profit-seeking motives of 
insurance companies and big pharma are at odds with providing 
comprehensive care for everyone in this country. Do you believe 
that government should play a role in insuring that corporate 
greed doesn't allow insurance companies to deny coverage to 
people with preexisting conditions?
    Ms. Corlette. I think absolutely government needs to play a 
role, both in terms of financing, and I think it is important--
you know, this committee is as aware as anybody else that 
employer-sponsored coverage is the source of the biggest 
subsidy in the Federal tax code. So critical role in terms of 
financing, but also to set the rules of the road. So, to the 
extent that we have private market actors on the provider side 
or the payer side, that there are clear rules of the road to 
protect people who need help, which is individuals, consumers, 
small businesses.
    Ms. Jayapal. So, thank you. In 2017--this is again a 
question for you--Aetena's CEO was paid nearly $59 million, 
Cigna's CEO took home almost $44 million, UnitedHealthcare's 
CEO $27 million. So, our healthcare system is underwritten by 
greed and health insurance companies and big pharma are 
profiting off of sick Americans. Without the protections 
ensured by the ACA, do you believe that insurance companies 
would continue to guarantee coverage for people with 
preexisting conditions?
    Ms. Corlette. No, I think they would go back to the 
business practices they were engaged in before the ACA was 
passed.
    Ms. Jayapal. Thank you. The Urban Institute estimates that 
17 million people will lose coverage in the first year alone if 
the Republican lawsuit stripping the ACA goes through. We have 
waited long enough for corporate executives to do the right 
thing, in my opinion. They simply aren't going to do so without 
government intervention. And that is why we passed the ACA.
    And, Mr. Chairman, that is why we must go further. 
Ultimately, I believe we need to take the pure profit-seeking 
motives out of our healthcare system and ensure that the No. 1 
thing we do is protect every American's right to have 
healthcare. And so today we are united as Democrats in 
protecting the ACA, making it clear that we stand with millions 
of Americans who are at risk of losing coverage. But I am also 
determined to put forward a bold new vision for Medicare for 
all, something that the majority of all Americans support. As 
Members of Congress, we are ready to listen to them and put 
people over profits.
    Thank you, Mr. Chairman, I yield back.
    Chairman Scott. Thank you. Gentleman from Michigan, Mr. 
Walberg.
    Mr. Walberg. Thank you, Mr. Chairman. Protections for 
individuals with preexisting conditions has been a consistent 
area of agreement for both Republicans and Democrats. We have 
to keep reiterating that.
    I strongly believe that these protections need to remain in 
place and I voted and co-sponsored legislation to safeguard 
them and give peace of mind to patients, and that is a matter 
of record.
    I am disheartened with my friends on the other side of the 
aisle's continued misinformation on our record on this issue. 
There was no Trumpcare, nothing got to his desk. There was the 
Affordable Health Care Act that dealt with all of the issues of 
concern that the ACA brought up because it didn't work for many 
people who did have a health care plan that they paid for, but 
when they went to use it, so many of them, so many of them did 
not have health care. So I hope that changes at some point in 
time, the rhetoric that continues on.
    This committee has jurisdiction over employer-sponsored 
health insurance. I know there are some that believe we need to 
move beyond the employer-sponsored coverage, however, the 
employer sponsored system currently provides health insurance 
for over 181 million Americans. So instead of forcing Americans 
off their plans that they like, or in the cases of union 
employees, forcing them to give up health plans that they 
worked hard for and made salary sacrifices to negotiate, we 
should explore ways to strengthen our employer sponsored 
system, reduce costs, so more businesses can offer these good 
benefits to their employees.
    I constantly hear from small employers in Michigan who are 
dealing with the cost and compliance burdens of providing 
health insurance coverage to their employees. While some small 
businesses are able to offer health coverage, many simply 
cannot afford to do so. One option among others, which was 
passed by this committee, is for small employers to band 
together to provide economies of scale for purchasing health 
insurance through an association health plan.
    Ms. Turner, thank you for being here. As you know, in 
August the Department of Labor issued a final rule to expand 
access to AHPs. In your opinion, when finalized, will DOL's 
rule help or hinder efforts to increase coverage for small 
employers and their employees?
    Ms. Turner. It absolutely will provide them an important 
new option to negotiate benefits on behalf of their employees. 
Talking with another H.R. director who has a work force of 
primarily medium and lower income workers, he said what happens 
is that as healthcare costs go up it eats up their wage 
increases. So employees see their wages as flat, but part of 
their compensation because too much of their compensation 
package is going to health benefits.
    Some employers are very creative, helping to provide 
coordinated care for people that they have identified that have 
the greatest healthcare needs. So I think employers play an 
important role and I think association health plans also play 
an important role, as well as the new health reimbursement 
arrangement rule, which would allow employers who cannot afford 
and do not have the resources to actually provide coverage to 
give their employees a stipend to be able to purchase health 
insurance on their own. We recommended they be able to combine 
salaries from two spouses, for example. One spouse may be 
offered health insurance at work, the other one can get a 
stipend to help make that a family plan rather than just an 
individual plan.
    Mr. Walberg. The beauty of more flexibility, creativity, 
and options that go on.
    Ms. Turner. Yes. And also to recognize the competition out 
there.
    Mr. Walberg. Right.
    Ms. Turner. Plans are competing, companies are competing, 
everybody is trying to do the best job to get the best value.
    Mr. Walberg. You mentioned in your testimony a study by Kev 
Coleman, a former analyst at the insurance information website 
HealthPocket. In his study, what type of plans did Mr. Coleman 
find that AHPs were offering? And let me ask this as well, are 
essential benefits covered in the plans that he discussed?
    Ms. Turner. The study by Kev Coleman showed that these AHP 
plans are offering benefits comparable to the largest employers 
that have negotiated these benefits for years and that they are 
not discriminating against patients with preexisting 
conditions. Many of these employers may have someone on their 
staff, maybe even a family member, that has a preexisting 
condition.
    Mr. Walberg. Or themselves.
    Ms. Turner. Yes. And so they want those benefits and they 
are really pressing the market to figure out how do you do that 
in a price that they can afford to purchase that coverage.
    Mr. Walberg. Thank you. I yield back.
    Chairman Scott. Thank you. Mr. Morelle from New York.
    Mr. Morelle. Yes, thank you, Mr. Chairman, for holding this 
very important hearing, and thank you to the panelists for 
being here and for answering the questions, particularly Mr. 
Riedy. Thank you for your courage in being here and sharing 
your story with us.
    Back in 1993 I co-sponsored and helped pass a law in New 
York that provided community rating for all New Yorkers that 
were in small business, the individual marketplace, as well as 
ending the practice of--well, beginning the practice of having 
protections for preexisting conditions. Something I am very 
proud of. So I took it as an article of faith that everywhere 
was like that, and then I became chair of the insurance 
committee about 15 years ago and during the time of the 
implementation of the ACA. I learned a great deal about what 
happens in the rest of the country. So this is very, very 
helpful in terms of understanding all of this.
    The first comment I would just make around coverage is we 
use the word coverage as though it means the same thing to 
everyone. The truth is, I remember as insurance chair, when 
people would come to me and say I had out-of-network benefits 
and it said out of network services were covered, yet it only 
covered 25 percent of my bill and I have this huge balance that 
I have to pay. You learn quickly that coverage doesn't mean 
coverage, that it means different things to different people. 
And cost avoidance is a big part of trying to provide coverage.
    But I wanted to just talk a little bit about the definition 
if I might. My daughter, Lauren, was diagnosed with triple 
negative breast cancer just a few years ago and she passed away 
about 17 months ago. I had never heard of triple negative 
breast cancer, but it is part of the diagnosis. And when you 
begin to look at treatment, you look at genetic panels and what 
you can learn from the genome. And it turned out that in 
Lauren's case while it wasn't passed on genetically, she did 
have a mutation in one of her genes.
    And so perhaps Ms. Corlette might be able to answer this, 
is there a concern that genetic predispositions will be defined 
more broadly as preexisting conditions in the way that some 
insurers view this or some people view it?
    Ms. Corlette. Well, there is a Federal law that was enacted 
before the ACA, the acronym, is GINA, the Genetic Information 
Nondiscrimination Act, that does prohibit insurance companies 
from discriminating against people based purely on genetic 
information.
    Mr. Morelle. And does that include then predispositions 
based on other things that would affect chronic conditions?
    Ms. Corlette. With respect to the preexisting conditions 
that we are talking about today, most insurance companies 
require you actually be diagnosed with a specific condition 
before it would be underwritten. Although I will say for short-
term plans, you know, they will look at your medical history 
and even if you were not given a formal diagnosis they might 
say that you had the condition, you know, the cancer cell was 
in your body before you enrolled and might disenroll you 
because of that.
    Mr. Morelle. Yes, because it is certainly hard to tell when 
it manifests itself and--
    Ms. Corlette. Exactly.
    Mr. Morelle [continuing]. when it actually becomes disease 
state. Also to my colleague, Mr. Courtney, mentioned as he 
showed the pamphlet, in the description had obesity, which that 
would be a preexisting condition presumably?
    Ms. Corlette. Yes. Yes.
    Mr. Morelle. And that would be the case even if you had not 
exhibited or manifested any disease because of that condition, 
is that correct?
    Ms. Corlette. Correct.
    Mr. Morelle. And obviously that is not genetic in nature, 
but that is effectively underwriting which could lead 
ultimately to preexisting conditions?
    Ms. Corlette. Right.
    Mr. Morelle. And I did want to just mention coverage too 
because when you have community rating, and we don't even do an 
adjustment in New York for community rating, it is all the 
same. So that you have as you get older--as I am finding you 
have more medical conditions as you get older. Young, healthy 
people, obviously we want in the pools, and adverse selection 
often leads people to avoid coverage until they have a reason 
for it. But the larger the pool and the more that you 
essentially flatten the experience of the larger pool is really 
what insurance is all about. The avoidance of that with some of 
the plans that have either high deductibles or that in a sense 
sequesters the better risks is actually what causes the case of 
either uninsured or high premiums. Is that not right?
    Ms. Corlette. That is exactly right. You said it better 
than I ever could.
    Mr. Morelle. And that is my real concern here, Mr. 
Chairman, members, is that as we talk about coverage, as I 
said, it is not all the same, and you could be left with 
significant balance billing for procedures where you thought 
you had coverage, and this notion of sort of shifting risk to 
other groups of less well people is essentially what I 
understand the Administration policy to be.
    Would you care to comment on that?
    Ms. Corlette. Yes. I mean with respect to association 
health plans, short-term plans, it is really about shifting the 
risk from young, healthy people to older and sicker people. So, 
it is sort of rearranging the deck chairs without addressing 
some of the underlying issues about cost. Which is they are 
real. We have a cost problem in this country. But just creating 
new winners and losers is I don't believe the answer.
    Mr. Morelle. Very good. Thank you. I yield back my time.
    Chairman Scott. Thank you. The gentleman from Alabama, Mr. 
Byrne.
    Mr. Byrne. Thank you, Mr. Chairman. I appreciate you 
holding this hearing.
    Ms. Turner, I am sort of just the facts type person, and I 
didn't get here until I was elected in 2013, so I am having to 
go back and sort of make sure I understand how we got where we 
are.
    When Congress passed Medicaid and Medicare, embedded in 
those programs was protection for people with preexisting 
conditions. I think that is correct. And when they created some 
other public programs, like TRICARE, they did the same thing. 
And then I think I was told that when HIPAA was passed in 1996, 
bipartisan bill, that we provided similar protection to people 
that are in-group plans, employer-provided plans. Have I got 
that right?
    Ms. Turner. Absolutely.
    Mr. Byrne. So I asked my staff to go back and look at the 
most recent numbers we could get, which was 2017. Forty-nine 
percent of the people in America are under an employer provided 
plan. When you add up all the people on the public plans, like 
Medicare and Medicaid, it is another 36 percent. So if I am 
doing my math right, since at least 1996, 85 percent of the 
people in America have had protections on preexisting 
conditions as a result of bipartisan acts of the U.S. Congress. 
Have I got that right?
    Ms. Turner. Yes.
    Mr. Byrne. OK. So that is another 15 percent and every one 
of those people in the 15 percent is important. I do not think 
any of us can gain say that, but sometimes we start talking 
about this, we forget that 85 percent of the people in America 
have got the protections that they need. So when we look at 
what happened in the Affordable Care Act--and I was not here 
when it was passed, so I was not a part of that debate--I have 
actually talked to people in my district who were in that 15 
percent. In fact, the very moment I was running for Congress is 
when those notices went out to people, who were told by the 
President of the United States that if they liked their health 
care plan they could keep it, they actually came up to me at a 
high school football game where I am passing out pamphlets, and 
showed me the notice they got from their insurance company that 
said we are canceling your health care plan. But here is our 
new one for you, and the cost was a multiple of what they were 
used to paying. And these people, while they were working 
people, they could not afford it. And ACA did not provide those 
type people with the sort of help they need financially to do 
it. So I have met those people across my district who now are 
uninsured because they can't pay their premiums.
    So let me just ask you, are there individuals, including 
individuals with preexisting conditions, that the ACA might 
have actually materially hurt?
    Ms. Turner. There are people who say that the coverage that 
they had before, even in the individual market, was better than 
the coverage they have now because it is more affordable. Some 
of them are facing deductibles of $10,000. And they say that I 
might as well not be insured because I can't meet that 
deductible.
    Another friend who had a liver transplant needs significant 
anti rejection medications and he says that a health savings 
account actually is beneficial to him because he knows what his 
out-of-pockets costs are going to be, he can pay that on a tax 
free basis, and his catastrophic coverage actually was much 
better because it allowed him to wee any doctor without so many 
restrictions.
    So, yes, there are people who preferred the coverage they 
had before, but I absolutely agree with you that preserving the 
preexisting condition protections is vital. And also not 
frightening people to think that they might lose it. I had a 
friend write to me saying that she was worried if the court 
case were to be successful that she would lose her preexisting 
condition protection and Medicare. And there is no reason for 
her to be so frightened.
    Mr. Byrne. No, there have been scare tactics out there like 
that. It is unfortunate because even on Medicare you have got 
older people and they have got lots of other things that they 
are thinking about, and we don't need to be scaring them, we 
need to be helping them.
    I have talked to many Members of Congress since I have been 
here. I have not met a single person in either party that 
doesn't want to protect people that have preexisting 
conditions. The question is how do you do it? What is the 
smartest way to do it? What is the most cost-effective way to 
do it? But when you get up and tell the people of the United 
States, if you like your healthcare plan, you can keep it, and 
then they get a notice that says no, I can't keep it, and the 
substitute is something I can't afford, you have materially 
hurt people in the United States. And everybody in this 
Congress, Democrat or Republican, we should all want to work 
together to make sure we help those people, because those are 
the good, hardworking people in America who depend on us to 
look after them.
    I appreciate your testimony. And I yield back the balance 
of my time.
    Chairman Scott. Thank you. The gentleman from California, 
Mr. Harder.
    Mr. Harder. Thank you, Mr. Chairman, and thank you to all 
of our witnesses for being here on such an important issue.
    Protecting folks with preexisting conditions is the entire 
reason I ran for this office. On my district in the California 
Central Valley this is my highest priority. Over 100,000 people 
in our district have health insurance only thanks to the 
Affordable Care Act. And those 100,000 folks were at risk of 
losing their coverage if the Affordable Care Act was repealed, 
and it was only after that vote a year and a half ago, almost 2 
years ago now, that I decided to get on in and see what I could 
do to fix that. And I think the reality is, is in a district 
like ours, where nearly 50 percent of our individuals have a 
condition that qualifies as a preexisting condition, this 
affects every single human being, every person in my community 
has a loved one who would be affected if the Affordable Care 
Act was threatened. Every single person, including me. In my 
case it is my little brother David. He was born 10 weeks 
premature, less than 2 pounds when he was first born, spent the 
first 2 years of his life in and out of a hospital, came out 
with a healthcare bill 104 pages long. And because of that he 
would be without insurance until he is 65 and on Medicare if we 
did not have protections for folks with preexisting conditions.
    And, Mr. Riedy, I really was so touched to hear your story. 
I think your voice gives power to millions of folks. I think we 
need to be humanizing these statistics. And so when folks think 
about what life is really like with a preexisting condition, 
they are thinking about people like my little brother, they are 
thinking about people like you, and all of us, because the 
reality is each one of us has a loved one who would be affected 
by these changes.
    And in your testimony you mentioned you had a cost of 
medical treatment $450,000 in 2018. Is that correct?
    Mr. Riedy. That is correct. That was just for the cost of 
medicines.
    Mr. Harder. One year, one year. And I think that, you know, 
in a district like ours, where we have a high rate of 
unemployment, we have a lot of folks that have real financial 
stress, there is a lot of folks that could be impacted by that.
    I am very interested, based on your own experiences, Mr. 
Riedy, how do the annual lifetime caps affect patients with 
costly medical conditions?
    Mr. Riedy. So with the passing of the ACA and the ban on 
lifetime caps, it has--and annual caps, it has allowed me 
personally, and others with preexisting conditions, to have a 
better frame of mind to be able to focus on our health versus 
if I go and see this doctor, or I get sick and I have to go 
into the hospital or I have to have some costly procedure, what 
is that going to do, how close is that going to get me toward 
that cap, and then potentially if I get to that cap, what 
happens then. So not only are you dealing with having to fight 
to stay alive or have to focus on treatment regimens that take 
3 to 4 hours a day in my case, you are also then focusing on 
the mental aspect of this also and trying to focus on if I get 
to this point am I going to have to make decisions basically 
that affect my care and my family's wellbeing versus 
essentially dying or not being able to access that care which 
then will shorten my life and others.
    Mr. Harder. What do you would believe would happen to 
people like yourself and the people you advocate for if the 
Affordable Care Act was undermined by the court in the Texas 
case?
    Mr. Riedy. You know, I worry if the court case is upheld, I 
worry that insurers will institute lifetime and annual caps 
again, that they will reinstitute the ability potentially for 
me to be denied coverage simply because I was born with a 
genetic disease and have a preexisting condition, and that I 
will lose the comfort knowing that no matter where I work or 
what happens to me that I can continue to be there for my 
family and focus on what needs to happen versus--to take care 
of myself versus what the cost of that medicine is that my 
doctor prescribed, or not even being able to go and see 
especially--the highly specialized care that I need to take 
care of my lungs and by body.
    Mr. Harder. Thank you for your powerful testimony and for 
putting a face on what this really looks like. I think there 
are so many of us affected, nearly 50 percent of my district, 
and of many others. And we talk about millions of Americans, we 
talk about the 100,000 people in our community that would be 
without insurance if the Affordable Care Act were repealed and 
if it were undermined by some of these efforts of litigation, 
but I think the most important thing that we need to be 
considering is really understanding the day to day lives of 
folks who are living through these challenges today and 
understanding how those lives would be so different if we had 
not passed the Affordable Care Act.
    Thank you so much for your powerful testimony today.
    Mr. Chairman, I yield back my time.
    Chairman Scott. Thank you. The gentleman from Georgia, Mr. 
Allen.
    Mr. Allen. Thank you, Mr. Chairman, and thank you for 
having this hearing today. It is very enlightening. Obviously, 
you know, I have some preexisting conditions, I have family 
members that have preexisting conditions, so we are all very, 
very interested in how we go about making healthcare available 
to all Americans.
    The question and the big debate is how do we pay for it. 
Obviously we have the resources in this country to provide--
and, Mr. Riedy, thank you for your testimony--to provide 
excellent medical care and hopefully a cure. We are all praying 
for cures for Alzheimer's, for all types of issues that we are 
dealing with in this country. And we are spending a lot of 
money to try to find cures for those things. But in the 
meantime, what is the best way to provide health care?
    Now, the question is, does the government do it more 
efficiently than the private sector? And I think, Ms. Turner, 
is there any information, like for every dollar of taxes that 
we pay, how much of that dollar gets back to take care of a 
patient under the Affordable Care Act.
    Ms. Turner. I have not seen--well, there is a medical loss 
ratio, so we know that based upon the company's size that 
either 20 or 15 percent of the money can only go to 
administration, the rest has to go to medical care.
    Mr. Allen. Right.
    Ms. Turner. But I do think that it is important to look at 
the approach that the American Health Care Act that the House 
passed in 2017 took. It actually dedicated specific resources 
to help people that have high health care costs--$123 billion. 
A similar amount in a Senate bill that didn't make it through, 
but that would have separately subsidized and provided extra 
money for the people that have chronic healthcare conditions. 
The ACA put them in the same market with everybody else and 
that raised prices to the point that you are driving the 
healthy people out. So there is a lot of evidence that if you 
separately subsidize those with the highest cost and the 
highest risks, you can lower premiums for other, get more 
people covered, and then focus on providing the coordinated 
care that people with multiple health conditions actually need.
    Mr. Allen. Exactly. And, you know, right now I think that 
Health and Human Services has a budget of about $1.2 trillion, 
the largest single piece of the Federal budget, and, you know, 
out of that $1.2 trillion I am interested--of course my 
background is the business world--and I am interested in 
exactly how much of that $1.2 trillion is taking care of Mr. 
Riedy. And I think we need to look at that and then we need to 
look at what would it cost if we returned health care back to 
the health professionals and we were able to, through programs 
deal directly in our health providers, deal directly with our 
health providers rather than got through HHS and these other 
agencies that have these huge budgets.
    And, frankly, as I understand it, our health care in this 
country is much more expensive than compared to other 
industrialized countries in the world. Is that correct?
    Ms. Turner. That is correct. We are also the research 
center for the planet. The great majority of new prescription 
drugs, like the one that Mr. Riedy says is so valuable, are 
developed in the United States. We pay a disproportionate share 
both for the research and for the drugs, and also new medical 
technologies and other innovations.
    Mr. Allen. Right. So we are subsidizing health care across 
the world? Would that be correct?
    Ms. Turner. Well--
    Mr. Allen. How can we afford--we are $21 trillion in debt 
and, of course, you know, I do not know who is going to be 
paying my health care bills, but it is probably going to be one 
of my grandchildren or great-grandchildren, but we have got to 
solve this problem. We have the ability to take care--you know, 
I tell folks back home, we have got plenty of money to take 
care of folks, particularly those with preexisting conditions, 
I just think it is all in Washington, and we need to get it out 
in our States and our communities and make healthcare 
affordable.
    And with that I yield back.
    Chairman Scott. Thank you. Dr. Schrier.
    Dr. Schrier. Thank you, Mr. Chairman, and thank you to our 
witnesses today.
    I just want to say that I can't think of a more important 
topic to bring up today as our first hearing because one thing 
that I have heard about from all of my constituents is 
healthcare, and that is their No. 1 issue. And I sit here today 
not just as a Member of Congress, but also as a pediatrician, a 
doctor who is taking care of patients for the last two decades, 
and as a person with Type I diabetes. And so I really share a 
kinship with people in my district and in this country with 
preexisting conditions.
    So, I can report to you first hand that my patients are 
worried. They are worried that either they or their loved ones 
will not be covered if they have a preexisting condition or 
that they will be priced out of the market, as we have been 
hearing a lot about, and they are worried even in these popular 
employer-based health plans that their prices are also going up 
and their deductibles are skyrocketing.
    And so, you know, I came here to bring down costs and 
protect my patients and make sure that no family goes bankrupt 
because of medical expenses. And so, I hear about these 
solutions, like these short-term health plans. And you can 
imagine, as a pediatrician, that preventative care, essential 
health benefits, and mental health care, well woman care, these 
are all critical, and that is why they are essential health 
benefits.
    And I just want to clarify, Dr. Gupta, you have not had to 
communicate anything for a while, so I thought I would give you 
a chance. Can you just be--very clearly, are those services 
covered under these short-term health plans?
    Dr. Gupta. Thank you for that questions. Certainly they do 
not have to be covered. I mean the idea of motherhood being a 
sort of preexisting condition comes back after a decade again. 
The idea well woman, well child preventative care, knowing that 
we are going through an opioid epidemic today that we are 
having a lot of adverse childhood experiences and a whole 
generation is going to have to deal with as children and grow 
up. And that will be the future of this country. None of those 
things will be covered. Neither will be things like 
vaccinations. Those will not be covered. Mental health 
screenings, domestic violence screening will not be covered 
potentially. Of course mammograms, pap smears, none of those 
things have to be covered.
    Dr. Schrier. Thank you. You are speaking my language. And 
then just also to clarify, do patients know that these are not 
covered when they buy these short-term less expensive health 
plans that are proposed to be a solution to skyrocketing 
medical costs?
    Dr. Gupta. That will certainly be in fine print, as was 
mentioned today. And I am sure that most of us are not going to 
realize until you get sick and then that will be the time that 
most patients will realize that they were not covered for those 
services.
    Dr. Schrier. And to read that fine print you would need 
glasses like these.
    OK, my next question is that I have seen in my own 
practice, you know, the classic story, a girl with a terrible 
rash whose mom brought her in and it had been weeks that they 
had been trying to deal with this at home with all the powders 
and creams and everything they possibly could. And when she 
finally came to me it was a disaster, she needed antibiotics 
and steroid creams. But she delayed care because of the cost of 
care. She knew that because of her deductible it would cost her 
a lot to come in and that she may as well try everything in the 
kitchen cabinet at home.
    And so when I think about these short-term plans and that 
preventative care would not be covered--and I know how 
important those well child checks are--I just would like your 
opinion as to how many families will show up for that 
critically important primary care and preventative care if 
those are not provided for free.
    Dr. Gupta. We know from studies that compared to the 
insured population, uninsured individuals tend to delay their 
care. That leads to lack of those preventative services, 
ultimately poor outcomes, and more expensive outcomes, not just 
from health but also for financial reasons. And what we saw 
after ACA was the amount of uninsured childbearing women went 
down from about 20 percent to 13 percent. So additional 5.5 
million women got the care for things like maternity care. So 
those things are happening now that we will again walk back 
several steps and we will end up the emergency rooms with 
uncompensated care, at doctors' offices, while mostly in 
primary care, where we already have shortages of tremendous 
amount across the field. And those offices will once again be 
seeing a lot of patients who do not have insurance and, like 
you have, I often provide care for those without regard to the 
level of insurance they have.
    Dr. Schrier. Thank you, Dr. Gupta. And I yield back my 
time.
    Chairman Scott. Thank you. The Gentleman from Kentucky, Mr. 
Comer.
    Mr. Comer. Thank you, Mr. Chairman. And I would like to 
talk about healthcare in Kentucky. Obamacare, or the Affordable 
Care Act, however you want to pronounce it, in Kentucky was a 
great deal for people who got free health care via Medicaid. 
But it was a terrible deal for working Kentuckians who actually 
have to pay for their health care premiums. In Kentucky, 30 
percent of the State is on Medicaid. That is pretty much free 
health care. But the rest of Kentuckians in the State who are 
working, struggling to pay health care premiums, they do not 
have a very favorable opinion of the Affordable Care Act.
    Ms. Turner, I would like to ask you a question addressing 
the rising cost of health care, including premiums, 
deductibles, and out-of-pocket expenses. This is a huge concern 
for most Americans and it should be a concern for the 
democrats. What options do you think policymakers should 
consider when discussing how to lower the cost of health 
insurance and provide a variety of affordable options, 
especially for employers and workers?
    Ms. Turner. I described in my testimony a plan that I have 
helped to develop with a number of my policy colleagues, called 
the health care choices plan. And it basically recognizes the 
States have a lot more knowledge about their individual markets 
and the needs of their citizens, and it is very difficult for 
Washington to finely tune legislation enough to let them do 
what they need to do. So we have recommended formula grants to 
the States to let them figure out how do they make sure that 
existing populations are supported. But they have the 
flexibility to be able to get coverage not only for the 
continued coverage for them, but to make sure that new people 
can come into the market and afford coverage, and quality 
coverage.
    Mr. Comer. Mm-hmm. If there is one thing that I think all 
of us would agree on in both parties is that everyone should be 
protected with preexisting conditions in health care. No one 
should be denied coverage based on their medical history. Given 
that, and given current law, Ms. Turner, are any reforms needed 
to ensure that individuals with preexisting conditions have 
access to health coverage?
    Ms. Turner. One of the things that several States have done 
is request waivers to use some of the ACA money to more heavily 
subsidize those with high risks to make sure they can have 
access to care and coverage. I talked about Janet in my 
testimony who is now under ACA coverage in Colorado, but it is 
inferior coverage to the high-risk pool coverage she had 
before. States can fine-tune that, high-risk pools, invisible 
high-risk pools, reinsurance, to make sure those with the 
highest healthcare costs are covered. Devote money to them, you 
cannot only lower premiums for other but increase access for 
the healthy people we need to come into the market.
    Mr. Comer. In Kentucky, prior to passage of the Affordable 
Care Act, we had a high-risk pool, called Kentucky Access, and 
it was successful. But it was eliminated with the passage of 
the Affordable Care Act.
    Just to followup on that question, would you say there are 
other factors that affect consumer access to health care?
    Ms. Turner. Well, that is one of the reasons I believe 
these short-term limited duration plans are so important, 
because somebody may be, you know, in a bridge between--they 
have just graduated from college, they had coverage then, they 
don't have a job yet, they are older than 26. Somebody who is 
near Medicare eligibility needs bridge coverage, somebody who 
is starting a new business needs to--there are people who need 
these temporary plans and that is another option.
    Indiana had a great plan called the Health Indiana Plan, a 
State-based plan. An account to make sure that people could get 
the preventative care they need, but they also had major 
medical coverage. There are a lot of other options, but I think 
that the State creativity, working with healthcare providers, 
is really valuable.
    Mr. Comer. Thank you very much. Mr. Chairman, I yield back.
    Chairman Scott. Thank you. The Gentlelady from Illinois, 
Ms. Underwood.
    Ms. Underwood. So, we have just heard from our colleagues, 
Ms. Foxx and Mr. Comer, who mentioned how they support 
protections for individuals with preexisting conditions. 
However, congressional Republicans and the Trump Administration 
have had relentless--attacked protections passed by the 
Affordable Care Act. And so many of my colleagues here voted 
more than 70 times to repeal parts of the ACA. Moreover, last 
August the Administration finalized a rule that expands short-
term limited duration insurance, commonly known as junk plans. 
Junk plans do not have to comply with key Federal laws that 
protect patients and they can pose a serious risk to patients 
with preexisting conditions.
    Earlier today, along with Representative DeSaulnier, my 
Democratic colleagues and I introduced my first legislation in 
Congress to overturn the Trump Administration's rule expanding 
junk plans. Insurers should never have the option to 
discriminate against patients with preexisting conditions.
    So, Dr. Gupta, can you tell us more about why they are 
called junk plans and what kinds of consumer protections can 
junk plans exclude?
    Dr. Gupta. Well, thank you. I think part of the--what is 
important is not just the preexisting conditions protections, 
but also the affordability as well as the accessibility in 
terms of essential health benefits. So, none of this is covered 
or required to be covered in these short-term plans, or also as 
you termed them, junk plans. There are States that have taken a 
proactive lead, like California, Oregon, New York, New Jersey, 
who have actually worked to prohibit those plans in the way 
that they are today. And, obviously, other States will have to 
do more. Because what that does basically is sells people out 
there who may not be suspecting a bill of goods that they have 
no idea about. So, unless they read the fine print, when in so 
many ways stepping back to about a decade ago, and people when 
they find that they need the help that they need, they are not 
going to be able to get it because the preventative care, as 
well as a number of those essential health benefits, including 
maternity care, will not be covered.
    For example, prior to the ACA only 11 States required 
maternity care in individual plans, and only 13 percent of the 
insurers' individual plans covered maternity care.
    Ms. Underwood. That is why patients' groups, including the 
March of Dimes, the American Cancer Society, the American Heart 
Association are opposing the junk plan rule.
    Mr. Chairman, at this time I would like to ask unanimous 
consent to enter a letter from those patient groups opposing 
the rule into the record.
    Chairman Scott. Without objection.
    Ms. Underwood. Thank you. Dr. Gupta, what effects can junk 
plans have on patient access to care, particularly patients 
with preexisting conditions?
    Dr. Gupta. Ultimately it will cost their lives or their 
bank account, or both. The challenge with that is when somebody 
needs the help, early help to be able to detect cancer, like 
breast cancer, colon cancer, or be immunized for important 
conditions that could be communicable--we are seeing outbreaks 
of measles, for example--those could get worse. And people we 
diagnose much later in their stage and then they will not be 
able to be covered by those because of the preexisting 
conditions clause missing, and therefore they will be--again, 
will lose life and it will cost us a lot more. It is just the 
most--the least effective way of administering healthcare.
    Ms. Underwood. In fact, an analysis by the Los Angeles 
Times found that not a single group, not a single group 
representing patients, physicians, nurses, or hospitals 
supports the junk plan rule. And 90 percent of the comments 
from the public on this rule were either critical or opposed 
the rule outright.
    So, Ms. Corlette, are you concerned that public opinion on 
junk plans was disregarded when the rule was written? What 
needs to be done to ensure the needs of patients with 
preexisting conditions are truly represented in this debate?
    Ms. Corlette. Well, certainly with respect to the comments 
on the short-term plan rule, it would suggest that the 
Administration's mind was made up about what they wanted to do 
before the rule was finalized and the public comments did not 
make much of a difference there.
    I do think there is a real concern that a lot of people who 
are healthy before they sign up for these plans, have an 
unexpected medical event, and are left on the hook for 
thousands, tens of thousands of dollars in unpaid medical 
bills.
    Of course, for those who have preexisting conditions, they 
couldn't buy these plans even if they wanted to. They would 
have to buy in the ACA market, but the ACA market will be more 
expensive. CBO has said it will be about 3 percent surcharge on 
premiums as a result of these plans.
    Ms. Underwood. Thank you, Mr. Chairman, and thank you to 
all the witnesses for being here.
    I yield back.
    Chairman Scott. OK, thank you. The gentleman from Texas, 
Mr. Wright.
    Mr. Wright. Thank you, Mr. Chairman.
    Chairman Scott. Thank you.
    Mr. Wright. I want to thank all of you all for being here 
today. Mr. Riedy, God bless you and your family. I think it 
speaks to your character and your determination that you are 
even here today participating. So thank you.
    Ms. Turner, I think you would agree that, you know, we 
should never have laws on the books that are unconstitutional, 
and when the Supreme Court made its decision on the ACA, Chief 
Justice Roberts, of course, his opinion was that it was 
Constitutional by virtue of being a tax. I thought that was a 
very slender thread, but that is the opinion. If you take that 
thread away, then it follows that the law is unconstitutional. 
And as a Texas Congressman I am terribly proud of my State 
attorney general for leading the effort in this lawsuit. 
Because, again, if the reason it was determined that it was 
unconstitutional was that it is a tax and you take that away, 
doesn't it follow that it is no longer Constitutional?
    What is your opinion, Ms. Turner?
    Ms. Turner. Well, this is going to go through the Courts to 
determine whether or not the fact that the Congress did in fact 
zero out the tax penalty for individual insurance does 
invalidate the law, but I think the important thing is that we 
have seen since then all of the efforts by you and others in 
Congress to repeal and replace the law. So I think we have seen 
that there are definitely places that improvement is needed and 
to try to find a way to replace the coverage that people are 
relying on, but to allow markets to work better so that healthy 
people are not being driven out.
    Mr. Wright. Yes, ma'am. And the key word there is replace. 
I think the assumption that if ACA had not passed or if it had 
been ruled unconstitutional, that nothing would have happened, 
that there would have been no improvements in healthcare, is a 
completely false narrative, just as if it were to go away 
tomorrow we are not going to revert back to the status quo of 
2009 because there was always, even in 2009--I don't know if 
you were part of crafting or helping either side on that, I was 
here then. I was the chief of staff for the ranking Republican 
on Energy and Commerce Committee. I sat in some of those 
meetings, saw the markup. There was always Republican 
alternatives that included coverage for preexisting conditions, 
even going back to 2009.
    So this narrative that we keep hearing that Republicans are 
somehow opposed to that or don't want it, is patently and 
demonstrably false, and it needs to stop because it is not 
true.
    My last question is this, it has to do with the idea that 
is being advanced by the other side, and we heard it earlier 
today, about Medicare for all. Well, Medicare-for-all is 
Medicare for none. Would you agree with that? Can you speak to 
it?
    Ms. Turner. It certainly would not be the Medicare that 
seniors know now.
    Mr. Wright. If we go to socialized medicine, where it is 
all run by the government, then doesn't Medicare cease to 
exist?
    Ms. Turner. As I mentioned in my testimony, my colleague, 
Doug Badger, has done some research looking at these cross 
subsidies from the employer-based system with 170-some billion 
people participating. They pay a higher rate to physicians and 
hospitals that allow Medicare and Medicaid to save taxpayer 
money and to pay a lower rate. But if those reimbursement rates 
went across the board, 40 percent of physicians and hospitals 
would find that they couldn't even keep their doors open.
    So we need the employer-based system.
    Mr. Wright. Absolutely.
    Ms. Turner. And the private sector, not only for its 
innovation but for the money that it provides to support 
existing public programs.
    Mr. Wright. Right. Thank you very much. Thank you, Mr. 
Chairman.
    Chairman Scott. Thank you. The gentlelady from Georgia, Ms. 
McBath.
    Ms. McBath. Thank you, Mr. Chairman. And I do want to thank 
you for holding this hearing today. And I would like to thank 
the witnesses who are here to discuss the importance of 
protecting access to healthcare for all Americans.
    This is an issue that is deeply personal to me. I myself, 
like millions of Americans, live with a preexisting condition. 
As a two-time breast cancer survivor, I understand what it is 
like to have your life turned upside down by this very 
diagnosis. I was first diagnosed with stage 1 breast cancer in 
2010. And after completing treatment my cancer returned again 
in 2012. My cancer was detected because of a routine mammogram. 
I will never forget the way that I felt when I first heard my 
doctor say the words stage 1 breast cancer.
    For each of the two cancer diagnoses that I have received I 
underwent surgery through a procedure called a lumpectomy to 
remove the remaining cancer. And I received radiation treatment 
and drugs thereafter. I did it all while raising my family and 
working full-time. And I can tell you I was terrified. Despite 
being lucky and having good health insurance through my job, I 
was still worried about my financial security. I was concerned 
about making it to radiation treatments, sometimes every single 
day for weeks, and then back to work and then back home to 
raise my son, Jordan. It was exhausting, both physically and 
emotionally. But I had to do it, just like millions of 
Americans out there who share a similar story to mine.
    I truly do not know what I would have done or what would 
have happened if I had lost that health insurance coverage. And 
I am happy to say today that I am cancer-free. But, Mr. 
Chairman, not everyone is as lucky as I am. And I am worried 
for Americans and for those in my State of Georgia who might 
not detect their cancer or chronic health condition early on, 
when it is most easily treatable.
    The Centers for Disease Control and Prevention states that 
preventing diseases is critical to helping Americans live 
longer, healthier lives and keeping healthcare costs down. It 
is so important that Americans have access to the preventive 
services that are an integral part of the Affordable Care Act. 
These include screenings for certain cancers, screenings for 
Type 2 diabetes, and other critical health services. And I am 
worried about their future and their financial security.
    We here in congress, we have a responsibility to protect 
people. That is what we must do.
    Ms. Corlette, could you talk a little bit more about how 
the ACA protects patients and has created greater access to 
preventive services, like breast cancer screenings or high 
blood pressure screenings? Particularly how the ACA cost-
sharing provisions impacts and also ensures Americans have 
access to these types of services?
    Ms. Corlette. Absolutely. Thank you for the question. So, 
the Affordable Care Act requires insurers both in the 
individual market and in the employer market to cover a set of 
evidence-based preventive services without any cost-sharing for 
the enrollee. And that includes many of the services that you 
mentioned in your Statement, but also vaccines, contraception, 
tobacco cessation counseling, a range of services that not only 
prevent disease but help keep people healthy over the long-
term. Those services can also help diagnose issues that people 
have and help get them early treatment in order to get a better 
outcome at the end of the day.
    So, if the ACA were overturned or this decision in the 
district court in Texas is upheld, insurance companies would no 
longer have to provide that protection and people would face 
cost-sharing. And we know, and Dr. Gupta mentioned, that if 
people do face co-insurance or cost-sharing for those services, 
they tend not to get them or they delay them.
    Ms. McBath. Thank you. And my followup question is how 
could the Texas litigation impact American's access and 
affordability of these lifesaving services?
    Ms. Corlette. If the Texas decision is upheld millions of 
people will lose their insurance, about 17 million in the first 
year and up to 32 million by 2026. It is well documented that 
people without insurance delay, forego care. Before the ACA 
about 22,000 people died each year simply for not having 
insurance.
    For people with job-based coverage, they lose access to 
critical protections, like the lifetime and annual limits that 
Mr. Riedy discussed, the protection against excessive out-of-
pocket costs--ACA has a cap on that every year--as well as the 
preventive services and essential health benefits that you 
mentioned.
    Ms. McBath. Thank you. Thank you.
    Chairman Scott. The gentleman from South Dakota, Mr. 
Johnson.
    Mr. Johnson. Thank you, Mr. Chairman. Mr. Riedy, you spoke 
so eloquently about your family. Are any members of your family 
with you here today?
    Mr. Riedy. Yes, my father and mother and my wife are 
sitting behind me.
    Mr. Johnson. I kind of suspected that was the case. And, of 
course, you were facing us during your testimony, and so I just 
want to take a minute to tell you, because you couldn't know, 
their faces were filled with an incredible pride during your 
testimony. And, of course, you should feel good because you did 
a good job. You should also feel very good because they clearly 
are very proud of you.
    Mr. Riedy. Thank you.
    Mr. Johnson. Almost every member of the Committee that has 
spoken has done a nice job raising their voice in support of 
protections for people with preexisting conditions. Of course, 
I want to raise my voice to echo theirs. Critically important 
and I am glad we are having this conversation.
    I also like how the panelists all in different ways have 
called forth this important connection between employer-based 
health coverage and some of these preexisting condition issues.
    I was a little concerned, Ms. Turner, in your testimony you 
talked about how 65 percent of employers offered health 
insurance in 2001, you mentioned that number had come down in 
recent years. I assume affordability is a key driver. Are there 
others that are maybe not as intuitive to me?
    Ms. Turner. It is primarily affordability, and also because 
there are fewer carriers now offering coverage in the 
individual and small group markets. But one point that I think 
is so important about when employers do offer coverage, they 
have an incentive. They were offering coverage for preventive 
care before the ACA because they know it works. It is so much 
better to detect breast cancer at stage one than at stage four. 
So helping their employees stay healthy, making sure that they 
have access to preventive care, and being able to access the 
diagnostics that they need early on for their coverage. So I 
think that employer coverage brings particular value to our 
health sector without the mandates. They know this is important 
because it works.
    Mr. Johnson. So I just want to make sure that I can square 
the math here. The number of employers how are offering this 
type of benefit has gone down. A number of people have talked 
about the how the number of people receiving that type of 
benefit has gone up. Is that just macRoeconomic trends, large 
employers getting larger, and smaller businesses being the ones 
more likely to drop this type of benefit?
    Ms. Turner. I could look further into the research, but 
based upon everything I have read since the ACA, the cost of 
compliance in providing health coverage to employees is 
significant. So it is not only the cost of the coverage, but 
also compliance. And if a company is hitting near that 50 
employee threshold where the employer mandate triggers, they 
often will sometimes put workers on part-time, they will scale 
back their staff, to avoid having to trigger that employer 
mandate.
    So I think in some ways the employer mandate has actually 
worked against smaller employers offering coverage. And without 
it and with more flexibility I think we would see more 
participation.
    Mr. Johnson. This is an area of concern, and I suspect it 
is an area of concern for everybody on the Committee, 
regardless of party or region, because so many people, from Mr. 
Riedy to others, have talked about how well I had an employer-
based coverage, or I had job-based coverage. It is clearly a 
really important leg of this stool about how we make sure 
Americans are covered, how they can get the healthcare service 
they need.
    Are there things that we can do to strengthen employer-
based coverage? Because the trends you are talking about we 
should not feel good about in this country right now.
    Ms. Turner. What employers want most is flexibility to meet 
the needs of their employees without having to charge so much 
that health insurance eats up their employees' pay increases. 
So they are looking for affordability, they want more 
competitors, they want more options rather than having to meet 
such specific benefit requirements to really allow them to--
there may be other benefits that their employees value more 
than the essential health benefits list. So giving them more 
flexibility to meet their employee needs and keep costs down 
would increase participation.
    Mr. Johnson. Thank you very much. Well, Mr. Chairman, I 
just think this is a critical area for further study by the 
Committee. And, of course, I appreciate the time and I yield 
back.
    Chairman Scott. Thank you. Gentlelady from Connecticut, Ms. 
Hayes.
    Ms. Hayes. Thank you, Mr. Chairman, and thank you to all of 
the people who have come to share your testimony today. I 
really appreciate it on this very critical issue.
    Before I begin my questioning, I cannot underscore what my 
colleague, Ms. Underwood, said before she left, that while we 
hear everyone talk about protecting preexisting conditions our 
Republican colleagues voted more than 70 times to either roll 
back or repeal the Affordable Care Act, which really undergirds 
those protections.
    My questions this afternoon are for Dr. Gupta. In your 
testimony you talked about how the Affordable Care Act has 
improved the lives of millions of Americans, particularly women 
and children. And this was strengthened by those 10 essential 
health benefits that we all know about. Of those benefits, we 
have mental health and substance abuse treatment. Do you think 
that those are important benefits to protect?
    Dr. Gupta. Thank you for the question. Absolutely. I think 
one of the things we have yet to appreciate is the increase in 
tens of millions of people across this country who are 
suffering now from substance use disorder that may not have 
been the case even a decade ago. And a lot of the--when we look 
at the data, access issues, fear of being fired from their 
employer are some of the reasons that people do not seek care. 
So, it is a big stigma issue as well. For women, things like 
breastfeeding supplies, very simple things like a breast pump 
and not having to cost share on those things, are another one 
of those things that we should be working to protect, in 
addition to the maternity care benefits.
    Ms. Hayes. Thank you. Because I know we are talking a lot 
about preexisting conditions and our conversations are centered 
around genetic conditions or health-related diseases. So I am 
happy to hear that you recognize that addiction is also 
something that really further exasperates those conditions. It 
is undeniable that we are in a crisis with opioid addiction. In 
my own home State of Connecticut we have had significant 
increases. Over the past 6 years our numbers have tripled. In 
2017 my State marked a grim milestone of over 1,000 opioid-
related deaths. And in June of last year we were on track to 
surpass that. In the district that I represent three of the top 
ten towns are the highest opioid deaths.
    This is no stranger to me. I grew up in a family that 
struggled with addiction. In my own hometown 45 people died 
last year as a result of opioid-related deaths.
    Does the current opioid crisis make the need for mental 
health and substance use disorder coverage more important?
    Dr. Gupta. Absolutely. And, again, when we talk about 
employer-based coverage, here is the real problem on the 
ground. When I am seeing patients at a charity clinic who have 
substance use disorders they are unable to have gainful 
employment because of their addiction issues, which need to be 
treated in the first place. And that allows them to actually 
gain and have meaningful employment to begin with. So, I think 
it is very important for us to make sure that we have systems 
in place that allow the treatment and access to treatment for, 
you know, one of the biggest crises to face our generation 
today.
    Ms. Hayes. I appreciate you viewing this as a crisis and 
talking about treatment and coverage and healthcare, as opposed 
to a criminal action, as we heard last week from our friends 
over at Purdue Pharma, who talked about people who were 
addicted to opioids as, ``reckless criminals''.
    During your time at the Department of Health and Human 
Services in Virginia you led several important initiatives to 
address the opioid crisis in your State. Could you tell us what 
impact the Affordable Care Act had on access to treatment for 
substance abuse disorder and families, not just the individual, 
but I am the daughter of an addict, so how families were 
impacted by the protections provided by the Affordable Care 
Act.
    Dr. Gupta. Absolutely. In a State like West Virginia, which 
is not any different from a number of States that are having to 
deal with this crisis firsthand on the ground, we found that 
having access to treatment, being able to expand those 
treatments and make that available--a part of which was 
Medicaid expansion. West Virginia was one of the first States 
that--we worked very hard to ensure Medicaid expansion. Allowed 
a number of people to enter the treatment spectrum and we found 
that the access to mental health treatment, access to the 
medications, being able to be able to transport it and being 
paid for being able to transport for treatment, are some of 
those factors that help us remove the stigma of addiction and 
help us move forward in that. And it is very important that we 
provide--reduce all the barriers to treatment when it comes to 
a stigmatizing disease, such as addiction.
    Ms. Hayes. Thank you for your time. Mr. Chair, I yield 
back.
    Chairman Scott. Thank you. The gentleman from Pennsylvania, 
Mr. Meuser.
    Mr. Meuser. Thank you, Mr. Chairman, thank you Dr. Foxx, 
thank you to all testifying today.
    Ms. Turner, I am Dan Meuser, Pennsylvania's 9th 
congressional district. And I appreciate you taking the time 
here, and all of you. I believe every American should have 
access to high-quality, affordable health care, regardless of 
health status, including preexisting conditions. Given current 
law, are there any reforms that you would feel, Ms. Turner, 
that are needed to ensure that individuals with preexisting 
conditions do in fact continue to have access to health care 
coverage?
    Ms. Turner. I don't think there is one particular answer, 
Congressman. I think they need a myriad of options. I think 
giving States the option to recreate their high-risk pools 
would be helpful to make sure people who have preexisting 
conditions have a place to go if their health insurance becomes 
so expensive. As Senator Bryce Reeves' constituent described, 
$4,000 a month premiums or deductibles that are $10,000. They 
need other options. And I think States also could do things 
like the Healthy Indiana Program, an account-based plan that 
allows people resources to access primary care, but knowing 
that they have major medical coverage as well.
    But I think the crucial issue is addressing cost and giving 
people more options, more flexibility, and giving companies the 
option to provide coverage that is more attractive, that 
healthy people want to get in the market, so they are not 
staying out of the market, putting more and more people who 
have high health costs in the market and driving up premiums 
for everyone.
    Mr. Meuser. That is encouraging to hear. Now that we have 
established that we are in agreement on preexisting conditions, 
I would like to ask you your thoughts on the Affordable Care 
Act's effect on association health plans. In Pennsylvania, for 
instance, the Pennsylvania Farm Bureau had 12,000 members in an 
association health plan and it worked very well, along with 
other organizations. The Trump administration has issued a 
final rule allowing for the use of AHPs, however, many 
Governors, democrat Governors it so happens to be, across the 
country, including in Pennsylvania, are blocking the formation 
of AHPs.
    Can you speak to the importance of the efforts to allow 
AHPs and maybe comment technically as to why these efforts 
would be blocked?
    Ms. Turner. So far association health plans are available 
in 13 States, about two-dozen plans in all. And some States are 
considering invalidating or blocking these plans, which they 
have full right to do, just as they are short-term limited 
duration plans. But what they are doing is foreclosing options 
for people who are otherwise likely to simply be uninsured. If 
they don't have an affordable option their family cannot only 
face bankruptcy, but not having access to that good high 
quality care that private insurance brings.
    So it is unfortunate if States take a view that because, I 
don't know, the Trump administration rules that therefore they 
should be opposed, because they are providing options for 
people who are desperate for coverage.
    Mr. Meuser. Yes. OK. That is unfortunate. Thank you.
    Medicare Advantage. I have people coming into my office and 
throughout my district talking about, speaking about how 
terrific Medicare Advantage programs are, how relatively 
affordable they are versus other Medicare plans. And, as a 
matter of fact, the Medicare Advantage plans have decreased, 
reduced in cost by 6 percent this past year when other plans on 
average are going up 12 percent. So would you say that this is 
a successful example of private sector innovation? And could 
you offer any other insight on the effectiveness of Medicare 
Advantage.
    Ms. Turner. They were created, as you know, in 2003 through 
the Medicare Modernization Act and went into effect in 2006. 
And there was no real significant promotion of Medicare 
Advantage plans. It was offered as an option for private 
coverage to seniors, so they didn't have to be in something of 
a Swiss cheese of a program with a fee-for-service Medicare. 
They have been hugely popular. I think almost half of seniors 
now have individually selected on their own, without any 
mandates, Medicare Advantage plans. And these plans compete 
fiercely for seniors. They have to cover a basic level--not 
basic but very generous level of benefits and many of the plans 
offer much more comprehensive coverage than people can get in 
traditional Medicare. And many of them also incorporate 
prescription drug coverage.
    I think that seniors see it is crucially important because 
it also provides an environment for coordinated care, rather 
than going from doctor to doctor and fee-for-service 
traditional medicine Medicare. Maybe getting the same 
prescription with different names from physicians and then 
winding up in the hospital with drug toxicity, they have 
somebody looking out for them and being able to really 
coordinate and help manage their care.
    Very, very beneficial. And, of course, these are private 
plans within Medicare.
    Mr. Meuser. OK. Do I have any more time, Mr. Chairman?
    Chairman Scott. Not really.
    Mr. Meuser. OK. Well, I yield the remainder of my time.
    Chairman Scott. Thank you. I appreciate it. The gentlelady 
from Florida, Secretary Shalala.
    Ms. Shalala. Thank you very much, Mr. Chairman. I don't 
want to add, a lot of my colleagues have asked the same 
questions I would have asked.
    I do want to point out that Medicare Advantage gets a lot 
more money than traditional Medicare and therefore it is 
expected to provide a lot more benefits. It also pays 
dramatically for the kind of marketing that the private plans 
want to do. So, we are paying with taxpayer money for Medicare 
Advantage significantly. And most analysis has shown that we 
are overpaying for Medicare Advantage given the benefits that 
are provided.
    I do have a couple of questions though. I want to ask Ms. 
Corlette, we focused here on preexisting conditions, but would 
coverage for preexisting conditions actually work very well if 
we didn't have the other consumer protections? I mean we could 
all agree on preexisting conditions, but if you don't take the 
caps off, preexisting conditions are limited. And Mr. Riedy 
would have a very difficult time with CF.
    Ms. Corlette. Yes, absolutely. And, in fact, New York is a 
great example of a State that had a number of preexisting 
condition protections before the ACA was passed, but they had a 
very expensive individual market because they didn't have the 
other provisions that the ACA included, such as the subsidies 
to support people up to 400 percent of the Federal poverty 
level to buy insurance, as well as the individual mandate 
penalty.
    So, it is important to note that the ACA included not just 
preexisting condition protections, but a number of provisions 
that were more holistically designed to try to make coverage 
accessible and affordable for people. All of those, of course, 
have been at least preliminarily ruled to be invalid by the 
Texas court.
    Ms. Shalala. Thank you very much. And, Dr. Gupta, yesterday 
the President said that he was going to invest some money in 
HIV drugs. And I want to ask you about that, because it is very 
important in my district. We have the highest incidence per 
capita, and therefore I am very supportive of any investment in 
HIV. But those investments don't work without a comprehensive 
plan around them. And could you talk a little about that?
    Dr. Gupta. Absolutely. Thank you for that question. So as 
opposed to the 1980's, where we had a challenge of diagnosing 
HIV, figuring out how to treat it, and make it a condition. 
People were dying on the streets because of that. Now, we have 
a challenge of finding those individuals who may not know that 
they have HIV. So, screening--that is why we have moved to what 
we call universal screening and you really have to opt out of 
it, otherwise most of us need to get screened. The idea behind 
that is most people that may have HIV do not know they have 
HIV. And if they can be caught early and put in treatment it 
becomes a chronic condition you can live with. You don't have 
to die because of the complications now.
    When you start to remove the other legs of that stool, in 
terms of essential health benefits, then obviously those people 
are going to not want to be screened for the HIV. The diagnosis 
will not occur and then they will not be treated. As a result 
they will continue to transmit the disease and we will result 
in having more cases than fewer cases and our conquest to 
eliminate HIV from the United States will not happen anytime 
soon.
    Ms. Shalala. Thank you very much. And, Ms. Turner, if I 
could ask a quick question about the flexibility you are 
talking about. Would it be OK with you if a State was willing 
to develop a plan that continued caps, had covered preexisting 
conditions but continued caps? Because, you know, private 
insurance is a mixed bag in this country. I have got half a 
million people in my own district that are covered by private 
insurance, but some of it is underinsurance because it has high 
deductibles. And how much flexibility would you give the States 
so that we would really recognize it as insurance and 
comprehensive insurance? Would you continue some of these 
consumer protections that we are talking about?
    Ms. Turner. I think that it is important to recognize that 
State officials have to answer to the same constituents when 
they are making changes, health policy changes that Federal 
officials do. And so that needs to be a conversation with their 
voters, and to make sure that they are answering the 
constituents' needs for affordable, quality coverage, but doing 
so in a way that may give them more flexibility.
    Some States in Medicaid, as you know, and I am sure under 
your Secretaryship some of the waivers were approved to give 
States like Oregon, for example, a lot of flexibility within 
its Medicaid program and what benefits were covered. So I think 
States can better fine-tune the mandates than a Washington 
mandate. The Affordable Care Act has been changed already 
either by administrative order or by acts of Congress 70 times. 
So, I think needing to give the States the flexibility to 
answer the needs of their constituents and know that their 
constituents actually can be better heard at the State level, I 
think is important.
    Ms. Shalala. I should point out that the Oregon simply took 
the same package. It actually didn't mix up the package of 
benefits very much. I am asking you specifically about caps and 
about preexisting conditions. Do you think that States ought to 
be able and the other consumer protections ought to be able to 
waive those consumer protections and would it actually be 
comprehensive insurance at the end of the day if they had 
flexibility on those consumer protections including preexisting 
conditions?
    Ms. Turner. We see with States that are saying they don't 
want short-term limited duration plans, California and offered 
in their States, Pennsylvania, restrictions on association 
health plans. If States feel that those consumer protections 
are important, I believe that they will keep them and if they 
feel that there needs to be some flexibility along with 
consumer awareness and transparency, then I think States should 
have the option of figuring out what works best for their 
constituents.
    Ms. Shalala. So you wouldn't favor ERISA protections for--
and overrule States--using ERISA protections?
    Ms. Turner. I think that right now we basically have under 
HIPAA we have the protections that allow people to go from 
their employer plan--
    Ms. Shalala. Right.
    Ms. Turner [continuing]. to another employer plan and 
maintain that continuity of coverage and not be discriminated 
against. So those protections are already on the books and 
because of the community rating within employer plans, people 
are protected to make sure that their health status does not 
affect their premium costs.
    Ms. Shalala. I yield.
    Chairman Scott. Thank you. Gentleman from Wisconsin, Mr. 
Grothman.
    Mr. Grothman. OK, thank you. Moving now, Ms. Turner, and 
one more time, I think you've answered this, but it seems to me 
the Republicans, the Democrats are all favored, in favor of 
protecting coverage for preexisting conditions. Can you just 
one more time tell us, we have said it so many times but not as 
many times as the ads we have saying otherwise running against 
us in election. Under current law, are workers with preexisting 
conditions allowed to be charged more, denied coverage based on 
their condition?
    Ms. Turner. I'm sorry, repeat.
    Mr. Grothman. Under current law, are people allowed to be 
charged more, denied coverage based on their conditions?
    Ms. Turner. No, Congressman.
    Mr. Grothman. OK. So that is the current law right now. 
Good. Now I will give you some other general questions. I am 
from Wisconsin. In 2018 last year, Scott Walker worked with the 
Trump administration and CMS to approve a 1332 State innovation 
waiver, which caused our premiums to drop. Are you familiar 
with that situation?
    Ms. Turner. Yes, I am, sir.
    Mr. Grothman. Could you talk about what we did in 
Wisconsin?
    Ms. Turner. I mentioned actually in my testimony some of 
them, some of the impact that these plans have had and of 
course I can't find this chart when I'm looking for it. But 
they have been able to basically repurpose existing ACA money 
to help increase access to coverage or to improve access to 
coverage for people with chronic conditions, preexisting 
conditions, and therefore lower premiums in their general 
market.
    So a number of States have--Wisconsin is often taking the 
lead in health policy innovations and waivers and I think that 
this is an important one to move forward with.
    Mr. Grothman. And at least I am told that premiums dropped 
a little over 4 percent, is that your?
    Ms. Turner. Premiums dropped and enrollment increased as a 
direct consequence.
    Mr. Grothman. Good. And in the past, before this type of 
thing, we saw incredible increases in premiums and open 
enrollment falling. Is that--we saw that in Wisconsin. Is that 
your nationwide?
    Ms. Turner. Because the premiums were so much higher--
    Mr. Grothman. Right. As the premiums--a lot of people just 
throw in the towel.
    Ms. Turner. People just can't afford it and they also--we 
talk about a high deductible. The deductibles are so high and 
the ACA plans that if people are not eligible for cost-sharing 
reduction subsidies they basically say they might as well not 
be insured because they can't afford to pay the first $10,000 
every year out of pocket before coverage kicks in.
    Mr. Grothman. I am glad you mentioned association plans. My 
experience with health care in general, when you take a group, 
not a Statewide group because it is hard for the State to 
duplicate it, but when you take a business with a 1,000 
employees or something, a lot of those innovative businesses 
were doing a very good job. One of the things they did is 
employer-based clinics which saved tremendous amount of money 
for a variety of reasons. Is there any way that you can see 
that sort of thing can be duplicated through something like 
Obamacare or is this the type of innovation that is why we want 
the vast majority of Americans hopefully still insured through 
their employer?
    Ms. Turner. Well, the Affordable Care Act did allow some 
innovation incentives for people to do--not association health 
plans, I'm blanking on the name of the creative coordinated 
care plans within Medicare. And because the rules that were 
written around the Affordable Care Act were so strict, even 
plans like the Mayo Clinic and Cleveland Clinic and others that 
had been--Geisinger, that had been very successful in managed, 
coordinated care, couldn't make it work.
    So I do think that flexibility is really important and 
trusting employers--some employers have said for example that 
they feel it is worth flying their employee to another State 
and family members to get care at a center of excellence, of 
cardiac care, cancer care. So they really do try to innovate to 
get the best value and the best quality care.
    Mr. Grothman. It is another thing. I did mention employer-
based clinics but these centers of value, flying people to 
other States because an employer has the ability to hire 
somebody and do a good job. Now I know there are a lot of 
people who always feel that setting up another big Federal 
bureaucracy is going to work after this seems to have failed 
like 120,000 times in a row, but what you are telling me is a 
way that the private insurance plans and for individual 
companies and hopefully to be duplicated by associated plans, 
they are able to find ways to reduce premiums and reduce costs 
that really as a practical matter are not being duplicated with 
a government bureaucracy.
    Ms. Turner. That is correct.
    Mr. Grothman. Thank you.
    Chairman Scott. Thank you. The gentleman from Michigan, Mr. 
Levin.
    Mr. Levin. Thank you, Mr. Chairman. I would like to dig in 
a little more deeply to the Texas v. United States case and I 
have a question to start for Ms. Corlette. In a departure from 
long standing precedent of defending Federal law against 
constitutional challenges, the Trump Administration's 
Department of Justice filed a brief last year requesting that 
the court strike down several provisions of the ACA in the 
Texas case. Among the provisions that the administration argues 
should be overturned include guaranteed issue, community 
rating, discrimination based on health status and preexisting 
conditions exclusions.
    Last week, President Trump told the New York Times that he 
is optimistic that the ongoing Texas lawsuit will terminate the 
Affordable Care Act. Would you say that the Justice 
Department's decision not to defend the ACA is consistent with 
Republican promises to protect patients with preexisting 
conditions?
    Ms. Corlette. Well, I would say that the Justice 
Department's provision--position if it prevails would strike 
down the protections that the ACA provides for people with 
preexisting conditions. So no, it's not consistent.
    Mr. Levin. And how does this, his statement reflect the 
Administration's approach to this issue?
    Ms. Corlette. I--
    Mr. Levin. Of preexisting conditions that we are here to 
talk about.
    Ms. Corlette. I have, yes. I have a little trouble divining 
exactly what the Administration's position is given that there 
do seem to be differences between what President Trump has said 
and what the Justice Department position is so I am not sure I 
can comment.
    Mr. Levin. And what they are actually doing. So you pointed 
out in your testimony that Republicans never have come up with 
a proposal to replace the ACA yet they continue with their 
efforts to unravel it, the most recent example being the Texas 
lawsuit.
    During the last Congress when we were debating the 
Republican bill to repeal the ACA, Republicans put proposed 
segmenting the population and dumping sick patients into high 
risk pools. The CBO had the following assessment of this 
proposal: ``Less healthy people would face extremely high 
premium. Over time it would become more difficult for less 
healthy people, including people with preexisting medical 
conditions in those States to purchase insurance because their 
premiums would continue to increase rapidly.''
    One of our witnesses, Ms. Turner, has put forth a similar 
proposal this morning or early this afternoon. Ms. Corlette, 
how do risk--high-risk pools stack up as an alternative to the 
coverage provided through the ACA?
    Ms. Corlette. Sure. Well, we have a history of high-risk 
pools. Before the ACA there were about 35 States that had high-
risk pools and they varied. They were different, but I can tell 
you that for people who were in high-risk pools, the premiums 
could be as much as two times the standard rate. They often had 
preexisting condition exclusions so the condition that got you 
denied coverage in the individual market you didn't get covered 
in the high-risk pool for up to a year. You had annual and 
lifetime limits quite often, high deductibles and often many of 
these high-risk pools limited enrollment. Even still, they 
operated at a loss so they needed to be subsidized by the 
government.
    Mr. Levin. OK, thank you. I have a question for Mr. Riedy. 
In your testimony, you described the enormous cost of your 
medical treatments, totaling nearly $450,000 last year. Prior 
to the ACA plans in the both the individual and employer market 
were permitted to impose annual and lifetime limits on care and 
many of them did, including more than 90 percent of the plans 
in the individual market. You better than most people can speak 
to the real-world impact of these limits. Based on your 
personal experience, how do annual or lifetime limits on 
coverage impact patients with high-cost conditions?
    Mr. Riedy. Thank you for the question. Annual and lifetime 
caps for me personally if they were allowed to exist again 
would cause a severe financial burden on my family. Not just 
from the cost of having to pay for the care that I receive, but 
also from the impact that if I do reach that cap, what happens 
next? Do I have to pay for them out of pocket? And if I do then 
those costs can be unmanageable.
    As you mentioned my care last year just for the medicines 
was $450,0000. That is a lot of money to take and so the 
impacts of those caps, having them now provide peace of mind. 
They also know that I can continue to receive the highly 
specialized care and that I have access to that coverage that 
allows me to get that care.
    Mr. Levin. I can't thank you enough for coming and sharing 
your story with us and with the American people. And just in a 
note of solidarity, I like the gentlewoman from Georgia who 
spoke earlier, I am a two-time cancer survivor but also Mary 
and I have four kids. The two oldest both have Crohn's disease 
and have for 14 years and we would have gone bankrupt multiple 
times over just trying to pay for their medications if they 
weren't covered and because of, you know, caps. Lifetime, we 
would have blown by lifetime caps already so I really thank you 
for sharing your story. I yield back, Mr. Chairman.
    Chairman Scott. Thank you. The gentleman from Kansas, Mr. 
Watkins.
    Mr. Watkins. Thank you, Mr. Chairman. My question is for 
Ms. Turner. Ma'am, I represent Kansas and in Kansas, Kansans 
with preexisting conditions face a number of challenges and 
hardships. And I am glad that a lot of Democrats and 
Republicans agree that Americans with preexisting conditions 
should and have been for years been protected, for decades 
actually. And so in that of course even before the Affordable 
Care Act so unfortunately since its passage, the ACA continues 
to be problematic. Premiums continue to rise and the answer I 
believe is not to double down on ACA but and seek a one size 
fits all government-run health care regime.
    Therefore, Ms. Turner, since the passage of Obamacare, can 
you speak to the lack of actual affordability for the vast 
majority of Americans? Also the rate of continued premium 
increases because of the law?
    Ms. Turner. Premiums in the exchange markets have about 
doubled on average since the law went into--since the exchanges 
took effect in 2014. That is much higher than in the regular 
market and certainly before that. And a consequence of that is 
that it's driving more and more healthy people out of the 
market.
    The ACA as you know forces young people to pay a 
disproportionally high amount for their coverage because of the 
three-to-one age rating in the exchanges. And so we are 
losing--if young people are not eligible for their parent's 
coverage and trying to afford premiums on their own, they're 
paying a disproportionate amount for people who are older and 
sicker and therefore they're dropping out as well. So I think 
it is crucial if we really want to increase access to health 
coverage that we figure out a way to get cost down and to 
attract the healthy people into the market.
    Senator Reeve's constituent in Virginia, he doesn't want to 
drop out of health insurance market but he can't afford $4,000 
a month for premiums and having no choices of coverage. Some 
people need more choices. They need to be able to have more 
flexibility with benefits to protect their family and they need 
some of these bridge plans like association health plans and 
short-term limited duration plans.
    Mr. Watkins. Thank you. I also want to touch on our 
increasingly strong economy propelled by comprehensive tax cuts 
and regulatory reform. In fact, CNBC recently noted that 
January job reports just last week payroll surged by 304,000 
smashing estimates. Thanks to recent pro-growth Federal policy 
changes, more and more Americans are finally finding good 
paying jobs. Many of these jobs offer generous employer 
sponsored healthcare. So all the employers simply know that 
they can--that they have to be competitive to attract good HR. 
So, Ms. Turner, can a strong jobs market spurred by pro-growth 
policies lead to increased coverage rates nationally for 
employees--employers with preexisting coverage? What are some 
policies that can continue fueling work force participation?
    Ms. Turner. You are absolutely right that employees highly 
value the, their workplace coverage and the workplace--the H.R. 
departments, especially for big companies work tirelessly to 
try to negotiate the best benefits, the best drug formulary and 
the access to the highest quality hospitals for their employees 
to attract them so that they won't go to a competitor. And 
there are how many, 2 million jobs, two and a half million jobs 
that aren't filled now and employers can't even find the 
workers to fill them. So being able to offer attractive, 
affordable health coverage with the flexibility to meet the 
needs of their workers, and having providers that are competing 
for that business to get, to offer those lower costs, higher 
value plans, I think is really a crucial part of a thriving 
economy.
    Mr. Watkins. Thank you, Ms. Turner. I yield back, Mr. 
Chairman.
    Chairman Scott. Thank you. The gentleman from Maryland, Mr. 
Trone.
    Mr. Trone. I thank you, Mr. Chairman. Ms. Corlette, 30 
years ago I started my business with my wife and two little 
girls and I know firsthand starting a business can be scary 
without the fear you are going to be able to afford healthcare 
for yourself and your family. You mentioned prior to the ACA 
people were often tied to jobs they'd have otherwise left but 
simply because they needed to maintain healthcare, access to 
affordable health insurance. Could you elaborate on what the 
ACA's protections for patients with preexisting conditions has 
meant for entrepreneurship, startups, small business creation?
    Ms. Corlette. Sure. So, before the ACA, if you were leaving 
a job-based plan, you were required to maintain what was called 
COBRA coverage which was continuation coverage, but you had to 
pay the full premium. And for most people that was 
unaffordable. And so, people often had a lapse in coverage and 
then if you had a preexisting condition it was almost 
impossible to find an individual market plan to cover you and 
your family.
    With the ACA you can now if you have a business idea or 
want to go out on your own and start a consultancy or invent 
something, you can do so without having to worry that your 
preexisting condition would cause you to be denied or have a 
preexisting condition imposed on your--exclusion imposed on 
your policy.
    Mr. Trone. So, Dr. Gupta, the opioid epidemic as you spoke 
about and you are from West Virginia. My district borders 
western Maryland so we are right there together in the heart of 
the opioid epidemic on I-81. I lost my nephew, age 24, to a 
fentanyl overdose a couple years ago and so many folks in my 
district have been adversely affected by this tragedy.
    With the ACA, we closed a lot of gaps in coverage, 
especially in the area of behavioral health. And I think that 
is so important and it is all part and parcel of this disaster 
substance disorders. If the ACA was gone, what do you see as 
the human toll?
    Dr. Gupta. Thank you for that question. Certainly we 
understand, you know, States with border counties populations 
don't treat those as States, they are one community within 
those areas. So, it's very important for people to be able to 
move across and not have to worry about what is the State 
regulation in this State and the State regulation in that 
State? ACA allows that consistency to happen State to State. 
The mental health protections as well as the ability to get the 
help that need and people would have so many other challenges 
ongoing at the same time. ACA really allows that to happen and 
I think that is the most important piece as we are combatting 
this opioid crisis is to be able to not have any extra barriers 
in terms of coverage and accessibility to care. As the good 
treatments are existing and more come up, we have got to be 
able to have the access to provide tens of millions of people 
who are suffering and dying actually, tens of thousands per 
year to be able to save them and get them back to work.
    Mr. Trone. As we put together legislation on opioids to 
address that, what do you see as a couple key points that 
should be in that to address the mental health connectivity 
which was so crucial and part and parcel of this at all times?
    Dr. Gupta. I think it is very important for us to go back 
to see what we did with HIV. We realized HIV was much more of a 
social determinant aspect of this in the 80's and we put 
together, you know, the Ryan White Care Act for example, that 
not just took care of you as an individual, your medication, 
but you--looked at your house and your access and all those 
things.
    So I think it is very important when you look at this 
crisis, we are looking at housing, we are looking at access, 
daycare, all of those tools that surround somebody who is 
suffering from addiction to be able to be provided so that they 
can get into treatment and then they can have a successful, 
fair chance of recovery and back into employment.
    So, it is a lot more than just pills or just counseling. 
There is a societal response that we must have to this crisis 
in order to address it and I think that is the part that we can 
do more, not less.
    Mr. Trone. OK, thank you. I yield the balance of my time.
    Chairman Scott. Thank you. The gentleman from Indiana, Mr. 
Fulcher.
    Mr. Fulcher. Thank you, Mr. Chairman, and panelists.
    Chairman Scott. Excuse me, Idaho. Excuse me.
    Mr. Fulcher. Yes, it is a common mistake. Thank you. 
Panelists take heart. I think the end is near. It is coming 
close here OK and please forgive the lack of attendance by some 
of us on the front end. I, for one, am still struggling with 
the multiple committees as the same time. And so please know 
that wasn't rudeness.
    My question and I will probably address this to Ms. Turner 
because I know some of this has been covered and I am going to 
shorten things up because Mr. Watkins hit part of that. But in 
our State of Idaho, 2012 I think it was we--I believe we were 
the only State with Republican leadership in the House, the 
Senate, and the Governor's office that embraced the State-based 
exchange. And I was in the Senate leadership role at that time 
and in hindsight it just hasn't worked out well for us.
    Our insurance premiums across the board have averaged 
somewhere between a 15 and a 27 percent per year increase. And 
so as we speak right now, in our State, there is a lot of 
things on the table. It is--that have been--that are being 
discussed right now. Alternatives to try to figure out a better 
path and I would just like to get your counsel, your input, on 
some of those things and I will just list a few. But the 
expansion of HSAs, medical memberships, medishare, charity 
care. The expansion of insurance procurement across State lines 
which in our State we can't do, high-risk pool reform. Those 
types of things which are--they are more market-based and given 
our history and our struggle with the status quo that there is, 
your thoughts, your counsel on that type of an approach.
    Ms. Turner. States do talk about the difficulty of figuring 
out how to address the needs of their State but it's even more 
than the State. It's sometimes at a county level. You have 
rural counties who have very different problems then Cincinnati 
and Canton and Cleveland. They've really need to have the 
resources and the flexibility to meet the needs of those areas.
    And I want to really reinforce what Dr. Gupta was saying 
about the social determinants of health. We put so much money 
just into health care when people may actually need other kinds 
of supports to make their lives work better. And I believe that 
Ohio is one of the States that has--is implementing work 
requirements as well for Medicaid. And people who work with 
these communities say that is a valuable thing to make sure 
that people have someplace to go once they get through 
rehabilitation treatment, to have a job, something to give 
stability to their life. Help them with housing.
    If States had more flexibility and I believe the Trump 
Administration is working to do that. As we have said before, 
Congress had repeatedly voted for money to dedicate money to 
high-risk pools. Many States that were doing--the States that 
were doing high-risk pools in the past were doing it all with 
State money. With the ACA there is new money to put on the 
table to make those risk pools work better so that you can 
provide dedicated resources for them and more comprehensive 
care for chronic conditions.
    So care management for those high end patients, being able 
to have more flexibility, to provide the kinds of benefits 
structures that people actually want to purchase to protect 
themselves and their families I think are really crucial. And 
hopefully we can work with Ohio and other States in trying to 
think about what some of those waiver options might be to 
work--make it work better for your State.
    Mr. Fulcher. Thank you. Mr. Chairman, a quick followup and 
I will--thank you. Ms. Turner, in a few words because I am 
going to yield my time here in just a second. But that makes 
sense. But when it comes right down to it, should we be 
focusing on solutions that come out of this room and out of 
this building and out of the building next door or should be 
focusing on more market--enabling market-based solutions to try 
to improve our situation?
    Ms. Turner. We see in Medicare advantage for example that 
market-based solutions to provide more comprehensive care and I 
believe it is really based upon a formula very close to what 
traditional Medicare pays for Medicare advantage, can give 
incentives to begin to find the same kinds of cost efficiencies 
in the health sector that we see at other sectors of the 
economy.
    When you have so much of the time of health care providers 
and administrators focused on following Washington's rules 
rather than figuring out what is best for the patient, what is 
best for our State that it really takes away time and energy 
from solving the problem.
    Mr. Fulcher. Thank you, panelists, Ms. Turner. Mr. 
Chairman, I yield back.
    Chairman Scott. Thank you. Gentlelady from Michigan, Ms. 
Stevens.
    Mr. Stevens. I would like to take a minute to thank our 
panelists today. Ms. Corlette, your expertise and knowledge 
was--is so welcome and we thank you for taking the time.
    Mr. Riedy, thank you for your courage and your words of 
wisdom and sharing your personal story. It was a delight to be 
in this room with your family who was looking at you with very 
proud eyes. You are one of the reasons why the ACA was so 
critical and critical to every American taxpayer and American 
worker and I admire you from the bottom of my heart.
    And, Ms. Turner, I want to thank you for your eloquence and 
answering a lot of questions today. And, Dr. Gupta, thank you 
for being here.
    As we are here examining threats to workers with 
preexisting conditions, this topic could not be more critical 
as our Ranking Member Foxx indicated. We have a healthy economy 
and the health of our taxpayers and our workers is paramount.
    And Dr. Gupta, I would like to take my questions to you and 
your expertise which we are delighted to have in the room 
today. In your testimony, you discussed the issue of high-risk 
pregnancy and delivery and how women prior to the enactment of 
the ACA often found that, you know, they reached their policy's 
cap. They would reach their policy's cap on the amount of care 
provided. They would find themselves exposed financially, 
unsupported in the workplace, and generally pushed to a brink. 
And so, I would like to ask you, what is the cost of high-risk 
pregnancy and how likely are women to run up against these caps 
in the absence of the ACA protections.
    Dr. Gupta. Certainly, thank you for that question. March of 
Dimes certainly is doing a lot of work around this because we 
know that maternal mortality and morbidity amongst the 49 
developed countries in the world, we are number 49. We are 
actually three times mortality of the next country in line 
which is UK. So we are really in a bad shape right now. For--we 
have women dying every single day.
    The cost can be tremendous and when we look at the cost 
really it is not just human lives lost, but we are talking 
about one complicated pregnancy can cause that woman to lose 
potentially her absolutely full annual lifetime limits. So, she 
may not have coverage for the rest of the year and have to take 
care of not just the baby but the rest of the family.
    Same way we go back to the severe prematurity. One simple 
birth with severe prematurity can land a child, an infant for 
multiple months in a neonatal ICU. So, when the baby returns 
home for the first time when there should be a cause for 
celebration, it would then be a cause that the baby could meet 
his or hers lifetime limits on care and not be insurable until 
Medicare. And that's just a terrible thing to think about and 
those are the challenges we are dealing with where we need to 
be making progress to work in those maternity care deserts.
    We have a third of the counties in this country or 1,000 
counties, 5 million women, 150,000 babies that are being born 
what no obstetric care. And so that we are actually, you know, 
talking about walking backwards.
    Mr. Stevens. Well, and not only is this a cost to the 
mother and the family, it is a cost to the employer as we, you 
know, are talking about the workforce and our economy writ 
large. And, Dr. Gupta, as you know, the Affordable Care Act 
requires insurers to cover preventative health services without 
cost-sharing and these obviously include family planning, well 
women visits, screenings for domestic violence and other 
crucial health services.
    And I, just to back this out a minute, I would love for you 
to just reflect on how pregnant women and other new members--
mothers, excuse me, utilize these services and what impact 
would overturning these provisions maybe through the Texas 
litigation have on these women?
    Dr. Gupta. So first of all, just the idea of preconception 
care to be healthy in order to get pregnant is very important. 
That would not happen. Then within prenatal care the notion of 
having things like vitamin--folic acid and vitamins, which we 
think is very basic, we recommend that all across the globe, 
yet we can have women that can have, deliver and cause real 
harm to the babies developing because of neural tube defects 
and other things that are not being provided. Throughout the 
prenatal care we know the amount of visits that happen with the 
doctor's office and this following a standard of care leads to 
better delivery, better care of not just the mother but also 
the baby as a result, getting the family dyad back together, 
the mom and baby. None of that would be possible if we were to 
remove that.
    And obviously one of the things that used to happen was the 
only time you could get into Medicaid was if you were--if you 
got pregnant and then it would be removed the coverage right 
after. Now we have 60 days, up to 60 days coverage post-partum. 
When we are dealing with challenges of post-partum depression, 
suicide, post-partum hemorrhage, hypertension, eclampsia, heart 
conditions, it's very critical for us to build on that coverage 
post-partum up to a year because of the increasing maternal 
mortality that is happening.
    This is still the most dangerous place for a woman to have 
birth in the developed world. And we need to be working again 
not at removing that but actually developing more steps but at 
this time, removal of ACA provisions will cost women and their 
children not only just their jobs but potentially their lives.
    Mr. Stevens. Yes. Well, Dr. Gupta, while you don't share my 
gender, I appreciate you sharing the stories of women and 
mothers and making that at the forefront of our minds today. 
Thank you.
    Chairman Scott. Thank you. The gentlelady from Nevada, Ms. 
Lee.
    Mr. Lee. Thank you. I wanted to first thank all of the 
panelists today for your testimony and answering the questions. 
And, Mr. Riedy, I wanted to speak directly to you. First of 
all, CF has had a place in my family. My husband lost a cousin 
about 30 years ago before groundbreaking technologies and 
treatments were available. And more importantly, my sister, 
Mary Lester, is a respiratory therapist at Keck Medical Center 
at USC and dealing with adult cystic fibrosis. So, through her 
years, through my years and I have experienced alongside her 
many of the struggles that patients like you go through. So, 
thank you very much for being here and your testimony.
    I wanted to ask, in your testimony you pointed out that 
you're fortunate to have comprehensive health coverage through 
your wife's employer. If your wife were to change jobs, choose 
to start a small business or possibly take time off for 
education, you might end up in a situation where you would have 
to change this coverage. And I wanted to know from you how do 
the Affordable Care Acts protections for patients with 
preexisting conditions provide peace of mind that you would 
never be without coverage?
    Mr. Riedy. Thank you for that question. Knowing that my 
wife or I could switch employers and still be adequately 
covered, it gives us peace of mind that allows us to be 
flexible and explore new opportunities potentially that before 
the ACA may not have existed. And without the ACA, you know, 
there is always that fear that leaving a job if I went to 
another one that I could still be denied insurance because of 
my preexisting condition or if my wife changed jobs, you know, 
would they deny me coverage because of my preexisting 
condition.
    Mr. Lee. And thank you. And to followup on that, what 
impact would an adverse decision in Texas case have on your 
wife's ability to change jobs?
    Mr. Riedy. Well, if the ACA was--if the ruling stands, my 
wife would have less of the opportunity to explore new 
opportunities. She is a teacher so she is at a great place 
right now but if she had to--if she wanted to do something 
other than teach or switch employers there's still that fear 
that we may be or I may be denied coverage or access to it. So, 
it could lock her into where she is.
    Mr. Lee. Lock her in. All right, thank you. One other 
question. According to the Department of Health and Human 
Services, the number of Americans with preexisting conditions 
ranges from at least 23 percent, 61 million people to as many 
as 133 million people. And prior to the Affordable Care Act 
these Americans with preexisting conditions could be denied 
coverage or charged an exorbitant premium to get coverage, 
something that my parents had experience both having high blood 
pressure at one point in their lives.
    Some families have even declared bankruptcy from high 
medical bills due to having a preexisting condition. Today, 
however, insurance companies cannot discriminate against people 
based on their medical history.
    Mr. Riedy, without employer-sponsored health insurance or 
insurance through your family prior to the Affordable Care Act, 
do you believe you would have been able to attain affordable 
health insurance?
    Mr. Riedy. Before the ACA I would have likely been denied 
coverage because of my preexisting condition without the access 
to employer-sponsored health coverage. And the ACA provides me 
with the opportunity to be adequately covered on the individual 
market I'm currently in. Without them I don't know if that 
would be possible.
    Mr. Lee. Well, thank you so much for your testimony. I want 
to say I texted my sister to tell her I was going to be 
speaking with you today and she sent me this message back that 
said please make sure we help people with cystic fibrosis 
because these patient needs to have their medical needs met and 
it is extremely expensive illness. She said they didn't cause 
this disease, but they must fight it and so thank you for your 
courage for being here. I appreciate it.
    Chairman Scott. Thank you. The gentlelady from 
Massachusetts, Ms. Trahan.
    Ms. Trahan. Thank you. Thank you, Mr. Chairman, for having 
this hearing and thank you, everyone, for hanging in for a long 
hearing. Part of the challenge of being later in the program 
and new here is so many of the thoughtful inquiries have 
already been made but I do have a couple of questions. I am a 
mother of two young girls, 8 and 4 as well as three grown 
stepsons who have benefited from the ACA and being able to stay 
on my health plan as they enter the workforce.
    Before the ACA women were often charged more than men just 
because of their gender and some couldn't even get coverage on 
the individual market. For women of childbearing age, the 
discrimination was particularly blatant, and the vast majority 
of plans excluded maternity coverage of any kind. And I 
appreciate my colleague from Michigan and her inquiry around 
maternal care.
    Dr. Gupta, I am wondering if you could just explain to us 
what it was like for women to get health insurance coverage 
before ACA and how many plans covered maternity coverage in the 
individual market and what improvements have women and their 
families seen since ACA?
    Dr. Gupta. Certainly, thank you for that. We know that 
prior to the ACA, only 11 States mandated the coverage of 
maternity care. Only 13 percent of the individual health market 
actually covered maternity care. We know that at that time 
obviously the gender of being female was a preexisting 
condition in effect. We also know that 47 percent of people who 
tried, adults who try to get coverage with preexisting 
condition were either denied, charged more or were precluded 
from at least one condition. That's from the Commonwealth Fund 
Study. So, we know that this was a big problem.
    Since then, March of Dimes did a study in 2015 and found 
that between 2013 and 2015 the uninsured coverage for 
childbearing age women went down from about 20 million to 13 
million, I'm sorry 20 percent to 13 percent. That means that 
another 5 and a half million of childbearing age gained 
coverage. Not only that, the unmet needs actually went down by 
10 percent points of those women. So clearly that has been a 
big gain.
    I would say when we talk about preexisting conditions, 
health inequities are the first cause of preexisting 
conditions. And when I talk about maternal mortality, a black 
woman in this country is more likely to die--three to four 
times more than a white woman. So, we still have for healthcare 
institutions across and healthcare systems across the country, 
today, race is a preexisting condition and we need to continue 
to work on that and I think that is a critical piece that I 
must bring up as well.
    Ms. Trahan. Thank you. Thank you, Dr. Gupta. and, Ms. 
Corlette, to borrow a phrase that is going around a lot, the 
dignity of work is something that means a lot of me. And I am 
the daughter of a union ironworker. My mom worked multiple 
part-time jobs while raising my sisters and me. I am constantly 
thinking about how are we going to support work and labor as it 
transitions to the future and what the future of work actually 
looks like?
    We talk a lot about our economy and adding more jobs but 
those don't always translate into employer-sponsored plans. So, 
a recent Department of Labor survey found that 10 percent of 
the workforce are categorized as either independent contractors 
or self-employed. This represents a growing segment of the 
workforce, in fact more than half of all ACA marketplace 
enrollees are small business owners, self-employed individuals 
or small business employees.
    I am wondering if you have looked at any additional 
research on the impact of the Texas lawsuit or even just the 70 
plus ACA repeal attempts would have on the future of work? And 
also, if we have time, can you discuss the impact of removing 
preexisting condition protections for gig economy workers, 
independent contractors specifically?
    Ms. Corlette. Sure. Thank you. It's a great question. So, 
for folks who do have job-based coverage, there are a couple of 
things to be concerned about if the Texas court decision 
stands. One of course is that people could lose--with chronic 
or high-cost health needs could lose some of the protections 
that Mr. Riedy has spoken so eloquently about. The other issue 
of course is job lock, and this is a phenomenon that was well-
documented before the ACA where folks sort of hung onto their 
jobs and their job-based coverage because of the uncertainty of 
the individual market. And they may have had a great business 
idea or been a terrific entrepreneur but did not pursue that 
because of their need to maintain job-based coverage.
    Ms. Trahan. Great. Thank you. Thank you, Mr. Chairman, I 
yield back.
    Chairman Scott. Thank you. The gentlelady from North 
Carolina, Dr. Adams.
    Ms. Adams. Thank you, Mr. Chairman and thank you all very 
much for your testimony and for sitting out with us, we 
appreciate that very much. Mr. Riedy, thank you so much for 
sharing your story.
    Mr. Chairman, I would like to enter into the record first 
from the--some organizations that have commented regarding the 
preexisting conditions and the GOP plan. First, the American 
Cancer Society Action Network who says that these protections 
are hollow if patients and survivors can't afford insurance. 
From the American HealthCare Association, the plan would do 
just the opposite and not serve the health needs of all 
Americans. And then they also say that the greatest achievement 
of the ACA is protecting those with preexisting conditions. The 
National Disabilities Rights Network says that GOP plan permits 
discrimination against people with disabilities in the 
insurance market for preexisting conditions and I would like to 
enter this into the record, Mr. Chairman.
    Thank you. Let me just say as I have listened to you, all 
of you I thought about Dr. Martin Luther King, Jr., who talked 
about healthcare and inequities and who said that ``of all the 
forms of inequality, injustice in healthcare is the most 
shocking and most inhumane'' and indeed it is. I do want to 
just mention the impact that ACA has had on communities of 
color, in particular the protections of those with preexisting 
conditions.
    I am a diabetic and that's an illness that was considered, 
is considered a preexisting condition. It is very prevalent in 
my family. I had a sister who suffered with sickle cell, from 
sickle cell anemia, a preexisting condition who passed away 
before she was 27. African-Americans are 80 percent more likely 
than Whites to have been diagnosed with diabetes. About 365 
African Americans suffer with sickle cell anemia. Latin--Latino 
Americans have the highest rates of cervical cancer and Asian 
women are at the highest risk of osteoporosis.
    Simply put, the Affordable Care Act has saved lives and has 
provided healthcare to millions who previously thought 
affordable treatment was just a dream. Folks like me, families 
that grew up who didn't have healthcare at all, no health 
insurance, having to go to the emergency room to get our care.
    Dr. Gupta just one or two questions. For those with 
preexisting conditions or minority communities, how many more 
people with chronic illnesses have been covered and have those 
who suffer from chronic ailments seen improvements in their 
conditions as a result?
    Dr. Gupta. I can tell you that there has been a great 
progress made in that and I will certainly get you the exact 
numbers but the great progress made in that and the ability to 
again, level the playing field in our pursuit to level the 
playing field to get people to be covered. And we, I say that 
because these conditions are a part and representative of your 
socioeconomic condition. They're representative oftentimes of 
the culture we come from and lots of other things. What we call 
social determinants of health, education level. So being able 
to provide the basic healthcare that has happened as part of 
the health ACA has allowed our communities of color actually to 
be--have one less thing to worry about. So that's one of the 
things.
    The other piece I will go back to, you know, as March of 
Dimes we are focused on the health of moms and babies and 
nowhere is it more evident, the disparities and health 
inequities when we look at moms and babies. As I mentioned, 
three times to four times more likely to die if you're a black 
woman. Same way prematurely. Twice as likely to die if you're a 
premature child who is African-American. So, these are the type 
of things that we are fighting for and I think it is very 
important to understand that this will take us many steps 
backwards and we need to be moving forwards.
    Ms. Adams. Great, thank you very much. Wanted to just, you 
know, note that since the President assumed office we have seen 
a constant attack against ACA. So much so that we are seeing a 
reversal in quite a bit of the progress that we have made and 
just wanted you to just briefly comment on how this reversal in 
progress has impacted people of color specifically.
    Dr. Gupta. I think what we are--once again will end up 
happening, we will have individuals who will be dependent again 
on emergency care and urgent care as a result of which 
screenings will not happen, preventive visits will not happen. 
As a result of which we will not have--be able to catch those 
diseases early. It will be delayed, it will be more expensive 
and it will cost more lives. As Ms. Corlette eloquently pointed 
out a couple of times that we have clear data for ACA that when 
people were uninsured there were about, over 20,000, 22,000 
people we know in this country were dying every year because of 
the lack of insurance per say. We will go back to that.
    Ms. Adams. Thank you very much. I yield back, Mr. Chairman.
    Chairman Scott. Thank you. Gentlelady from Minnesota, Ms. 
Omar.
    Ms. Omar. Thank you, Chair. Thank you all for being here. 
Thank you for having this really important, critical 
conversation but sometimes frustrating conversation. And I say 
frustrating because of two reasons. One, to see the disconnect 
between what some of my colleagues would say in committee about 
healthcare and what their votes say about where their 
priorities and their values are, seems very, very frustrating 
for me.
    And the second is for us to have conversations about policy 
that have real impact on humans but to not really think about 
the humans that we are talking about in this discussion. So I 
am one that sees healthcare as a human right and I want to take 
some time for us to humanize this particular conversation 
because, you know, there are--there are people who will talk 
about the costs, they will talk about, you know, what struggles 
corporations will have or companies will have or a small 
businesses or all of these kind of things. But oftentimes we 
don't talk about the kind of stresses and the traumas that 
people like yourself, Mr. Riedy, have lived with as you not 
only deal with getting the diagnosis and figuring out how you 
go on with life, with the condition that could be a hindrance 
to your day-to-day life or could, you know, maybe end your 
life.
    So, what I wanted to do was maybe have you walk us through 
what it must have been like to go through the process to 
receive those letters from insurance companies before the 
passage of the ACA.
    Mr. Riedy. Well, thank you for the question. And this was, 
back in 2007 and to know--have spent 7 days in the hospital and 
to know that--what the cost of that care is and then after that 
I also spent 14 days at home on IV antibiotics at home which 
required a home healthcare nurse who came every couple days to 
draw blood and just check on the dressing and the IV and 
everything.
    But to receive information that describes the cost of your 
care A, is a shock to see how much it actually costs. But then 
to see how that is then compiled toward a limit of what an 
insurance company or someone is willing to pay is worrisome and 
scary because you know that without that care or access to--
without access to the coverage that will give you that care, it 
will be much harder for you to stand a chance. And not just for 
me but for others with CF or with other preexisting conditions 
that faced those same struggles.
    It takes a toll not only on us as people but also on our 
families and those that love us because it, it's not just me 
that would sit and think about it. It's my wife, right. And my 
kids are--at the time at 2007 they weren't alive yet. But now 
if that was to happen again, that puts an unnecessary burden on 
them as well.
    And having the knowledge that there are no caps and not 
having to receive those letters anymore allows us to focus on 
our family and to continue to seek the best coverage and care 
that allows - and medicines that are highly specialized to 
target what the issues are with my disease and to help prolong 
my life so that like I mentioned earlier I can see my children 
grow up and go to college and not fear that I may have to make 
a decision one day so that they can continue to grow and me not 
have to have that coverage.
    Ms. Omar. Thank you. I see an immorality in the way that we 
are creating policy without taking in the actual impact that it 
has on the people's lives. We take a constitutional oath to 
protect the safety and the wellbeing of the people that we 
serve. So, thank you so much for sharing your story and I will 
tell you that you have people here in Congress who will make 
sure to constantly center that. So, thank you. I yield back.
    Chairman Scott. Thank you. And I recognize myself now for 
questions and the vote has been called so these are going to be 
some quick questions. Appreciate some quick answers.
    Ms. Corlette, you mentioned the New York situation where 
they covered--they guaranteed issue notwithstanding the 
preexisting condition and when the Affordable Care Act came in, 
is it true that the cost for individual insurance dropped more 
than 50 percent?
    Ms. Corlette. Yes. It's true.
    Chairman Scott. The effect of the Texas case, is it true 
that if the case is upheld there will be no protection, 
national protection against--for preexisting conditions?
    Ms. Corlette. The ACA protections will be stuck down, yes.
    Chairman Scott. Now we have heard that if it is 
unconstitutional the court would provide some transition time. 
Is there any--you are a lawyer, is there any guarantee that 
there would be a transition time if they call it 
unconstitutional?
    Ms. Corlette. There is no such guarantee.
    Chairman Scott. Now the repeal and replace, are you 
familiar with the American HealthCare Act that passed the 
House?
    Ms. Corlette. I do remember it, yes.
    Chairman Scott. OK. Is it true that if that had passed 23 
million fewer people would have insurance, costs would go up 
about 20 percent the first year, and there would be fewer 
consumer protections?
    Ms. Corlette. I don't remember the exact numbers but that 
sounds like what I remember, yes.
    Chairman Scott. And we have heard a citation in the bill 
that protects people with preexisting conditions but what 
wasn't read was an ability for States to waive that protection, 
so if you are unlucky enough to be in the wrong State that you 
could have no protection against preexisting conditions. Is 
that right?
    Ms. Corlette. Right.
    Chairman Scott. 11 million people who have, who got 
coverage through Medicaid expansion would they lose their 
coverage?
    Ms. Corlette. Yes.
    Chairman Scott. And the 10 essential benefits including 
prescription drugs, mental health, maternal and newborn care, 
preventive care, would those evaporate if the bill, if the 
law--if the ruling is upheld?
    Ms. Corlette. Yes.
    Chairman Scott. And we have heard about essential benefits 
and Dr. Gupta has been very articulate on that. If maternal 
and--maternity care were optional, who would buy it?
    Ms. Corlette. Well, who would offer it is the first 
question? Insurance companies generally would not offer it. And 
if they did, it would typically be as what is called a rider 
and the cost would be exorbitant.
    Chairman Scott. Because the only people that would buy it 
would be those who expect to have a baby in the next year.
    Ms. Corlette. Right.
    Chairman Scott. And the cost would be not insurance but 
essentially prepaid maternity care.
    Ms. Corlette. That's exactly right.
    Chairman Scott. And that is why it would be unaffordable. 
Now on the association plans, as I understand it you can get a 
healthy group, young healthy men and who would pay less. The 
arithmetic therefore says everybody left behind would pay more. 
Is that right?
    Ms. Corlette. That's correct.
    Chairman Scott. Now the navigators which you mentioned are 
community-based organizations that help consumers sign up for 
coverage. Language recently published by the Centers of 
Medicaid and Medicare--Medicare and Medicaid--states that 
priority will be granted and funding organizations that promote 
``coverage options in addition to marketplace plans such as 
association health plans, short term limited duration 
insurance.'' Is that consistent with the original purpose of 
the navigators?
    Ms. Corlette. No. Navigators are supposed to help people 
enroll in marketplace coverage.
    Chairman Scott. The--you know what has happened to the rate 
of bankruptcy because of medical bills as a result of the 
Affordable Care Act?
    Ms. Corlette. I don't have that data at my fingertips, but 
it has gone down.
    Chairman Scott. And can you say another word about job lock 
and why the Affordable Care Act gives people, particularly 
entrepreneurs the opportunity to switch jobs?
    Ms. Corlette. Sure. So, for people who have a preexisting 
condition themselves or somebody in their family who has a 
health condition, economists documented this phenomenon called 
job lock which prior to the ACA led a lot of people to stay 
with job-based coverage even if that job was not optimally 
deploying their skills or talents.
    Since the ACA if you are an entrepreneur or you want to 
start your own business, you can do so without worrying about 
coverage for your preexisting condition and if you are at least 
initially not earning much income, you can qualify for 
subsidies or even Medicaid.
    Chairman Scott. Thank you. I would like to thank our 
witnesses for their testimony. I now recognize the 
distinguished ranking member for closing comments.
    Mrs. Foxx. Thank you, Mr. Chairman, and I want to thank our 
witnesses also for being here. I particularly appreciate the 
opportunity that this hearing has given for Republicans to set 
the record straight on our position on preexisting conditions.
    I believe most every member spoke to it but we know that 
every member believes in coverage for preexisting conditions 
both those of us who were here to vote for the replace bill and 
the other, and the numerous replacement bills that we have 
offered.
    There is so much to say to correct the record here that 
there is not enough time. Perhaps I will submit some things for 
the record but I want to point out that if the court rules the 
ACA illegal, it would not repeal ERISA. It would not repeal 
HIPAA. There are safeguards in both of those pieces of 
legislation for preexisting conditions. Some of our witnesses 
have been extremely careful in how they have answered those 
questions and I appreciate that because they have been very 
careful not to completely mislead people about that situation. 
Contrary to what has been said about the work of Republicans, 
we have made provisions in all our proposals and past 
legislation that protects people with preexisting conditions. 
And I think it is important we continue to say that.
    The Affordable Care Act was built on lies. If you like your 
insurance, you can keep your insurance. If you like your 
doctor, you can keep your doctor. All of those things were said 
and they--or costs will be lowered. Those were not true. The 
ACA ordered people into a one-size-fits-all plan which 
increased costs dramatically and we know that. What America--
what Republicans have done is to offer Americans freedom and 
choice. And what we should have been talking about today was 
what the ACA has done to raise the costs of healthcare and make 
it less affordable and less accessible. And with that again I 
thank the witnesses and I yield back.
    Chairman Scott. Thank you. Again, I want to thank the 
witnesses and members for their participation. What we have 
heard I think is a very valuable. The hearing has allowed us to 
take stock of where we are, to examine the attacks on 
preexisting conditions through unnecessary litigation, harmful 
rules that have a negative impact on those with preexisting 
conditions and I think we should try to improve and protect the 
healthcare that we have now and not jeopardize it.
    It is obvious that even the employer-based coverage with 
the protection for preexisting condition, those with employer-
based coverage if we don't have the individuals covered, we 
will have uncompensated cost-shifting so they will be paying 
more if these, all off these other protections are repealed. If 
there is no further business to come before the committee, the 
hearing is now adjourned.
    [Additional submissions by Ms. Adams follow:)
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]


    [Whereupon, at 1:49 p.m., the committee was adjourned.]

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