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

    TEXAS v. U.S.: THE REPUBLICAN LAWSUIT AND ITS IMPACTS ON AMERICANS
                         WITH PREEXISTING CONDITIONS

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

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 FIRST SESSION
                                   __________

                                FEBRUARY 6, 2019
                                   __________

                                Serial No. 116-2

                      [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

          Printed for the use of the Committee on Energy and Commerce

                       govinfo.gov/committee/house-energy
                            energycommerce.house.gov

                                  ___________

                        U.S. GOVERNMENT PUBLISHING OFFICE

    35-377 PDF                 WASHINGTON : 2019

                        COMMITTEE ON ENERGY AND COMMERCE

                         FRANK PALLONE, Jr., New Jersey
                                     Chairman
    BOBBY L. RUSH, Illinois              GREG WALDEN, Oregon
    ANNA G. ESHOO, California              Ranking Member
    ELIOT L. ENGEL, New York             FRED UPTON, Michigan
    DIANA DeGETTE, Colorado              JOHN SHIMKUS, Illinois
    MIKE DOYLE, Pennsylvania             MICHAEL C. BURGESS, Texas
    JAN SCHAKOWSKY, Illinois             STEVE SCALISE, Louisiana
    G. K. BUTTERFIELD, North Carolina    ROBERT E. LATTA, Ohio
    DORIS O. MATSUI, California          CATHY McMORRIS RODGERS, Washington
    KATHY CASTOR, Florida                BRETT GUTHRIE, Kentucky
    JOHN P. SARBANES, Maryland           PETE OLSON, Texas
    JERRY McNERNEY, California           DAVID B. McKINLEY, West Virginia
    PETER WELCH, Vermont                 ADAM KINZINGER, Illinois
    BEN RAY LUJAN, New Mexico            H. MORGAN GRIFFITH, Virginia
    PAUL TONKO, New York                 GUS M. BILIRAKIS, Florida
    YVETTE D. CLARKE, New York, Vice     BILL JOHNSON, Ohio
        Chair                            BILLY LONG, Missouri
    DAVID LOEBSACK, Iowa                 LARRY BUCSHON, Indiana
    KURT SCHRADER, Oregon                BILL FLORES, Texas
    JOSEPH P. KENNEDY III,               SUSAN W. BROOKS, Indiana
        Massachusetts                    MARKWAYNE MULLIN, Oklahoma
    TONY CARDENAS, California            RICHARD HUDSON, North Carolina
    RAUL RUIZ, California                TIM WALBERG, Michigan
    SCOTT H. PETERS, California          EARL L. ``BUDDY'' CARTER, Georgia
    DEBBIE DINGELL, Michigan             JEFF DUNCAN, South Carolina
    MARC A. VEASEY, Texas                GREG GIANFORTE, Montana
    ANN M. KUSTER, New Hampshire
    ROBIN L. KELLY, Illinois
    NANETTE DIAZ BARRAGAN, California
    A. DONALD McEACHIN, Virginia
    LISA BLUNT ROCHESTER, Delaware
    DARREN SOTO, Florida
    TOM O'HALLERAN, Arizona
                                     ------

                               Professional Staff

                       JEFFREY C. CARROLL, Staff Director
                    TIFFANY GUARASCIO, Deputy Staff Director
                    MIKE BLOOMQUIST, Minority Staff Director
                             Subcommittee on Health

                           ANNA G. ESHOO, California
                                    Chairwoman
    ELIOT L. ENGEL, New York             MICHAEL C. BURGESS, Texas
    G. K. BUTTERFIELD, North Carolina,     Ranking Member
        Vice Chair                       FRED UPTON, Michigan
    DORIS O. MATSUI, California          JOHN SHIMKUS, Illinois
    KATHY CASTOR, Florida                BRETT GUTHRIE, Kentucky
    JOHN P. SARBANES, Maryland           H. MORGAN GRIFFITH, Virginia
    BEN RAY LUJAN, New Mexico            GUS M. BILIRAKIS, Florida
    KURT SCHRADER, Oregon                BILLY LONG, Missouri
    JOSEPH P. KENNEDY III,               LARRY BUCSHON, Indiana
        Massachusetts                    SUSAN W. BROOKS, Indiana
    TONY CARDENAS, California            MARKWAYNE MULLIN, Oklahoma
    PETER WELCH, Vermont                 RICHARD HUDSON, North Carolina
    RAUL RUIZ, California                EARL L. ``BUDDY'' CARTER, Georgia
    DEBBIE DINGELL, Michigan             GREG GIANFORTE, Montana
    ANN M. KUSTER, New Hampshire         GREG WALDEN, Oregon (ex officio)
    ROBIN L. KELLY, Illinois
    NANETTE DIAZ BARRAGAN, California
    LISA BLUNT ROCHESTER, Delaware
    BOBBY L. RUSH, Illinois
    FRANK PALLONE, Jr., New Jersey (ex
        officio)

                                 C O N T E N T S

                                  ----------
                                                                       Page
    Hon. Anna G. Eshoo, a Representative in Congress from the State
      of California, opening statement...............................     1
        Prepared statement...........................................     3
    Hon. Michael C. Burgess, a Representative in Congress from the
      State of Texas, opening statement..............................     4
        Prepared statement...........................................     6
    Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, opening statement.........................     8
    Hon. Greg Walden, a Representative in Congress from the State of
      Oregon, opening statement......................................    10
        Prepared statement...........................................    12

                                   Witnesses

    Christen Linke Young, Fellow, USC-Brookings Schaeffer Initiative
      for Health Policy..............................................    14
        Prepared statement...........................................    17
        Answers to submitted questions...............................   156
    Avik S. A. Roy, President, Foundation for Research on Equal
      Opportunity....................................................    22
        Prepared statement...........................................    24
    Elena Hung, Cofounder, Little Lobbyists..........................    32
        Prepared statement...........................................    34
        Answers to submitted questions...............................   161
    Thomas P. Miller, Resident Fellow in Health Policy Studies,
      American Enterprise Institute..................................    48
        Prepared statement...........................................    50
        Answers to submitted questions...............................   163
    Simon Lazarus, constitutional lawyer and writer..................    70
        Prepared statement...........................................    72

                               Submitted Material

    Letter of January 9, 2019, from Ms. Castor, et al., to Hon. Ron
      DeSantis, Governor, State of Florida, submitted by Ms. Castor..   116
    Letter of January 13, 2018, from Hon. Bill Nelson, a United
      States Senator from the State of Florida, et al., to Hon. Rick
      Scott, Governor, State of Florida, submitted by Ms. Castor.....   121
    Letter of January 26, 2017, from Mr. O'Halleran, et al., to Hon.
      Paul D. Ryan, Speaker of the House, and Hon. Mitch McConnell,
      Majority Leader, United States Senate, submitted by Mr.
      O'Halleran.....................................................   124
    Letter of April 23, 2018, from American Cancer Society Cancer
      Action Network, et al., to Hon. Alex Azar, Secretary,
      Department of Health and Human Services, et al., submitted by
      Ms. Eshoo......................................................   128
    Letter of February 6, 2019, from Michael L. Munger, M.D., Board
      Chair, American Academy of Family Physicians, to Ms. Eshoo and
      Mr. Burgess, submitted by Ms. Eshoo............................   139
    Statement of the American College of Physicians, February 6,
      2019, submitted by Ms. Eshoo...................................   141
    Editorial of December 16, 2018, ``Texas ObamaCare Blunder,'' The
      Wall Street Journal, submitted by Ms. Eshoo....................   146
    Article of December 15, 2018, ``What the Lawless Obamacare Ruling
      Means,'' by Jonathan H. Adler and Abbe R. Gluck, The New York
      Times, submitted by Ms. Eshoo..................................   149
    Amici Brief of June 14, 2018, American Medical Association, et
      al., Civil Action No.:4:18-cv-00167-O, submitted by Ms. Eshoo
      \1\
    Amici Brief of June 15, 2018, Families USA, et al., No. 4:18-cv-
      00167-O, submitted by Ms. Eshoo \1\
    Amici Brief of June 14, 2018, American Cancer Society Cancer
      Action Network, et al., Case No. 4:18-cv-00167-O, submitted by
      Ms. Eshoo \1\
    Amici Brief of June 15, 2018, AARP Foundation, Civil Action
      No.:4:18-cv-00167-O, submitted by Ms. Eshoo \1\
    Letter of February 5, 2019, from Mr. Walden and Mr. Burgess to
      Mr. Pallone and Ms. Eshoo, submitted by Mr. Burgess............   153

    ----------

    \1\ The information has been retained in committee files and also is
    available at https://docs.house.gov/Committee/Calendar/
    ByEvent.aspx?EventID=108843.

    TEXAS v. U.S.: THE REPUBLICAN LAWSUIT AND ITS IMPACTS ON AMERICANS WITH
                             PREEXISTING CONDITIONS

                                  ----------

                          WEDNESDAY, FEBRUARY 6, 2019

                      House of Representatives,
                                Subcommittee on Health,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 10:16 a.m., in
    room 2322, Rayburn House Office Building, Hon. Anna G. Eshoo
    (chairwoman of the subcommittee) presiding.
        Members present: Representatives Eshoo, Butterfield,
    Matsui, Castor, Lujan, Cardenas, Schrader, Ruiz, Kuster, Kelly,
    Barragan, Blunt Rochester, Rush, Pallone (ex officio), Burgess
    (subcommittee ranking member), Upton, Guthrie, Griffith,
    Bilirakis, Bucshon, Brooks, Mullin, Hudson, Carter, Gianforte,
    and Walden (ex officio).
        Also present: Representatives Veasey and O'Halleran.
        Staff present: Jeffrey C. Carroll, Staff Director;
    Elizabeth Ertel, Office Manager; Waverly Gordon, Deputy Chief
    Counsel; Zach Kahan, Outreach and Member Service Coordinator;
    Saha Khatezai, Professional Staff Member; Una Lee, Senior
    Health Counsel; Kaitlyn Peel, Digital Director; Tim Robinson,
    Chief Counsel; Samantha Satchell, Professional Staff Member;
    Andrew Souvall, Director of Communications, Outreach, and
    Member Services; C. J. Young, Press Secretary; Adam Buckalew,
    Minority Director of Coalitions and Deputy Chief Counsel,
    Health; Margaret Tucker Fogarty, Minority Staff Assistant;
    Caleb Graff, Minority Professional Staff Member, Health; Peter
    Kielty, Minority General Counsel; Ryan Long, Minority Deputy
    Staff Director; J. P. Paluskiewicz, Minority Chief Counsel,
    Health; Kristen Shatynski, Minority Professional Staff Member,
    Health; Danielle Steele, Minority Counsel, Health.

     OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN
                 CONGRESS FROM THE STATE OF CALIFORNIA

        Ms. Eshoo. The Subcommittee on Health will now come to
    order. The Chair recognizes herself for 5 minutes for an
    opening statement, and the first thing that I would like to say
    is, ``Welcome.''
        Welcome back the 116th Congress under the new majority, and
    I want to thank my Democratic colleagues for supporting me to
    do this work, to chair the subcommittee.
        It is an enormous honor and it is--what is contained in the
    committee, of course, are some of the most important issues
    that the American people expressed at the polls in the midterm
    elections.
        To our Republican colleagues, I know that there are areas
    where we can really work together. In some areas, we are going
    to have to stretch. But know that I look forward to working
    with all of you, and to those that are new members of the
    subcommittee, welcome to each one of you.
        I know that you are going to bring great ideas and really
    be instructive to the rest of us, so welcome to you.
        As I said, healthcare was the single most important issue
    to voters in the midterm elections, and it is a rarity that
    there would be one issue that would be the top issue in every
    single congressional district across the country. So this
    subcommittee is front and center.
        We are beginning the Health Subcommittee's work by
    discussing the Texas v. United States lawsuit and its
    implications for the entire healthcare system, both public and
    private.
        For over a hundred years, presidents, including Teddy
    Roosevelt, Harry Truman, Richard Nixon, and others attempted to
    reform our Nation's health insurance system and provide access
    to affordable health insurance for all Americans.
        In 2010, through the efforts that began in this committee,
    the Affordable Care Act was signed into law and bold reforms to
    our public and private insurance programs were made.
        Since the Affordable Care Act was signed into law, over 20
    million Americans have gained health insurance that is required
    to cover preexisting conditions. The law disallows charging
    sick consumers more, it allows children to stay on their
    parents' health insurance policy to the age of 26, and provides
    coverage for preventive health services with no cost sharing.
        Last February, 20 attorneys general and Governors sued the
    Federal Government to challenge the constitutionality of that
    law. They claimed that, after the individual mandate was
    repealed by the Republicans' tax plan, the rest of the
    Affordable Care Act had to go, too.
        The Trump administration's Department of Justice has
    refused to defend the Affordable Care Act in court and in
    December Judge Reed O'Connor of the Northern District of Texas
    declared the entire ACA invalid.
        Twenty attorneys general, led by the attorney general from
    California, our former colleague, Xavier Becerra, have appealed
    Judge O'Connor's ruling.
        For those enrolled in the Affordable Care Act, if the
    Republican lawsuit is successful, the 13 million Americans who
    gained health insurance through the Medicaid expansion will
    lose their health insurance.
        The 9 million Americans who rely on tax credits to help
    them afford the insurance plan will no longer be able to afford
    their insurance and health insurance costs will skyrocket
    across the country when healthy people leave the marketplace
    for what I call junk insurance plans that won't cover them when
    they get sick--another implication leaving the sick and the
    most expensive patients in the individual market, driving up
    premiums for so many.
        The insurance reforms of the ACA protect every American,
    including those who get their health insurance through their
    employer. Every insurance plan today is required to cover 10
    basic essential health benefits.
        No longer are there lifetime limits. The 130 million
    patients with preexisting conditions cannot be denied coverage
    or charged more, and women can no longer be charged more
    because they are females.
        [The prepared statement of Ms. Eshoo follows:]

                    Prepared statement of Hon. Anna G. Eshoo

        Welcome to the first Health Subcommittee hearing of the
    116th Congress, under a Democratic majority, and welcome to the
    new members of the Health Subcommittee.
        Healthcare was the single most important issue to voters in
    the 2018 election. It is a rarity for one issue to be so
    important in every Congressional District in the country.
        We're beginning the Health Subcommittee's work by
    discussing the disastrous Texas v. United States lawsuit and
    its implications for the entire healthcare system, both public
    and private.
        For over 100 years, presidents including Teddy Roosevelt,
    Harry Truman, and Richard Nixon attempted to reform our
    Nation's health insurance system and provide access to
    affordable health insurance for all Americans.
        In 2010, through efforts that began in this committee, the
    Affordable Care Act was signed into law and bold reforms to our
    public and private insurance programs were implemented.
        Since the Affordable Care Act was signed into law over 20
    million Americans have gained health insurance that is required
    to cover preexisting conditions; disallows charging sick
    consumers more; allows children to stay on their parent's
    health insurance until the age of 26 and provides coverage for
    preventive health services with no cost sharing.
        Last February, 20 attorneys general and Governors sued the
    Federal Government to challenge the constitutionality of that
    law. They claimed that after the individual mandate was
    repealed by the Republican's tax plan, the rest of the
    Affordable Care Act had to go, too.
        The Trump administration's Department of Justice refused to
    defend the Affordable Care Act in court and in December, Judge
    Reed O'Connor of the Northern District of Texas declared the
    entire ACA invalid. 20 attorneys general, led by California's
    Xavier Beccera, have appealed Judge O'Connor's ruling.
        For those enrolled in the Affordable Care Act, if the
    Republican lawsuit is successful, the 13 million Americans who
    gained health insurance through the Medicaid expansion will
    lose their health insurance; the 9 million Americans who rely
    on tax credits to help them afford their insurance plan will no
    longer be able to afford their insurance; and health insurance
    costs will sky rocket across the country when healthy people
    leave the marketplace for junk insurance plans that won't cover
    them when they get sick, leaving the sick and most expensive
    patients in the individual market, driving up premiums.
        The insurance reforms of the ACA protect every American,
    even those who get their health insurance through their
    employer. Every insurance plan today is required to cover ten
    basic Essential Health Benefits; there are no longer lifetime
    limits; the 130 million patients with preexisting conditions
    cannot be denied coverage or charged more; and women can no
    longer be charged more because they are females.
        Judge O'Connor's ruling in Texas v. United States declared
    the Affordable Care Act invalid in its entirety, threatening
    every one of the gains I just described. It is now up to the
    Democratic House to protect, defend and strengthen the ACA.
        Even if legislation to require insurance companies to cover
    these patients' preexisting conditions is passed, insurers
    could charge anything they want to cover these services if the
    ACA is overturned.
        On the very first day of this Congress, House Democrats
    voted to intervene in the Texas v. United States case as it
    moves through appeal. The House of Representatives will now
    represent the Government in this case to defend and uphold the
    ACA, because this administration refused to do so.
        In the majority's work to defend and strengthen the ACA,
    this subcommittee will explore how the Trump administration's
    junk insurance plans are affecting the individual insurance
    market and harming people with preexisting conditions.
        These plans aren't required to cover the same Essential
    Health Benefits as ACA-compliant plans and patients don't know
    that their health insurance won't pay for their treatments
    until they've gotten sick and it's too late.
        Next week, our subcommittee will explore specific
    legislation to reverse the Trump administration's actions to
    expand junk plans. We're also going to discuss legislation that
    would restore outreach and enrollment funding that has been
    slashed by the Trump administration so that we can ensure
    healthcare is more affordable and assessible. And we will also
    discuss legislation that would reverse the Trump
    administration's guidance on 1332 waivers that would allow
    States to undermine the ACA's protections for preexisting
    conditions and could harm people's access to care.
        We will work to reverse the harmful policies that have made
    healthcare more expensive for individuals who rely on the ACA
    and deliver on our promises to the American people to lower
    healthcare and prescription drug costs.
        Welcome to our witnesses, and I look forward to your
    testimony.

        Ms. Eshoo. I am going to stop here, and I am going to yield
    the rest of my time to Mr. Butterfield.
        Mr. Butterfield. Thank you, Chairwoman Eshoo, for holding
    this very important hearing on the absolute importance of the
    Affordable Care Act and thank you for giving us an opportunity
    to expose the poorly written Texas case.
        I want to talk a few seconds about sickle cell disease.
    More than one out of every 370 African Americans born with
    sickle cell disease and more than 100,000 Americans have this
    disease, including many in my State.
        The disease creates intense pain, that patients usually
    must be hospitalized to receive their care. Without preexisting
    condition protections, tens of thousands of Americans with
    sickle cell could be charged more for insurance, they could be
    dropped from their plans and be prevented from enrolling in
    insurance plans altogether.
        Republicans have tried and tried and tried to repeal the
    ACA more than 70 times. We, in this majority, have been sent
    here to protect the Affordable Care Act.
        Thank you for the time. I yield back.
        Ms. Eshoo. I thank the gentleman.
        Next week--I just want to announce this--our subcommittee
    is going to explore specific legislation to reverse the
    administration's actions to expand the skinny plans--the junk
    insurance plans--and we are also going to discuss legislation
    that would restore outreach in enrollment funding that has been
    slashed by the administration, so we can ensure that healthcare
    is more affordable and accessible for all Americans.
        We want to thank the witnesses that are here today. Welcome
    to you. We look forward to hearing your testimony. And now I
    would like to recognize Dr. Burgess, the ranking member of the
    Subcommittee on Health, for 5 minutes for his opening
    statement.

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

        Mr. Burgess. Thank you, Chairwoman Eshoo.
        Let me just take a moment to congratulate you. As you are
    quickly finding out, you now occupy the most important
    subcommittee chair in the entire United States House of
    Representatives, and I know this from firsthand experience.
        We were the most active subcommittee in the United States
    House of Representatives in the last Congress. Hundreds of
    hours in hearings on health policy, and certainly look forward
    to that continuing through this term as well.
        I want to thank our witnesses all for joining us this
    morning. We are here to discuss the issue of protecting access
    to healthcare for individuals with preexisting medical
    conditions in addition to the Texas v. Azar case.
        So I think you heard the president say this last night in
    the State of the Union Address. There is broad bipartisan
    support for providing protections for patients with preexisting
    conditions.
        I am glad we are holding our first hearing of the year. It
    is the end of the first week of February. So it is high time
    that we do this. It is unfortunate we are having a hearing that
    actually doesn't move toward the development of any policies
    that actually would improve healthcare for Americans.
        To that effect, there are numerous options that you could
    bring before us that could moot the Texas v. Azar case. But the
    subcommittee apparently has chosen not to do so. For example,
    the bill to repeal the individual mandate is one that I have
    introduced previously.
        You can join me on that effort, and if the individual
    mandate were repealed the case would probably not exist.
        You could reestablish the tax in the individual mandate,
    which would certainly be your right to do so and, again, that
    would remove most of the argument for the court case as it
    exists today.
        You know, I hear from constituents in north Texas concerned
    about not having access to affordable healthcare. In the
    district that I represent, because of the phenomenon known as
    silver loading, as the benchmark silver plans' premiums
    continue to increase, well, if you are getting a subsidy--what,
    me worry? No problem--I got a subsidy so I am doing OK.
        But in the district that I represent, a schoolteacher and a
    policeman couple with two children are going to be covered in
    the individual market, and they are going to be outside the
    subsidy window.
        So they buy a bronze plan because, like everybody, they buy
    on price, so that is the least expensive thing that is
    available to them, and then they are scared to death that they
    will have to use it because the deductible is so high.
        If you get a kidney stone in the middle of the night and,
    guess what, that $4,500 emergency room bill is all yours. So I
    take meetings with families who are suffering from high
    healthcare and prescription drugs costs, and unfortunately we
    are not doing anything to address that today.
        We could be using this time to discuss something upon--to
    develop policies to help those individuals and families. But,
    again, we are discussing something upon which we all agreed,
    but we are taking no substantive action to address.
        Look, if you believe in Medicare for All, if you believe in
    a single-payer, Government-run, one-size-fits-all health
    system, let us have a hearing right here in this subcommittee.
    We are the authorizing committee. That is our job.
        Instead, we have the House Budget Committee holding those
    hearings, and Democrats on that committee are introducing
    legislation. But these bills belong in the jurisdiction of the
    Energy and Commerce Committee, and yet we have not scheduled a
    hearing to discuss this agenda.
        Do I agree with the policy or think it would be a good idea
    for the American people to have Medicare for All or one-size-
    fits-all health plans? No, I do not, and I would gladly engage
    in a meaningful dialogue about what such a policy would mean
    for the American people.
        Single-payer healthcare would be another failed attempt at
    a one-size-fits-all approach. Americans are all different, and
    a universal healthcare plan that does not meet the varying
    needs of each and every individual at different stages of their
    life will probably not be successful.
        Today, we should be focusing on the parts of the health
    insurance market that are working for Americans. Seventy-one
    percent of Americans are satisfied with employer-sponsored
    health insurance, which provides robust protections for
    individuals with preexisting conditions.
        Quite simply, the success of employer-sponsored insurance
    markets--it is not worth wiping that out with the single-payer
    healthcare policy. Yet, the bill that was introduced last term,
    that is exactly what it did.
        But today, there are a greater percentage of Americans in
    employer health coverage than at any time since the year 2000.
        Since President Trump took office, the number of Americans
    in employer health coverage has increased by over 2\1/2\
    million. Given that the United States economy added more than
    300,000 jobs in January, the number of individuals and families
    covered by employer-sponsored plans is likely even greater
    still.
        Instead of building upon the success of our existing health
    insurance framework, radical single-payer, Government-run
    Medicare would tear it down. It would eliminate the employer-
    sponsored health insurance, private health insurance, Indian
    health insurance, and make inroads against taking away the VA.
        Again, I appreciate that we have organized and we are
    holding our first hearing. I believe we could be using our time
    much more productively. There is bipartisan support for
    protecting patients with preexisting conditions. I certainly
    look forward to hearing the testimony of our witnesses.
        Thank you, I yield back.
        [The prepared statement of Mr. Burgess follows:]

                 Prepared statement of Hon. Michael C. Burgess

        Good morning, everyone, and thank you for joining us this
    morning for our first Health Subcommittee hearing of the 116th
    Congress. I would like to take a moment to congratulate our new
    Chair, Anna Eshoo. I look forward to partnering with you
    throughout this Congress.
        Today, we are here to discuss the issue of protecting
    access to healthcare for individuals with pre-existing medical
    conditions in addition to the Texas v. U.S. court case. Let me
    be clear: This is an issue for which there is broad bipartisan
    support.
        While I am glad that we are finally holding our first
    hearing of the year, I am disappointed that we are holding a
    passive hearing that doesn't move toward the development of any
    policies to improve healthcare for Americans. To that effect,
    there are numerous options that you could bring before us that
    could moot the Texas v. U.S. case, but you have chosen not to
    do so.
        My constituents in North Texas are consistently concerned
    about not having access to affordable healthcare. In my
    district, that is the policeman and the schoolteacher with two
    children who have a bronze plan and cannot afford their high
    deductible. I take countless meetings with families suffering
    from high healthcare and prescription drug costs, but
    unfortunately that's not why you've convened us here today. We
    could be using this valuable time to develop policies to help
    those individuals and families, yet we are here discussing
    something upon which we all agree but are taking no substantive
    action to address.
        If you believe in Medicare for All, a single-payer,
    Government-run, ``one-size-fits-all'' healthcare system, we
    should have a hearing on it right here in this subcommittee.
    The House Budget Committee and others are having hearings on
    this, and Democrats are introducing legislation. These bills
    belong in the jurisdiction of Energy and Commerce, and yet we
    have not scheduled a hearing to discuss this agenda. Do I agree
    with the policy or think it would be good for the American
    people? No, I do not; however, I would gladly engage in a
    meaningful dialogue about what such a policy would mean for the
    American people.
        Single-payer healthcare would be another failed attempt at
    a one-size-fits-all approach to healthcare. Americans are all
    different and a universal healthcare plan will not meet the
    varying needs of each and every individual. Single-payer is not
    one-size-fits-all, it is really one-size-fits-no-one.
        Today, we should be focusing on the parts of the health
    insurance market that are working for Americans. For example,
    71 percent of Americans are satisfied with their employer-
    sponsored health insurance, which provides robust protections
    for individuals with preexisting conditions. Quite simply, the
    success of the employer-sponsored insurance market is not worth
    wiping out with single-payer healthcare. In fact, today there
    is a greater percentage of Americans in employer health
    coverage than at any time since 2000.
        Since President Trump took office, the number of Americans
    in employer health coverage has increased by more than 2.5
    million. Given that the United States economy added more than
    300,000 jobs in January, the number of individuals and families
    covered by employer-sponsored plans is likely even greater.
        Instead of building upon the successes of our existing
    health insurance framework, radical, single-payer, Government-
    run Medicare for All policy would tear it down. It would
    eliminate employer-sponsored health insurance, private
    insurance, the Indian Health Service, and Medicaid and CHIP,
    and pave the road to the elimination of the VA. Existing
    Medicare beneficiaries would not be exempt from harm, as the
    policy would raid the Medicare Trust Fund, which is already
    slated to go bankrupt in 2026.
        Again, while I appreciate that we have organized and are
    holding our first hearing, I believe that we could be using our
    time much more productively. There is bipartisan support for
    protecting individuals with preexisting conditions, and I look
    forward to future hearings where we can have substantive,
    bipartisan policy-based discussions. With that, I yield back.

        Ms. Eshoo. I thank the ranking member, and let me just add
    a few points. You raised the issue of employer-sponsored
    healthcare. Our employer is the Federal Government, and we are
    covered by the Affordable Care Act.
        Number two, we on our side support universal coverage, and
    so--but what the committee is going to be taking up is, and you
    pointed out some of the chinks in the armor of the Affordable
    Care Act--we want to strengthen it, and what you described
    relative to your constituents certainly applies to many of us
    on our side as well. So we plan to examine that, and we will.
        Mr. Burgess. Will the gentlelady yield on the point on
    employer coverage for Members of Congress?
        Ms. Eshoo. Mm-hmm.
        Mr. Burgess. I actually rejected the special deal that
    Members of Congress got several years ago when we were required
    to take insurance under the Affordable Care Act and we all were
    required to join the DC exchange.
        But we were given a large tax-free monthly subsidy to walk
    into that exchange. I thought that was illegal under the law. I
    did not take that. I bought a bronze plan--an unsubsidized
    bronze plan at healthcare.gov, the most miserable experience I
    have ever been through in my life.
        And just like constituents in my district, I was scared to
    use my health insurance because the deductible was so high.
        I yield back.
        Ms. Eshoo. I thank the gentleman. It would be interesting
    to see how many Members have accepted the ACA, they and their
    families being covered by it.
        And now I would like to recognize the chairman of the full
    committee, Mr. Pallone, who requested that this hearing be the
    first one to be taken up by the subcommittee--the Texas law
    case--and I call on the gentleman to make his statement.
        Good morning to you.

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

        Mr. Pallone. Thank you, Madam Chair, and thank you for all
    you have done over the years to help people get health
    insurance, to expand insurance, to address the price of
    prescription drugs and so many other things, and I am glad to
    see you in the chair of this subcommittee hearing.
        Now, I was going to try to be nice today. But after I
    listened to Mr. Burgess, I can't be. You know, and I am sure
    this is--he is going to see this as personal, but I don't mean
    it that way.
        But I just have to speak out, Mr. Burgess. Look, you were
    the chairman of this subcommittee the whole time that the
    Republicans tried unsuccessfully to repeal the Affordable Care
    Act.
        I have had so many meetings where I saw you come in and
    take out your copy of the hearings on the Affordable Care Act
    and repeatedly tell us that the Affordable Care Act was bad
    law, terrible law, it needs to be repealed.
        I saw no effort at all in the time that you were the
    chairman to try to work towards solutions in improving the
    Affordable Care Act. What I saw were constant efforts to join
    with President Trump to sabotage it.
        And the reason that this hearing is important--because the
    ultimate sabotage would be to have the courts rule that the ACA
    is unconstitutional, which is totally bogus.
        You found this, you know, right-wing judge somewhere in
    Texas--I love the State of Texas, but I don't know where you
    found him--and you did forum shopping to find him, and we know
    his opinion is going to be overturned.
        But we still had to join a suit to say that his opinion was
    wrong and it wasn't based in any facts or any real analysis of
    the Constitution, and the reason we are having this hearing
    today is because we need to make the point that the Republicans
    are still trying to repeal the Affordable Care Act.
        They are not looking to work with us to improve it. There
    were many opportunities when the senators--Senator Lamar
    Alexander and others--were trying to do things to improve the
    Affordable Care Act, to deal with the cost sharing that was
    thrown out by the president, to deal with reinsurance to make
    the market more competitive, and at no point was that brought
    up in this subcommittee under your leadership.
        You know, you talk about the employer-sponsored system.
    Sure, we all agree 60 percent of the people get their insurance
    through their employer.
        But those antidiscrimination provisions that you said are
    protected with employer-sponsored plans they came through
    actions of the Democrats and the Affordable Care Act that said
    that you could not discriminate--that you could not
    discriminate for preexisting conditions, that you had to have
    an essential benefit package. Those are a consequence of the
    ACA.
        So don't tell us that, you know, somehow that appeared
    miraculously in the private insurance market. That is not true
    at all.
        Talk about Medicaid expansion, your State and so many other
    Republican States blocked Medicaid expansion. So there is so
    many people now that could have insurance that don't because
    they refuse to do it for ideological reasons.
        You mentioned the Indian Health Service. I love the fact
    that the gentleman from Oklahoma had that Indian healthcare
    task force. Thank you. I appreciate that.
        But I asked so many times in this subcommittee to have a
    hearing on the Indian Health Care Improvement Act which, again,
    was in the Affordable Care Act, otherwise it would never have
    passed, and that never happened.
        We will do that. But talk about the Indian Health service--
    you did nothing to improve the Indian Health Service. And I am
    not suggesting that wasn't true for the gentleman of Oklahoma.
    He was very sympathetic.
        But, in general, we did not have the hearing and we would
    not have had the Indian Health Service Improvement Act but for
    the ACA.
        And finally, Medicare for All--who are you kidding? You are
    saying to us that you want to repeal the ACA and then you want
    to have a hearing on Medicare for All. You sent me a letter
    asking for a hearing on Medicare for All.
        When does a Member of Congress, let alone the chairman or
    the ranking member, I guess, in this case, ask for a hearing on
    something that they oppose? I ask for hearings on things that I
    wanted to happen, like climate change and addressing climate
    change.
        I don't ask for hearings on things that I oppose. I get a
    letter saying, ``Oh, we should have a hearing on Medicare for
    All but, by the way, we are totally opposed to it. It is a
    terrible idea. It will destroy the country.''
        Oh, sure. We will have a hearing on something that you
    think is going to destroy the country. Now, don't get me wrong.
    We will address that issue. I am not suggesting we shouldn't.
        But the cynicism of it all--the cynicism of coming here and
    suggesting that somehow you want--you have solutions? You have
    no solutions. I am more than willing to work with you. I am
    sure that Chairman Eshoo is willing to as well.
        But don't tell us that you had solutions. You did not, and
    you continue not to have solutions. And I am sorry to begin the
    day this way, but I have no choice after what you said. I mean,
    it is just not--it is just not--it is disingenuous.
        Thank you, Madam Chairwoman.
        Ms. Eshoo. Thank you.
        And now I will recognize the ranking member. Good morning.
        Mr. Walden. Good morning.
        Ms. Eshoo. The ranking member of the full committee, my
    friend Mr. Walden.
        Mr. Walden. Thank you, Madam Chair. Congratulations on
    taking over the subcommittee.
        Ms. Eshoo. Thank you very much. I appreciate it.
        Mr. Walden. I always enjoyed working with you on
    telecommunications issues, and I know you will do a fine job
    leading this subcommittee.
        Ms. Eshoo. Thank you.
        Mr. Walden. I look forward to working with you. As we--I
    cannot help but respond a bit.

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

        Mr. Walden. I do wish we were meeting to pass bipartisan
    legislation and protect Americans with preexisting health
    conditions from losing their coverage, given the pending court
    case. And let me speak on behalf of Republicans because we
    fully support protecting Americans with preexisting conditions.
        We have said this repeatedly, we have acted accordingly,
    and we mean it completely. We could and should inject certainty
    into the system by passing legislation to protect those with
    preexisting conditions, period.
        On the opening day of the 116th Congress, House Republicans
    brought a powerful but simple measure to the floor that called
    on this body to legislate on what we all agree needs to be
    done, and that is to lock in protections for patients with
    preexisting conditions.
        Unfortunately, that went down on a party-line vote. Our
    amendment was consistent with our long-held views with respect
    to the American Health Care Act, which our Democratic
    colleagues, frankly, in some cases, continue to misrepresent.
        We provided protections for those with preexisting
    conditions under the AHCA. Insurance companies were prohibited
    from denying or not renewing coverage due to a preexisting
    condition, period.
        Insurance companies were banned from rescinding coverage
    based on a preexisting condition, period. Insurance companies
    were banned from excluding benefits based on a preexisting
    condition, period.
        Insurance companies were prevented from raising premiums on
    individuals with preexisting conditions who maintain continuous
    coverage, period.
        The fact is, this is something we all agree on, and we
    should and could work together to expeditiously guarantee
    preexisting condition protections for all Americans and do so
    in a manner that can withstand judicial scrutiny. That is
    something I think we could find common ground on.
        And while a status check on the ACA lawsuit is interesting
    and important, the ruling has been stayed. The attorneys
    general across the country have filed appeals. Speaker Pelosi
    has moved to intervene in the case I think three times and
    Americans' premiums and coverage for this year are not
    affected.
        But what really does affect American consumers is out-of-
    control costs of healthcare. That is what they would like
    Congress to focus on and something I think we need to tackle as
    well.
        The fact of the matter is that for too many Americans
    health insurance coverage exists solely on paper because
    healthcare costs and these new high deductibles are putting
    family budgets in peril.
        When the Affordable Care Act passed, Democrats promised
    people that their insurance premiums would go down $2,500.
    Unfortunately, the exact opposite has occurred for many
    Americans, and not only have premiums gone up, not down, but
    think of what out-of-pocket costs have done. They have
    skyrocketed.
        The latest solution from my friends on the other side of
    the aisle is some sort of Medicare for All proposal. And yes,
    we did ask for a hearing on it because I think it's something
    that Democrats ran on, believe in fully, and we should take
    time to understand it.
        We know this plan would take away private health insurance
    from more than 150 million Americans. We are told it would end
    Medicare as we know it and would rack up more than $32 trillion
    in costs, not to mention delays in accessing health services.
        So, Madam Chairwoman, other committees in this body have
    announced plans to have hearings on Medicare for All. Speaker
    Pelosi has said she is supportive of holding hearings on this
    plan, and Madam Chairwoman, I think I read you yourself said
    such hearings would be important to have.
        A majority of House Democrats supported Medicare for All in
    the last Congress. In fact, two-thirds of the committee--
    Democrats' 20 Members, 11 whom are on this subcommittee--have
    cosponsored the plan.
        I think it is important for the American people to fully
    understand what this huge new Government intervention to
    healthcare means for consumers if it were to become law.
        Yesterday, Dr. Burgess and I did send you and Chairman
    Pallone a letter asking for a hearing on Medicare for All and
    we think, as the committee of primary jurisdiction, that just
    makes sense.
        So as you're organizing your agenda for the future, we
    thought it was important to put that on it. The American people
    need to fully understand how Medicare for All is not Medicare
    at all but actually just Government-run, single-payer
    healthcare.
        They need to know about the $32 trillion price tag for such
    a plan and how you pay for it. They need to know that it ends
    employer-sponsored healthcare, at least some versions of it do,
    forcing the 158 million Americans who get their health
    insurance through their job or through their union into a one-
    size-fits-all, Government-run plan.
        So if you like waiting in line at the DMV, wait until the
    Government completely takes over healthcare. Seniors need to
    fully understand how this plan will affect the Medicare trust
    fund that they've paid into their entire lives and the impacts
    on access to their care.
        Our Tribes need to understand how this plan could impact
    the Indian Health Service and our veterans deserve to know how
    this plan could pave the way to closing VA health services.
        So the question is, when will we see the bill and when we
    will have a hearing on the legislation? Meanwhile, we need to
    work together to help States stabilize health markets damaged
    by the ACA.
        Cut out-of-pocket costs, promote access to preventive
    services, encourage participation in private health insurance,
    and increase the number of options available through the
    market.
        And I want to thank Mr. Pallone for raising the issue
    involving Senator Lamar Alexander. He and I and Susan Collins
    worked very well together to try and come up with a plan we
    could move through to deal with some of these issues.
        Unfortunately, we could not get that done. So let us work
    together to lock in preexisting condition protections. Let's
    tackle the ever-rising healthcare costs and help our States
    offer consumers more affordable health insurance, and if you
    are going to move forward on a Medicare for All plan, we would
    like to make sure we have a hearing on it before the bill moves
    forward.
        So with that, Madam Chair, thank you and congratulations
    again, and I yield back.
        [The prepared statement of Mr. Walden follows:]

                     Prepared statement of Hon. Greg Walden

        Good morning, Madam Chair. Congratulations on taking over
    the helm of this very important subcommittee. I only wish we
    were meeting today to pass bipartisan legislation to protect
    Americans with preexisting health conditions from losing
    coverage. Let me speak on behalf of Republicans: We fully
    support protecting Americans with preexisting conditions. We've
    said this repeatedly, we we've acted accordingly, and we mean
    it completely. We could-and should-inject certainty into the
    system by passing legislation to protect those with preexisting
    conditions.
        On the opening day of the 116th Congress, House Republicans
    brought a powerful but simple measure to the floor that called
    on this body to legislate on what we all agree needs to be
    done--locking in protections for patients with preexisting
    conditions. Unfortunately, House Democrats voted it down.
        Our amendment was consistent with our long-held views. With
    respect to the American Health Care Act, which our Democratic
    colleagues continue to mispresent, we provided protections for
    those with preexisting conditions. Under the AHCA:
         Insurance companies were prohibited from denying
    or not renewing coverage due to a preexisting condition.
    Period.
         Insurance companies were banned from rescinding
    coverage based on a preexisting condition. Period.
         Insurance companies were banned from excluding
    benefits based on a preexisting condition. Period.
         Insurance companies were prevented from raising
    premiums on individuals with preexisting conditions who
    maintain continuous coverage. Period.
        The fact is, we agree on this issue. And we can work
    together expeditiously to guarantee preexisting condition
    protections for all Americans and do so in manner that can
    withstand judicial scrutiny.
        And while a status check on the ACA lawsuit is interesting,
    the ruling has been stayed, Attorneys general across the
    country have filed appeals, Speaker Pelosi has moved to
    intervene in the case, and Americans' premiums and coverage for
    this year are not affected.
        But what really does affect American consumers is the out-
    of-control costs of healthcare. That's what they would like
    Congress to focus on. When will we tackle the high cost of
    healthcare?
        The fact of the matter is that for too many Americans
    health insurance coverage exists solely on paper because
    healthcare costs and high deductibles are putting family
    budgets in peril. When the Affordable Care Act passed,
    Democrats promised people their insurance premiums would go
    down $2500. Unfortunately, the exact opposite has occurred for
    many Americans. And not only have premiums gone up-not down-but
    also out-of-pocket costs have skyrocketed.
        The latest ``solution'' from the Democratic Party is a
    Government takeover of healthcare, called Medicare for All. We
    know that this plan would take away private health insurance
    from more than 150 million Americans, end Medicare as we know
    it, and rack up more than $32-trillion in costs, not to mention
    delays in accessing health services.
        Madam Chairwoman, other committees in this body have
    announced plans to have hearings on Medicare for All. Speaker
    Pelosi has said she is supportive of holding hearings on this
    radical plan. Madam Chairwoman, in fact, you yourself called
    for such hearings.
        A majority of House Democrats supported Medicare for All in
    the last Congress--in fact, two-thirds of committee Democrats,
    20 Members, 11 of whom serve on the Health Subcommittee,
    cosponsored the plan.
        I think it is important for the American people to fully
    understand what this huge, new, Government intervention into
    healthcare means for consumers. Yesterday, Dr. Burgess and I
    sent a letter to you and Chairman Pallone asking for a hearing
    on Medicare for All, as we are the committee with primary
    jurisdiction over healthcare issues.
        The American people need to fully understand how Medicare
    for All is not Medicare at all, but actually just Government-
    run, single-payer healthcare. They need to know about the $32
    trillion price tag for such a plan, and the tax increases
    necessary to pay for it. They need to know that it ends
    employer-sponsored healthcare, forcing the 158 million
    Americans who get their healthcare through their job or union
    into a one-size-fits-all, Government-run plan. If you like
    waiting in line at the DMV, wait until the Government
    completely takes over healthcare.
        Seniors need to fully understand how this plan does away
    with the Medicare Trust Fund that they have paid into their
    entire lives, and the impacts on their access to care. Our
    tribes need to understand how this plan impacts the Indian
    Health Service, and our veterans deserve to know how this plan
    paves the way to closing the VA.
        So the question is, When will we see the bill, and when
    will we have a hearing on the legislation?
        Meanwhile, we need to work together to help States
    stabilize health markets damaged by the ACA, cut out-of-pocket
    costs, promote access to preventive services, encourage
    participation in private health insurance, and increase the
    number of options available through the market.
        So let's work together to lock in preexisting condition
    protections, tackle ever-rising healthcare costs, and help our
    States offer consumers more affordable health insurance. And if
    Democrats must move forward on a complete Government takeover
    of healthcare, please pledge to give the American people a
    chance to read the bill so that we'll all know what's in it
    before we have to vote on it.

        Ms. Eshoo. I thank the ranking member of the full committee
    for his remarks. Several parts of it I don't agree with, but I
    thank him nonetheless.
        Now we will go to the witnesses and their opening
    statements. We will start from the left to Ms. Christen Linke
    Young, a fellow, USC-Brookings Schaeffer Initiative for Health
    Policy.
        Welcome to you, and you have 5 minutes, and I think you
    know what the lights mean. The green light will be on, then the
    yellow light comes on, which means 1 minute left, and then the
    red light.
        So I would like all the witnesses to stick to that so that
    we can get to our questions of you, expert as you are. So
    welcome to each one of you and thank you, and you are
    recognized.

       STATEMENTS OF CHRISTEN LINKE YOUNG, FELLOW, USC-BROOKINGS
        SCHAEFFER INITIATIVE FOR HEALTH POLICY; AVIK S. A. ROY,
     PRESIDENT, THE FOUNDATION FOR RESEARCH ON EQUAL OPPORTUNITY;
      ELENA HUNG, COFOUNDER, LITTLE LOBBYISTS; THOMAS P. MILLER,
     RESIDENT FELLOW IN HEALTH POLICY STUDIES, AMERICAN ENTERPRISE
       INSTITUTE; SIMON LAZARUS, CONSTITUTIONAL LAWYER AND WRITER

                   STATEMENT OF CHRISTEN LINKE YOUNG

        Ms. Young. Good morning, Chairwoman Eshoo, Ranking Member
    Burgess, members of the committee. Thank you for the
    opportunity to testify today.
        I am Christen Linke Young, a fellow with the USC-Brookings
    Schaeffer Initiative on Health Policy. My testimony today
    reflects my personal views.
        The Affordable Care Act has brought health coverage to
    millions of Americans. Since the law was passed, the uninsured
    rate has been cut nearly in half. The ACA's marketplaces are
    functioning well and offering millions of people comprehensive
    insurance.
        Thirty-seven States have expanded Medicaid, and many of the
    remaining States are considering expansion proposals. Beyond
    its core coverage provisions, the ACA has become interwoven
    with the American healthcare system.
        As just a few examples, the law put in place new consumer
    protections in employer-provided insurance, closed Medicare's
    prescription drug doughnut hole, changed Medicare reimbursement
    policies, reauthorized the Indian Health Service, authorized
    biosimilar drugs, and even required employers to provided space
    for nursing mothers.
        One of the core goals of the ACA was to provide healthcare
    for Americans with preexisting conditions, and I would like to
    spend a few minutes discussing how the law achieves the
    objective.
        By some estimates, as many as half of nonelderly Americans
    have a preexisting condition, and the protections the law
    offers to this group cannot be accomplished in a single
    provision or legislative proclamation.
        Instead, it requires a variety of interlocking and
    complementary reforms threaded throughout the law. At the
    center are three critical reforms.
        Consumers have a right to buy and renew a policy regardless
    of their health needs, have that policy cover needed care, and
    be charged the same price. Further, the ACA prohibits lifetime
    limits on care received and requires most insurers to cap
    copays and deductibles.
        Crucially, the law ensures that insurance for the healthy
    and insurance for the sick are part of the single risk pool and
    it provides financial assistance tied to income to help make
    insurance affordable.
        However, a recent lawsuit threatened this system of
    protections. In Texas v. United States, a group of States argue
    that changes made to the ACA's individual mandate in 2017
    rendered that provision unconstitutional.
        Therefore, they puzzlingly argue that the entire ACA should
    be invalidated, stripping away protections for people with
    preexisting conditions and everything else in the law.
        The Trump administration's Department of Justice has agreed
    with the claim of a constitutional deficiency, and they further
    agree that central pillars of the preexisting condition
    protection should be eliminated.
        But, unlike the States, DOJ argues that the weakened
    remainder of the law should be left to stand. Other scholars
    can discuss the weakness of this legal argument. I would like
    to discuss its impacts on the healthcare system.
        DOJ's position, that the law's core protections for people
    with preexisting conditions should be removed, would leave
    Americans with health needs without a reliable way to access
    coverage in the individual market.
        Insurers would be able to deny coverage and charge more
    based on health status. In many ways, the market would look
    like it did before the ACA. Components of the law would
    formally remain in place, but it is unclear how some of those
    provisions would continue to work.
        The States' position would wreak even greater havoc and
    fully return us to the markets that predated the ACA. In
    addition to removing central protections for those with
    preexisting conditions, the financial assistance for families
    purchasing coverage, and the ACA's funding for Medicaid
    expansion would disappear.
        The Congressional Budget Office has estimated the repeal of
    the ACA would result in as many as 24 million additional
    uninsured Americans, and similar results could be expected
    here.
        In addition, consumer protections for employer-based
    coverage would be eliminated, changes to Medicare would be
    undone, the Indian Health Service would not be reauthorized,
    the FDA couldn't approve biosimilar drugs. Indeed, these are
    just some of the many and far-reaching effects of eliminating a
    law that is deeply integrated into our healthcare system.
        Before I close, I would like to briefly note that Texas v.
    United States is not the only recent development that threatens
    Americans with preexisting conditions. Recent policy actions by
    the Trump administration also attempt to change the law in ways
    that undermine the ACA.
        As just a few examples, guidance under Section 1332 of the
    ACA purports to let States weaken protections for those with
    health needs. Nationwide, efforts to promote short-term
    coverage in association health plans seek to give healthy
    people options not available to the sick and drive up costs for
    those with healthcare needs.
        Additionally, new waivers in the Medicaid programs allows
    States to place administrative burdens in front of those trying
    to access care.
        To summarize, the Affordable Care Act has resulted in
    significant coverage gains and meaningful protections for
    people with preexisting conditions. Texas v. U.S. threatens
    those advances and could take us back to the pre-ACA individual
    market where a person's health status was a barrier to coverage
    and care.
        The lawsuit would also damage other healthcare policies,
    and this litigation coincides with administrative attempts to
    undermine the ACA's protections for people with preexisting
    conditions.
        Thank you.
        [The prepared statement of Ms. Young follows:]
        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you very much.
        Next, Mr. Avik Roy, president of the Foundation for
    Research and Equal Opportunity. Welcome.

                      STATEMENT OF AVIK S. A. ROY

        Mr. Roy. Chairwoman Eshoo, Ranking Member Burgess, and
    members of the Health Subcommittee of the House Energy and
    Commerce Committee, thanks for inviting me to speak with you
    today.
        I am Avik Roy and I am the president of the Foundation for
    Research on Equal Opportunity, a nonpartisan nonprofit think
    tank focussed on expanding economic opportunity to those who
    least have it.
        When we launched in 2016, our first white paper showed how
    universal coverage done the right way can advance both the
    progressive and conservative values at the same time, expanding
    access while reducing Federal spending and burdensome
    regulations.
        In my oral remarks, I am going to focus on a core problem
    that, respectfully, Congress has failed to solve: how to
    protect Americans with preexisting conditions while also
    ensuring that every American has access to affordable health
    insurance.
        Thirty-two million U.S. residents go without coverage
    today. Fewer than half of those eligible for subsidies in the
    ACA exchanges have enrolled in ACA-based coverage.
        This failure is the result of the flawed theory first
    articulated by MIT economist Jonathan Gruber underlying Title 1
    of the Affordable Care Act--that if Congress requires that
    insurers offer coverage to those with preexisting conditions
    and if Congress forces insurers to overcharge the healthy to
    undercharge the sick, Congress must also enact an individual
    mandate to prevent people from jumping in and out of the
    insurance market.
        We should all know by now that Professor Gruber is not
    omniscient. After all, in 2009, Gruber said, what we know for
    sure about the ACA is that it will, quote, ``lower the cost of
    buying nongroup health insurance.''
        In reality, premiums have more than doubled in the ACA's
    first 4 years, and the ACA subsidies only offset those
    increases for those with incomes near the poverty line.
        There are two flaws with Gruber's theory, sometimes called
    the three-legged stool theory. First, the two ACA provisions
    that have had the largest impact on premiums have nothing to do
    with preexisting conditions.
        Second, the ACA's individual mandate was so weak with so
    many loopholes that its impact on the market was negligible.
    Guaranteeing offers of coverage for those with preexisting
    conditions has no impact on premiums because the ACA limits the
    enrollment period for guaranteed issue plans to six weeks in
    the fall or winter.
        The limited enrollment period, not the mandate, ensures
    that people can't game the system by dropping in and out. While
    community rating by health status does cause some adverse
    selection by overcharging healthy people who buy coverage,
    thereby discouraging healthy people from signing up, among
    enrollees of the same age this is not an actuarially
    significant problem.
        The largest impact is from the ACA's 3-to-1 age bans which
    on their own double the cost of insurance for Americans in
    their 20s and 30s, forcing many to drop out of the market
    because younger people consume one-sixth of the healthcare that
    older people do.
        In the court cases consolidated as NFIB v. Sebelius,
    President Obama's Solicitor General, Neal Katyal, repeatedly
    argued that if the individual mandate were ruled to be
    unconstitutional, much of the ACA should remain but that the
    ACA's guaranteed issue and health status community rating
    provisions, the ones that impact those with preexisting
    conditions, should also be struck from the law.
        The Trump Justice Department has merely echoed this belief.
    Both administrations are more correct than the district judge
    in Texas v. Azar, who, in an egregious case of judicial
    activism, argued that the entirety of the ACA was inseparable
    from the mandate.
        However, it is clear that both Justice Departments are also
    wrong. The zeroing out of the mandate penalty has not blown up
    the insurance market. Indeed, it has had no effect.
        To be clear, it is not just ACA enthusiasts who have bought
    into Gruber's flawed theories. Many conservatives have as well.
    A number of conservative think tank scholars have argued that,
    because they oppose the individual mandate, we should also
    repeal the ACA's protections for those with preexisting
    conditions--that is, guaranteed issue and community rating by
    health status.
        These scholars have argued that a better way to cover those
    with preexisting conditions is to place them in a separate
    insurance pool for high-risk individuals.
        I want to state this very clearly: Those scholars are
    wrong. The most market-based approach for covering those with
    preexisting conditions is not to repeal the ACA's guaranteed
    issue and health status provisions but to preserve them and to
    integrate the principles of a high-risk pool into a single
    insurance market through reinsurance.
        I have been pleased to see Republicans in Congress support
    legislation that would ensure the continuity of preexisting
    condition protections irrespective of the legal outcome in
    Texas v. U.S. I hope both parties can work together to achieve
    this.
        Both parties can further improve the affordability of
    individual insurance by enacting a robust program of
    reinsurance and restoring 5-to-1 age bans.
        On these and other matters, I look forward to working with
    all members of this committee both today and in the future to
    ensure that no American is forced into bankruptcy by high
    medical bills.
        Thank you.
        [The prepared statement of Mr. Roy follows:]
        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you very much, Mr. Roy.
        You have testified here before, and we appreciate you being
    here again today. I would like to just suggest that, for the
    benefit of Members, that you get your testimony to us much
    earlier, all right?
        Mr. Roy. I apologize.
        Ms. Eshoo. Yes.
        Mr. Roy. I was, of course, officially invited to testify
    before this committee on Monday. I had some personal and
    professional obligations that limited my ability to get the
    testimony in a timely fashion.
        Ms. Eshoo. Yes.
        Mr. Roy. I will be happy to brief any members of this
    committee or their staffs at another time.
        Ms. Eshoo. Well, we thank you. I just--I have a bad habit,
    I read everything, and it wasn't there. So--but I heard today,
    and then we will all ask you our questions. Thank you.
        The next witness is Ms. Hung, and she is the cofounder of
    Little Lobbyists. You are recognized for 5 minutes, and
    welcome.

                        STATEMENT OF ELENA HUNG

        Ms. Hung. Thank you. Good morning.
        Thank you, Chairwoman, Ranking Member, and members of the
    subcommittee for the opportunity to tell my story and share my
    concerns with you today.
        My name is Elena Hung, and I am a mom. I am a proud mom of
    an amazing 4-year-old. My daughter, Xiomara, is a happy child.
    She is kind and smart and funny and a little bit naughty. She
    is the greatest joy of my life.
        She is at home right now, getting ready to go to school.
    She attends an inclusive special education pre-K program, and I
    asked her if she wanted to come here today. She said she wanted
    to go to school instead.
        It has been a long road to this moment. Xiomara was born
    with chronic complex medical conditions that affect her airway,
    lungs, heart, and kidneys. She spent the first 5 months of her
    life in the neonatal intensive care unit.
        She uses a tracheostomy tube to breathe and a ventilator
    for additional respiratory support. She relies on a feeding
    tube for all of her nutrition. She participates in weekly
    therapies to help her learn how to walk and talk. But I am
    thrilled to tell you that Xiomara is thriving today.
        This past year was her best year yet healthwise, and
    ironically it was also when her access to healthcare has been
    the most threatened. I sit before you today because families
    like mine--families with medically complex children--are
    terrified of what this lawsuit may mean for our kids.
        You see, our lives are already filled with uncertainty--
    uncertainty about diagnoses, uncertainty about the effects of
    medications and the outcomes of surgeries. The one certainty we
    have is the Affordable Care Act and the healthcare coverage
    protection it provides.
        We don't know what Xiomara's future holds, but with the
    ACA's protections in place we know this: We know Xiomara's 10
    preexisting conditions will be covered without penalty, even if
    we switch insurance plans or employers.
        We know a ban on lifetime caps means that insurance
    companies cannot decide that her life isn't worth the cost and
    cut her off care just because she met some arbitrary dollar
    amount.
        We know we won't have to worry about losing our home as a
    result of an unexpected hospitalization or emergency. We know
    Medicaid will provide the therapies and long-term services and
    supports that enable her independence.
        I sit before you today on behalf of families like mine who
    fear that the only certainty we know could be taken away,
    pending the outcome of this lawsuit--this lawsuit that seeks to
    eliminate protections for people with preexisting conditions--
    and if that happens our children's lives will then depend on
    Congress where every so-called replacement plan proposed over
    the last 2 years has offered far less protection for our kids
    than the ACA does.
        I sit here before you today on behalf of Isaac Crawley, who
    lost his insurance in 2010 after he met his lifetime limit just
    a few weeks after his first birthday but got it back after the
    ACA became law;
        Myka Eilers, who was born with a preexisting congenital
    heart defect and was able to obtain health insurance again when
    her dad reopened his own business after being laid off;
        Timmy Morrison, who spends part of his childhood in
    hospitals, both inpatient and outpatient, because his insurance
    plan covers what is essential to his care;
        Claire Smith, who has a personal care attendant and is able
    to live at home with her family and be included in her
    community, thanks to Medicaid;
        Simon Hatcher, who needs daily medications to prevent life-
    threatening seizures, medications which would cost over $6,000
    a month without insurance;
        Colton Prifogle, who passed away on Sunday and was able to
    spend his final days pain-free with dignity, surrounded by
    love, because of the hospice care he received.
        These are my friends, my friends that I love. These are
    Xiomara's friends. This is our life. I cofounded the Little
    Lobbyists, this group of families with medically complex
    children, some of whom are here today, because these are
    stories that desperately need to be told and heard alongside
    the data and numbers and policy analysis.
        There are children like Xiomara in every State. That's
    millions of children with preexisting conditions and
    disabilities across the country. I sit before you today on the
    eve of another trip to the Children's Hospital.
        Tomorrow I will hold my daughter's hand as I walk her to
    the OR for her procedure, and as I have done every time before,
    I know I will drown in worry, as a mother does.
        But the thing that has always given me comfort is knowing
    that my Government believes my daughter's life has value and
    that the cost of medical care she needs to survive and thrive
    should not financially bankrupt us. It is my plea for that to
    always be true.
        Thank you.
        [The prepared statement of Ms. Hung follows:]
        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you, Elena. Beautiful testimony. Beautiful
    testimony. I wish Xiomara were here. Maybe we can provide a
    tape so that when she gets older she can hear her mother's
    testimony in the Congress of the United States. Thank you.
        I now would like to recognize Mr. Thomas Miller, resident
    fellow at the American Enterprise Institute. Welcome, and thank
    you. You have 5 minutes.

                     STATEMENT OF THOMAS P. MILLER

        Mr. Miller. Thank you, Chairwoman Eshoo. The mortifying
    silent C in my written testimony in your name must have been
    due to the speed with which I delivered the testimony on time.
    But I apologize for that.
        Thank you also, Ranking Member Burgess and members of the
    subcommittee. Now let us all take a deep breath and get to it.
        The Texas case remains in its relatively early stages. Its
    ultimate fate is as much as another 16 months away. The
    probability of a Supreme Court ruling that would overturn the
    entire ACA remains very, very low, just by last December's
    decision at the Federal district court level.
        Any formal enforcement action to carry out that decision
    has been stayed while the case continues on appeal. We have
    been here before. Two longer-term trends in health policy
    persist: our overreliance on outsourcing personal healthcare
    decisions to third-party political intermediaries and then our
    chronic inability to reach compromises and resolve health
    policy issues through legislative mechanisms. They have fuelled
    a further explosion in extending health policy battles to our
    courts.
        So welcome back to Groundhog Day, ACA litigation version.
    The plaintiff's overall case is not frivolous, but it does rely
    heavily on taking the actual text of the ACA literally and
    thereby limiting judicial scrutiny to what the Congress that
    enacted appeared on the limited record of that time to intend
    by what it did.
        The plaintiffs are attempting to reverse engineer and
    leverage the unusually contorted Supreme Court opinion of Chief
    Justice Roberts in NFIB v. Sebelius.
        Now, come critics insist that the 115th Congress that
    zeroed out the mandate tax also expressed a clear intent to
    retain all other ACA provisions. This ignores the limited scope
    of what that Congress had power to do through the vehicle of
    budget reconciliation in the tax-cutting Jobs Act. All that its
    Members actually voted into law was a change regarding
    individual mandate.
        It did not and could not extend to the ACA's other
    nonbudgetary regulatory provisions, nor did it change the
    findings of fact still in statutory law first made by the 111th
    Congress that insisted the individual mandate was essential to
    the functioning of several other ACA provisions, notably,
    guaranteed issue and adjusted community rating.
        The plaintiffs are not out of bounds in trying to hold
    Congress to its past word--it happens once in a while--and in
    building on the similar reasoning used by other Supreme Court
    majorities to strike down earlier ACA legal challenges.
        Since that's the story for ACA defenders, they should have
    to stick to it, at least until a subsequent Congress actually
    votes to eliminate or revise those past findings of fact
    already in permanent law.
        But, even if appellate courts also find some form of
    constitutional injury in what remains of the ACA's individual
    mandate as a tax-free regulatory command, the severability
    stage of such proceedings will become far more uphill for the
    plaintiffs.
        Most of the time, the primary test is functionality in the
    sense of ascertaining how much of the remaining law with the
    Congress enacting it believe could be retained and still
    operate as it envisioned.
        Given the murkiness of divining or rewriting legislative
    intent in harder cases like this one, it remains all but
    certain that an ultimate Supreme Court ruling would, at a
    minimum, follow up previous inclinations revealed in the 2012
    and 2015 ACA challenges and try to save as much of the law as
    possible.
        Even appellate judges in the Fifth Circuit will note
    carefully the passage of time, the substantial embedded
    reliance costs, and the sheer administrative and political
    complexity of unwinding even a handful of ACA provisions on
    short notice.
        So don't bet on more than a narrow finding that could sever
    whatever remains of an unconstitutional individual mandate
    without much remaining practical impact from the rest of the
    law.
        On the health policy front, we might try to remember that,
    when congressional action produces as flawed legislative
    product justified in large part by mistaken premises and
    misrepresentations, it won't work well.
        The ACA's architects and proponents oversold the
    effectiveness and attractiveness of the individual mandate,
    claiming it could hold the law's insurance coverage provisions
    together while keeping official budgetary costs and coverage
    estimates within the bounds of CBO's scoring.
        But what worked to launch the ACA and keep it viable in
    theory and politics did not work well in practice, and, to be
    blunt, one of the primary ways that the Obama administration
    sold its proposals for health policy overhaul was to exaggerate
    the size, scope, and nature of the potential population facing
    coverage problems due to preexisting health conditions.
        Of course public policy should address remaining problems.
    It could and should be improved in other less proscriptive and
    more transparent ways than the ACA attempted.
        My written testimony suggests a number of option available
    to lawmakers if some of the ACA's current overbroad regulatory
    provisions were stricken down in court in the near future.
        However, we are not back in 2012 or 2010 or even 2017
    anymore, at least outside of our court system. Changes in
    popular expectations and health industry practices since 2010
    are substantial breaks on even well-structured proposals for
    serious reform. But that is where the real work needs to be
    restarted.
        It is often said with apocryphal attribution that God takes
    care of children, drunks, or fools, and the United States of
    America. Well, let's not press our luck. To produce better
    lawsuits, fewer lawsuits, let us try to write and enact better
    laws.
        Thank you.
        [The prepared statement of Mr. Miller follows:]
        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you.
        And now our last witness, Mr. Thomas Miller, resident
    fellow--I am sorry--Mr. Simon Lazarus, constitutional----
        Mr. Miller. I think he's younger than I am.
        Ms. Eshoo [continuing]. Constitutional lawyer and writer.
    Welcome. It is lovely to see you, and thank you for being here
    to be a witness and be instructive to us.
        You have 5 minutes.

                       STATEMENT OF SIMON LAZARUS

        Mr. Lazarus. Thank you, Chair Eshoo, and Ranking Member
    Burgess and members of the subcommittee. My name is Simon
    Lazarus. I am a lawyer and writer on constitutional and legal
    issues relating to, among other things, the ACA.
        I have had the privilege of testifying before this
    subcommittee and other congressional committees numerous times.
    I am currently retired, and the views that I express here are
    my own and cannot be attributed to any of the organizations for
    which I previously worked or other organizations.
        I have to say that I am not sure how important my task is,
    because I think all of the witnesses have pretty much agreed
    with the bottom line, and that includes the witnesses invited
    by the minority, and that is that this decision to invalidate
    the entire ACA is, in significant respects, and I think many of
    us agree that in all respects, completely baseless legally and
    has close to zero chances of being upheld on appeal.
        And in light of all of that, Tom, I have to--I am puzzled
    by your assertion that the lawsuit is not frivolous, because
    that sounds to me like the definition of frivolousness in a
    lawsuit.
        In any event, I think it should be underscored that it is
    not a coincidence that even the minority witnesses think very
    little of this lawsuit, because, as soon as the decision came
    down, it was attacked in extremely strong terms across the
    political spectrum.
        As the Wall Street Journal editorialized, ``While no one
    opposes Obamacare more than we do, Judge O'Connor's decision is
    likely to be overturned on appeal.'' Legal experts, including
    prominent anti-ACA conservatives, have blistered Judge
    O'Connor's result.
        For example, Phillip Klein, the executive editor of the
    Washington Examiner, called the decision ``an assault on the
    rule of law.'' Professor Jonathan Adler, who is an architect of
    the second fundamental legal challenge to the ACA--that's King
    v. Burwell--which I think the idea for which was hatched at a
    meeting that you probably hosted----
        Mr. Miller. I have been here before.
        Mr. Lazarus. OK. And that effort to kill the ACA was
    rejected by the Supreme Court in 2015. In any event, Professor
    Adler called the decision, quote, ``an exercise of raw judicial
    power unmoored from the relevant doctrines concerning when
    judges may strike down a whole law because of a single alleged
    legal infirmity buried within it.''
        And on the courts, if one is going to be a prognosticator,
    just look at the basic facts. Chief Justice John Roberts'
    pertinent opinions nearly ensure at least a 5-4 Supreme Court
    majority to reverse Judge O'Connor, and moreover it should be
    noted that Justice Brett Kavanaugh, looking at his prior
    decisions as a DC circuit judge, also looks very likely to join
    a larger majority to reverse Judge O'Connor.
        So my job here is just to try to explain what the legal
    reasons are for this negative judgment on O'Connor's decision,
    so I am going to try to briefly do that.
        To begin with, the court could well dismiss the case for
    lack of standing to sue on the part of any of the plaintiffs
    who brought the case. The State government plaintiffs barely
    pretend to have a colorable standing argument.
        The two individual plaintiffs complain that, though it is
    enforceable, the mandate nonetheless imposes a legal obligation
    to buy insurance and they would feel uncomfortable violating
    that obligation.
        The problem with this is that Chief Justice Roberts in his
    2012 NFIB v. Sebelius decision, which upheld the mandate,
    expressly ruled that and based his decision, really, on the
    determination that, if individuals did not buy insurance--thus,
    quote, ``choosing to pay the penalty rather than obtain
    insurance''--they will have fully complied with the law.
        Now, post-TCJA--the Tax Cut and Jobs Act--a nonpurchaser
    will still not be in violation of the law simply because
    Congress reduced to zero the financial incentive to choose the
    purchase option.
        So no one is compelled to buy insurance in order to avoid a
    penalty since none exists nor to follow the law, because he
    will be following or she will be following the law.
        So there is no injury period, no standing to sue. That is a
    very likely result, even in the Fifth Circuit, I would say.
        Ms. Eshoo. Mr. Lazarus, can you just summarize----
        Mr. Lazarus. OK. I am sorry.
        Well, in addition, I would just say on the merits the ACA's
    mandate provision remains a valid exercise of the tax power and
    that is pretty much for the same reasoning that there is no
    standing, and that is because Congress' determination after the
    original ACA passed to drop the penalty to zero did not strip
    Congress of its constitutional power under the tax authority.
        And nor can its subsequent determination sensibly mean that
    it was no longer using that power. And finally, I would just
    want to add really to what other people have said and some of
    the members of the subcommittee have eloquently said, that to
    take the further leap that, if the mandate provision is
    unconstitutional after the reduction of the penalty to zero--
    which it really should not be found, but if it is--there is
    absolutely no basis whatsoever for striking down the rest of
    the ACA.
        [The prepared statement of Mr. Lazarus follows:]
        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you very much.
        All right. I am going to--we have how concluded the
    statements of our witnesses. We thank you again for them. Each
    Member will have 5 minutes to ask questions of the witnesses,
    and I will start by recognizing myself for 5 minutes.
        I appreciate the discussion about the legalities, and of
    course we are discussing Texas v. United States today. But the
    issue of preexisting conditions keeps coming up, and I would
    like Ms. Young and anyone else to chime in.
        This issue of what our Republican colleagues say that they
    are for, and I listen to C-SPAN a lot and especially during the
    days running up to the election, and they covered Senate races
    and House races, and I heard Republicans over and over and over
    again in those debates with their opponents saying, ``I am for
    preexisting conditions.''
        Now, can anyone address how you extract that out of what we
    have now, the Affordable Care Act, and have standalone
    insurance policies? Where is the guarantee about what the price
    would be for that policy?
        Would you like to----
        Ms. Young. The Affordable Care Act--absolutely. The
    Affordable Care Act requires that all insurance plans charge
    consumers the same price regardless of----
        Ms. Eshoo. That I understand. That's what we put in. But
    the minority is saying that they are for preexisting
    conditions, except they have voted against the ACA countless
    times.
        So if you were to extract just that one issue and write a
    bill on it, where is the guarantee on what the price would be
    for that standalone policy?
        Ms. Young. In my view, it is very difficult to put together
    a system of protections for people with preexisting conditions
    that doesn't include a panoply of reforms similar to many of
    the reforms that were included in the Affordable Care Act.
        So you need to ensure people can buy a policy. You need to
    ensure that that policy doesn't exclude coverage for their
    particular healthcare needs.
        You need to ensure that they are able to purchase at a fair
    price and you need to surround that with reforms that really
    create a functioning insurance market by providing financial
    assistance, stable risk adjustment, and other associated
    provisions like that.
        Ms. Eshoo. I want to get to something that is out there,
    and that is what I refer to in my opening statement. I refer to
    them as junk plans. It is my understanding that many of these
    plans exclude coverage for prescription drugs, for mental
    health and substance use disorders.
        Who would like to address this? Is this correct?
        Ms. Young. I can address that.
        Ms. Eshoo. Uh-huh. Go ahead.
        Ms. Young. I believe you are referring to short-term
    limited duration coverage.
        Ms. Eshoo. Right. Mm-hmm.
        Ms. Young. Those plans are not required to cover any
    particular benefit, and many of them can and likely will
    exclude coverage for benefits like prescription drugs,
    maternity care, substance use and mental health services,
    things like that.
        Ms. Eshoo. Now, are these plans medically underwritten?
        Ms. Young. Many of them are, yes.
        Ms. Eshoo. And how does that differ from the process by
    which Americans get health insurance on the individual market
    today?
        Ms. Young. Medical underwriting refers to a process where
    insurance companies require individuals to fill out a detailed
    health history questionnaire and then use the results of that
    to determine if the individual can purchase a policy and if so
    on what terms.
        That was a common practice in the individual market before
    the Affordable Care Act. It is permitted for short-term limited
    duration plans today.
        In contrast, in the ACA-compliant individual market,
    insurers are not prohibited to medically underwrite. Consumers
    sign up for a policy based only on information about their age
    and their income if they are seeking tax credits with no health
    history screening.
        Ms. Eshoo. I see. Mr. Lazarus----
        Mr. Miller. Chairwoman Eshoo, could you ask the rest of the
    panel, and we are getting a one-sided view of this. The ACA's
    protections are----
        Ms. Eshoo. I didn't call on you. I would like to call on
    Mr. Lazarus. Are you giving us comfort that the lawsuit is not
    going to go anywhere? Is that what you believe?
        Mr. Lazarus. I think all of the witnesses have basically
    said that, at least with respect to the notion that, if the
    mandate provision is now found to be unconstitutional, which I
    don't think it will be or should be, the quantum leap that the
    Republican attorneys general and Judge O'Connor took to then
    say the whole law has to go, I don't think any member of the
    panel thinks that there is much chance of that occurring.
        So I don't know whether that answers your--that doesn't
    mean, however, that the fact that there is this dagger pointed
    at the heart of our healthcare system is out there causing
    uncertainty, that it was--basically, opponents of the ACA have
    outsourced to a judge, which Chairman Pallone correctly said
    was a target of forum shopping who has a widespread reputation
    of, one article said, tossing out Democratic policies that
    Republican opponents don't like.
        Ms. Eshoo. I think my time has more than expired. Thank
    you.
        I now would like to recognize the ranking member of the
    subcommittee, Dr. Burgess.
        Mr. Burgess. I thank you for the recognition.
        Mr. Miller, let me just give you an opportunity. You were
    trying to respond with something about the ACA protections.
        Mr. Miller. Sure. It is a complex issue, but we need to
    remember that in the best of the world, the ACA left a lot of
    other folks unprotected. If you didn't comply with the
    individual mandate, you didn't get coverage. You got fined. You
    got insult on top of injury, and there is no coverage to it.
        So there are breakdowns in any imagined perfect system.
    There are other approaches which can also fill that hole. You
    are going to have to put some money in. You are going to have
    to resolve----
        I don't think the Republicans did a good job of it in 2017
    in explaining and defining what that meant. They began
    backfilling as they went along with reinsurance. There are ways
    to extend HIPAA over to the individual market.
        Those are all thoughtful alternative approaches, and if you
    don't have an individual mandate, you should come up with
    something else. And we are not going to have an individual
    mandate. That appears to be the case.
        So you are leaving a hole there and there are other ways to
    provide stronger incentives, and it requires some robust
    protections where if you went into something like a high-risk
    pool or an invisible risk pool you could requalify for that
    full-scale portability after 18 months.
        So there are ways to connect the dots. It is heavier
    lifting, and it is more work than just waving your arms and
    saying, ``We mandated it, it must work,'' even though it
    doesn't.
        Mr. Burgess. And I thank you for that clarification, and
    just--continuous coverage was part of the bill that we worked
    on 2 years ago.
        Mr. Miller. A number of options. Yes.
        Mr. Burgess. Which, of course, is what exists in Medicare.
    I mean, if you do not purchase Medicare within 3 months of your
    65th birthday, guess what? You get an assessment for the rest
    of your life in Part B of Medicare.
        So, Mr. Miller, I actually agree with you and, I guess,
    other witnesses. My expectation is that this case will not be
    successful on appeal, and I base that on the fact that I have
    been wrong about every assumption I have made about the
    Affordable Care Act ever since its inception in 2009.
        So perhaps I can be wrong about that assumption, but I do
    assume that it will not survive on appeal.
        Let me just ask you, because I have had difficulty finding
    this information--you may have some sense--how much money has
    been collected under the individual mandate? The fines that
    have been paid--do we have an idea what that dollar figure is?
        Mr. Miller. Yes. I did that a couple years ago in the Ways
    and Means. I knew it was going to come up today. I can supply
    it for you.
        Mr. Burgess. Great.
        Mr. Miller. This is--with a bit of a lag it ends up being
    calculated. Not a lot, and it's somewhat randomly distributed.
    It tends to be the lower-income people who didn't know how to
    get out of the individual mandate who ended up paying it,
    surprisingly enough. But it did not amount to a large amount,
    and it didn't have a lot of coverage effects.
        Mr. Burgess. So, basically, the effect of the Tax and Jobs
    Act of 2017 was current law because no one behaved as if it was
    a real thing anyway.
        Mr. Miller. Well, it had some other ripple consequences.
    But in that, practical consequences were not as significant as
    is often said.
        Mr. Burgess. Well, let me ask you this. I mentioned in my
    opening statement that perhaps ways to end this lawsuit would
    be to either repeal the individual mandate outright or
    reestablish the tax within the individual mandate. Do you agree
    that either of those activities would----
        Mr. Miller. That requires actually legislating, which is a
    hard thing to do these days on Capitol Hill.
        Mr. Burgess. I think--yes, sir. But it would achieve the
    goal of breaking the lawsuit.
        Mr. Miller. Sure. And there is lots of other things. I
    mean, States could pay us their own individual mandate. As I
    said, you could also just rescind your findings of fact in the
    old Congress and say, ``We were wrong, we are sorry.''
        Mr. Burgess. I don't think that is going to happen.
        Let me just ask you. I mentioned the phenomenon of silver
    loading in my opening statement. Would you walk us through, for
    people who are not familiar with that as a technical term----
        Mr. Miller. Sure.
        Mr. Burgess [continuing]. The phenomenon of silver loading?
        Mr. Miller. It is a bit of a ripple of the other litigation
    over the cost-sharing reduction subsidies, and that has got a
    tangled web in itself.
        But, cleverly, a number of States, insurance regulators,
    and insurers figured out a way to game the system, which is how
    do you get bigger tax credits for insurance by increasing your
    premiums.
        There was also worry about what those market were doing,
    which fueled some of that increase, and a lot of spikes in the
    individual market over the previous 2 years as a result of
    that, and the silver loading embellished that.
        Now, that was great for folks who were already covered
    where, because of the comprehensiveness of their subsidy income
    related, they weren't out any extra dollars as those premiums
    went up.
        But the folks in the rest of the individual market--and
    Avik can talk to this as well--that is where we had our
    coverage losses, and that is where you got the damage being
    done. Those are the victims--the byproducts of doing good on
    one hand and it spills over into other people.
        Mr. Burgess. That's the teacher and policeman that I
    referenced in my district who have two children. They are
    outside the subsidy window.
        Mr. Roy, could you just briefly comment on the effect of a
    Medicare for All policy on what union members receive as their
    health insurance?
        Mr. Roy. Well, I mean, of course, there are many different
    definitions of Medicare for All, but if we define it as the
    elimination of private insurance then, obviously, union members
    who have either Taft-Hartley-based plans or employer-sponsored
    insurance, that would be replaced by a public option or
    something like that. I assume that is what you mean.
        Mr. Burgess. Yes, sir. Thank you. Thank you for being here.
        I yield back.
        Ms. Eshoo. Thank you, Ranking Member.
        And who are we going to? To recognize the gentlewoman from
    the great State of California and its capital, Sacramento, Ms.
    Matsui.
        Ms. Matsui. Thank you, Madam Chair.
        Thank you all for joining us today. The topic of this
    hearing is incredibly important to me and my constituents and
    all Americans whose lives have been changed by the Affordable
    Care Act.
        A special thank you to Ms. Hung for sharing your daughter's
    story and for your incredible advocacy work on behalf of
    children and families everywhere.
        When we started writing the ACA 9 years ago, I consulted
    with a full range of healthcare leaders in my district in
    Sacramento. They called together the hospitals, the health
    plans, the community health centers, the patients, and all
    those who contribute to our healthcare systems and all those
    who use it also.
        Everything was carefully constructed. We tried to think
    about everything but, obviously, you can't think of everything.
    But we consulted as widely as possible because we also knew
    that each policy would affect the next and the system as a
    whole.
        You simply cannot consider radical changes to the law in a
    vacuum, yet that is exactly what this ruling of the lawsuit
    does. By using the repeal of the individual mandate in the GOP
    tax bill as justification of this suit, the court has declared
    the entire Affordable Care Act invalid.
        Millions of Californians and Americans stand to lose
    critical health protections, including protections for people
    especially with preexisting conditions. Vital protections for
    Medicare beneficiaries including expanded preventive services
    and closing the prescription drug doughnut hole will be thrown
    into chaos.
        I was pleased to join my colleagues to vote for the House
    of Representatives to intervene in this lawsuit and defend the
    ACA in our continued fight to protect people with preexisting
    conditions and for the healthcare of all Americans, and I think
    you know that that is something that all Americans care about
    when you think about preexisting conditions. Everybody has some
    sort of preexisting conditions.
        For me, the potential consequences of the lawsuit are too
    great to not fully consider, especially for the impact on
    people confronting mental illness and substance abuse.
        The passage of the ACA was a monumental step forward in our
    fight to confront the mental health and substance abuse crisis
    in this country and led to the largest coverage gains for
    mental health in a generation through the expansion of
    Medicaid.
        Ms. Linke Young, can you briefly discuss why the consumer
    protections of the ACA are so important to individuals
    struggling with mental illness or substance abuse?
        Ms. Young. Absolutely. Preexisting law--law that existed
    prior to 2009--established a baseline protection for people
    with mental illness that said that, if their insurance plan
    covered mental illness--mental health needs--then it had to do
    so on the same terms that it covered their physical treatment.
        But it didn't require any insurance product to include
    coverage of mental health benefits. And so it was typical for
    coverage in the individual market to exclude mental health
    benefits completely.
        With the Affordable Care Act, plans were required to
    include coverage for mental health and substance use disorder
    services and to do so at parity on the same terms as they
    include coverage for physical health benefits, and that brought
    mental health benefits to about 10 million Americans who
    wouldn't have otherwise had it.
        In addition, the Medicaid expansion in the 37 States and DC
    and that have taken that option has enabled many, many people
    with serious mental health needs, including substance use
    disorder, to access treatment that they would not otherwise
    have been able to access.
        Ms. Matsui. So this would be very serious, and I am
    thinking about the 37 States that did expand Medicaid, if this
    decision was upheld.
        I just really feel, frankly, that it is difficult enough
    when you have mental illness or someone in your family does,
    the stigma that is attached to it, whereas with the Medicaid
    expansion I believe that most people will seek the treatment
    that they really need.
        And what do you foresee with the loss of this expansion if
    it were to happen?
        Ms. Young. If Federal funding for Medicaid expansion was no
    longer available, then the States that have expansion in place
    would need to choose whether to find State funding to fill that
    gap or to scale back their expansion or cut benefits or reduce
    provider rates or some combination of those policies.
        The Congressional Budget Office and most experts expect
    that many States would retract the expansion and move those
    residents that were covered through expansion off the Medicaid
    rolls, and most of them are likely to become uninsured and
    would not continue to have access to mental health and
    substance use disorder coverage.
        Ms. Matsui. So, in essence, we will be going backwards then
    once again. OK.
        Thank you very much, and I yield back the balance of my
    time.
        Ms. Eshoo. Thank you, Ms. Matsui.
        I would now like to recognize the gentleman from Kentucky,
    Mr. Guthrie.
        Mr. Guthrie. Thank you very much, and again,
    congratulations on your----
        Ms. Eshoo. Thank you.
        Mr. Guthrie [continuing]. On being the chair. I enjoyed
    being vice chair a couple of times and learned a lot about the
    healthcare system and moving forward.
        And I know today the title is how does the Texas case
    affect preexisting conditions, and I think we are hearing from
    everybody that it would probably be near unanimous if we did a
    legislative fix to preexisting conditions regardless of where
    the case goes, and so I was listening to Dr. Burgess talk
    earlier about having a hearing for Medicare for All, and I
    think the chair of the full committee said that, well, ``Why
    would you want to have a hearing for a piece of legislation you
    say you're not for?''
        I think it is important for us to talk about and the issues
    that would come because there are, I think, at least four or
    five presidential candidates that already said they were for
    it.
        So it is not just some obscure bill that somebody files
    every year. It has now gotten into the public space that we
    need to discuss.
        And Ms. Hung, I appreciate your testimony. I have nothing
    compared to your issues with your child, but I had a son that
    had some issues when he was a boy. He is 23 now, and so about a
    month of just, ``What is going to happen?''--so I understand
    the preexisting conditions--and then another year and a half,
    maybe 2 years, in and out of children's hospitals. But we got
    the best words a parent can hear when a physician walks in:
    ``We know what the problem is now, and we can fix it.''
        Matter of fact, just last fall he thought he was having
    some problems--so he lives in Chicago, west of Chicago. I went
    to see a--to a doctor with him and the doctor said, ``Hey, it
    is something else, it is something routine we can treat.'' He
    goes, ``By the way, you had a really great surgeon when he was
    8.'' So we were just reinforced with it. So everything kind of
    works.
        And so what has kind of impressed me, and I guess I am
    going to just talk a little bit instead of ask questions, but
    what has always impressed me about the care--Vanderbilt
    Children's Hospital is where we were--that he has received and
    just the innovation our healthcare system is producing.
        It is absolutely amazing innovation coming out in our
    healthcare system. The artificial pancreas is real now. People
    can have it now. You can cure hepatitis C with a pill. It is
    just amazing what is happening with some people, not a lot. It
    is not universal, but stage four melanoma is being cured with
    precision medicine.
        I mean, those things are happening in our healthcare
    system. They are expensive, and my biggest concern if we go to
    a Government-run, that we just lose that healthcare. We
    innovate, and the world--and President Trump talked about it a
    little last night--is living off our investment in innovation.
    But if we don't invest and innovate, who is going to do it and
    who is going to have the care that we have?
        As a matter of fact, we are investing and innovating so
    quickly, this committee spent an awful lot of time over the
    last couple of years to put 21st Century Cures in place so the
    Government regulatory structure can keep up with the vast
    investment.
        I know we spent a lot of time in the last couple years
    doing oversight. I hope we will continue to do oversight of
    implementation of 21st Century Cures.
        So my only point is, and I will yield back in just a couple
    seconds, is that it is important when we look at such massive
    changes to our healthcare system, the way people get health
    insurance.
        You know, most people still get it through their employer.
    Is that going to go away? People get it through--we talked
    about the Indian Health Services. Is that going to go away? Is
    it a road to get rid of the VA?
        Just, there is so much change that is proposed in what
    people boil down to one--a bumper sticker, Medicare for All--
    that it has implications for everybody. It has implications for
    the whole country, and universal coverage is a positive thing.
        But if you get to the--I tell you, if you get to the
    Medicare reimbursements throughout the entire healthcare
    system, I am convinced we won't have the innovation that
    completely--my son is completely healed--that had some
    innovative surgeries--for his privacy I won't say--but 15 years
    ago that now are probably completely different on what you see.
        My cousin is a NICU doctor, and the stuff that--the babies
    that he now sees that are surviving, and we have a colleague
    here that had a daughter born without kidneys who, I guess--
    Abby must be about 5 or 6 now.
        And so it is just--that is a concern, and I think that when
    we are going to have a piece of legislation that has kind of
    been boiled down to a bumper sticker but it is going to have
    impact on everybody living in this country and everybody
    throughout the world--because I wish the world would help
    subsidize some of the innovations that we are producing--that
    it is worthy for us to have serious discussions and not just
    dismiss it as we are not being serious.
        So and I can tell you I am, I know Dr. Burgess is and I
    think the rest of the committee would be, and I appreciate you
    guys all being here and sharing your stories.
        But we can fix preexisting conditions. I think we are all
    on board with that, and Madam Chair, I yield back.
        Ms. Eshoo. I thank you, Mr. Burgess. Always a gentleman.
        Let us see. Who is next? The chairman of the full
    committee, Mr. Pallone.
        Mr. Pallone. Thank you.
        I wanted to ask Ms. Young a couple questions--really, one
    question. On the day of the Texas district court's ruling,
    President Trump immediately praised Judge O'Connor's decision
    to strike down protections for preexisting conditions.
        The next day he referred to the ruling as, quote, ``great
    news for America,'' and just last week in an interview with The
    New York Times, President Trump boasted that the Texas lawsuit
    will terminate the ACA and referred to the ruling as a victory.
        In his testimony, Mr. Roy claims that President Trump
    supports protecting people with preexisting conditions. I think
    that could not be further from the truth. The truth is,
    President Trump has sought to undermine and unravel protections
    for more than 130 million Americans living with preexisting
    conditions and, understandably, that is not a record that
    Republicans want to promote.
        But I also want to remind folks that, since this is not a
    fact that my colleagues on the other side seem to want to
    acknowledge, and that is that the Republican lawsuit brought by
    Republican attorneys general, who asked the district court to
    strike down the entire ACA.
        So the fact that my colleagues and our minority witnesses
    today are trying to disassociate themselves from Judge
    O'Connor's ruling, which did exactly what the Republican AGs
    asked for, I think is quite extraordinary.
        Mr. Roy asserts in his written testimony that Congress
    should pass a simple bill reiterating guaranteed issue and
    community rating in the event that the district court's
    decision is upheld by the Supreme Court.
        So, and then we have this GOP bill or motion during the
    rules package where they said that, you know, they would do
    legislation that would only include guaranteed issue and
    community rating, and that would ensure sufficient protections
    for preexisting conditions, whatever the courts decide.
        So, basically, Ms. Young, I have one question. Can you
    explain why what Mr. Roy is asserting--that reinstating only
    these two provisions on guaranteeing issue and community
    rating--is insufficient to protect individuals with a
    preexisting condition and the same, of course, is with the
    House GOP bill that would do that.
        Why is this not going to work to actually guarantee
    protection for individuals with preexisting conditions?
        Ms. Young. The district court's opinion, as you note,
    struck down the entirety of the ACA. So not just its
    protections for people with preexisting conditions, but the
    financial assistance available to buy marketplace coverage,
    funding for Medicaid expansion, a host of provisions in
    Medicare, protections through the employer insurance and
    associated reforms.
        So a standalone action that reinstated two preexisting
    conditions protections without wrapping that in the financial
    assistance and the risk adjustment and the Medicaid expansion
    and the other components of the ACA that are, in my view,
    important to make the system function, would not restore the
    system that we have today where people with preexisting
    conditions have access to a functioning market where they can
    buy coverage that meets their health needs.
        In fact, there have been some efforts by the Congressional
    Budget Office to score various proposals that keep some types
    of preexisting condition protections in place but eliminate the
    financial assistance, and the Congressional Budget Office,
    under some scenarios, actually finds that those lead to even
    greater coverage losses than simply repealing the Affordable
    Care Act.
        So implementing those two provisions on their own without
    financial assistance and other protections would be
    insufficient.
        Mr. Pallone. I mean, I think this is so important because,
    you know, again, Mr. Roy--and he is just reiterating what some
    of my Republican colleagues say. They just neglect all these
    other things that are so important for people with preexisting
    conditions.
        You didn't mention junk plans. I mean, my intuition tells
    me, and I am not--you know, I talk to people about it in my
    district--you know, that if you start selling these junk plans
    that don't provide certain coverage, one of the things is it is
    important for people with preexisting conditions to have a
    robust plan that provides coverage for a lot of things that
    didn't exist before the ACA.
        I mean, that is, again, important--the fact that you have a
    robust essential benefits is also important for people with
    preexisting conditions, too, right?
        Ms. Young. Those are both critical protections. In
    particular, the ACA seeks to ensure that insurance for the
    healthy and insurance for the sick are part of a single
    combined risk pool.
        Efforts to promote short-term plans or other policies that
    don't comply with the ACA protections siphon healthy people out
    of the central market and drive up costs for those with
    preexisting conditions and anyone else seeking----
        Mr. Pallone. Yes. So you are pointing out the very fact
    that you have a larger insurance pool, which has resulted from
    the ACA, in itself is important for people with preexisting
    conditions and if you take out the healthier or the wealthier
    because you don't have a mandate anymore, that hurts them too,
    correct?
        Ms. Young. Efforts to move healthier people out of the
    individual market will increase premiums for those that remain
    in complaint coverage, yes.
        Mr. Pallone. All right. Thank you so much.
        Ms. Eshoo. Thank you, Mr. Pallone.
        And now I want to recognize the ranking member of the full
    committee, Mr. Walden.
        Mr. Walden. Thank you, Madam Chair, and I want to thank all
    of our witnesses. We have another hearing--an important one--
    going on downstairs. That is why some of us are bouncing back
    and forth between climate change and healthcare.
        And I want to again say thank you for being here and
    reiterate that as Republicans we believe strongly in providing
    preexisting condition protection for all consumers, and if you
    go back to 1996, when HIPAA was passed under Republicans, we
    provided for continuous coverage protection for people with
    pre-ex.
        I mean, this is something we believe in before ACA and
    something I believe in personally and deeply and something that
    we are ready to legislate on, and I think at least giving that
    guarantee and certainty to people would make a huge level of
    comfort for them.
        And I just--you know, I didn't mean to shake things up this
    morning, but asking for a hearing on Medicare for All was
    something I thought was appropriate, given that other
    committees are already announcing their hearings, and that
    going back to when ACA was shoved through here and then Speaker
    Pelosi saying we had to pass it so you could find out what is
    in it--we don't want to repeat that. We need to know what is in
    it. We need thoughtful consideration. I think this committee is
    the place to have that. So I still think that is important.
        I want to thank both Tom and Avik for being here--Mr. Roy--
    for being here on short notice. You said, Mr. Roy, that
    Congress should pass a simple standalone measure guaranteeing
    that insurers offer coverage in the individual health insurance
    market to anyone regardless of prior health status.
        Mr. Roy. Yes, I did.
        Mr. Walden. And do you want to respond? You didn't get a
    chance to kind of respond here. So do you want to respond to
    what was asked of the other witnesses around you?
        Mr. Roy. Well, thank you, Mr. Walden. I appreciate the
    opportunity to actually explain my written testimony----
        Mr. Walden. Go ahead.
        Mr. Roy [continuing]. In this setting. The key here is that
    three-fourths of the variation of the premiums in health
    insurance in a fully underwritten market are associated with
    age, not health status or gender or anything else--preexisting
    conditions.
        Mr. Walden. OK.
        Mr. Roy. So the point is, if everybody of the same age--all
    27-year-olds, all 50-year-olds, all 45-year-olds--if all 45-
    year-olds are charged the same premium, the variation in
    premiums between the healthy paying a little more and the sick
    paying a little less is not that big of a difference. It
    doesn't cause a lot of adverse selection.
        What drives adverse selection in the ACA is the fact that
    younger people are forced to pay, effectively, double or triple
    what they were paying before----
        Mr. Walden. Right.
        Mr. Roy [continuing]. To allegedly subsidize the premiums
    for older people. So revising age bands would be a huge step in
    moving in the right direction. Reinsurance, which is
    effectively a high-risk pool within a single-risk pool, would
    help basically also reduce the premiums that healthy people pay
    so that people with preexisting conditions could get better
    coverage.
        So you can have a standalone bill that would ensure that
    people with preexisting conditions have access to affordable
    coverage.
        Mr. Walden. I would hope so. I think it is really
    important. I mean, we were for preexisting protections. I was
    for getting rid of the insurance caps before ACA. I thought
    they were discriminatory against those who through no fault of
    their own had consequential health issues that could have blown
    through their lifetime caps.
        And so I think there are things we could still find common
    ground on, and I wonder if you want to address the Medicare for
    All proposal as well.
        Now, we haven't seen it spelled out. I know the Budget
    Committee is, I guess, having it scored and hearings on it. But
    I am concerned about the impacts it may have on delay in terms
    of getting healthcare. I am concerned about what it might do to
    the Medicare trust fund.
        Do you have--do you want to opine on that while you are
    here?
        Mr. Roy. Well, I have written a lot at Forbes and elsewhere
    about how Medicare for All from a fiscal standpoint is
    unworkable because of the gigantic transfers it would assign to
    the Federal Government.
        It would increase Federal spending by somewhere between 28
    and 33 trillion dollars over a 10-year period, which would be
    an increase in overall Federal spending of 71 percent.
        Now, that is not if--that excludes the impact of cutting
    what you pay hospitals and doctors and drug companies by 50
    percent, which is what you would have to do to effectively make
    the numbers work.
        I do want to urge you, Mr. Walden, and your colleagues that
    while Medicare for All is unworkable, and I think most people
    know that, the status quo is unacceptable, too.
        Mr. Walden. Right.
        Mr. Roy. And I think it is extremely important for this
    committee in particular to tackle the high cost of hospital
    care, the high cost of drug prices.
        Mr. Walden. Yes. That was--if I had stayed on as chair that
    was going to be our big priority this cycle. Surprise billing--
    I mean, you go in, you have a procedure, you have played by all
    the rules, and it turns out the anesthesiologist that put you
    under wasn't in your program and you get billed. That is wrong.
    That is just--I think we can find common ground on that one.
        We took on the issue of getting generic drugs into market,
    and under the change in the law we passed last year, Dr.
    Gottlieb now has set a record for getting new generics in the
    market and driving both choice and innovation but also price
    down, and this administration--I have been in the meetings with
    the president and CEOs of the pharmaceutical companies. He is
    serious about getting costs down on drugs and getting to the
    middle part of this, too.
        We need to look from one end to the other and, Madam Chair,
    I think we can find common ground here to do that and get
    transparency, accountability so consumers can have choice and
    so we can drive down costs.
        I have used up my time, and I thank our witnesses again.
        Madam Chair, I yield back.
        Ms. Eshoo. I thank the ranking member.
        We plan to examine all of that, and I think--I hope that we
    can find common ground on it because these are issues that
    impact all of our constituents, and they need to be addressed.
        And on the surprise billing, I know that the Senate is
    trying to deal with it, and we should here as well. I think
    that your clock is not working at the witness table.
        Mr. Roy. That is correct.
        Ms. Eshoo. But it is working up here, OK. So maybe you can
    refer to that one.
        Now I would like to call on the gentlewoman from Florida,
    Ms. Castor.
        Ms. Castor. Thank you, Madam Chair. Witnesses, thank you
    very much for being here, and colleagues, thank you for all of
    your attention here.
        I just think it is so wrong for the Trump administration
    and Republicans in Congress to continue to try to rip
    affordable health coverage away from American families,
    especially our neighbors with preexisting conditions.
        This lawsuit is just a continuation of their efforts to do
    that. When they couldn't pass the bill here in the Congress--in
    the last Congress, despite Republican majorities--and I am
    sorry to say that my home State of Florida under Rick Scott's
    administration joined that Federal lawsuit.
        Thirteen Democratic members of the Florida delegation have
    written to our new Governor and attorney general, asking--
    urging them to remove the State of Florida from the Federal
    lawsuit that would kill the Affordable Care Act and rip health
    coverage away from American families, including individuals
    with preexisting health conditions.
        This follows the letter we sent to Rick Scott as well, and
    I would like to ask unanimous consent that these letters be
    admitted into the record of this hearing.
        [The information appears at the conclusion of the hearing.]
        Ms. Castor. American families are simply tired of the
    assault on affordable healthcare and, Chairwoman Eshoo, you
    raised the point about the skimpy junk insurance plans, because
    one way that the Trump administration and Republicans are
    trying to undermine affordable care are these junk health plans
    that do not provide fundamental coverage.
        When you pay your hard-earned copayment and premiums, you
    should actually get a meaningful health insurance policy, not
    some skimpy plan that is just going to subject you to huge
    costs.
        These subpar and deceptive junk plans exclude coverage for
    preexisting conditions. They discriminate based on age and
    health status and your gender.
        Consumers are tricked into buying these junk plans,
    mistakenly believing that they are the comprehensive ACA plan,
    but then they are faced with huge out-of-pocket costs. For
    example, in a recent Bloomberg article, Dawn Jones from Atlanta
    was enrolled in a short-term junk plan when she was diagnosed
    with breast cancer. Her insurer refused to pay for her cancer
    treatment, leaving her with a $400,000 bill.
        Another patient in Pennsylvania faced $250,000 in unpaid
    medical bills because her junk short-term policy did not
    provide for prescription drug coverage and other basic
    services.
        The Trump administration now is actively promoting these
    junk plans, and I want American families and consumers across
    the country to be on alert. Don't buy in to these false
    promises.
        Ms. Young, you have talked a little bit about this, but
    will you go deeper into this? Help us educate families across
    the country. I understand that these plans often impose
    lifetime and annual limits. Is that correct?
        Ms. Young. It is, yes.
        Ms. Castor. And that is something the Affordable Care Act
    outlawed?
        Ms. Young. Correct.
        Ms. Castor. Can you describe what these plans typically
    look like and what kind of coverage they purport to provide?
        Ms. Young. Short-term limited duration insurance is not
    regulated at the Federal level. None of the Federal consumer
    protections apply. Some State law protections may apply or----
        Ms. Castor. Consumer protections--name them.
        Ms. Young. The requirement that plans cover essential
    health benefits, the prohibition on annual and lifetime limits,
    the requirement that the insurance company impose a cap on the
    total copays and deductibles an individual can face over the
    year, requirements to cover preventive services, to not exclude
    coverage for preexisting conditions and other----
        Ms. Castor. Wait a minute. Wait a minute. I have heard some
    of my Republican colleagues say they are all in favor of that.
    But can you be in favor of preexisting condition protection on
    the one hand and then say, ``Oh, yes, we believe these junk
    insurance plans are the answer,'' like the Trump administration
    and Republicans in Congress are promoting?
        Ms. Young. Short-term limited duration plans do not have to
    comply with the requirements about preexisting conditions. That
    is correct.
        Ms. Castor. Can you describe why an individual who is
    healthy when they sign up for one of these junk plans could
    still be subject to hundreds of thousands of dollars in medical
    bills?
        Ms. Young. There is no requirement that short-term plans
    cover any particular healthcare cost. So an individual who
    doesn't read the fine print behind their policy might discover,
    for example, that the plan only covers hospital stays of a few
    days and individuals are on the hook for all additional
    hospital expenses.
        They may find that the plan has a very low annual limit, so
    that once they have spent 10 or 20 thousand dollars, they are
    responsible for bearing the full cost or any variation like
    that where they simply discover when they need to access the
    healthcare system that the plan doesn't include the coverage
    that they had hoped to purchase.
        Ms. Castor. Thank you very much, and we will be working to
    ensure that consumers are protected and, when they pay their
    premiums and copays, they actually get a meaningful health
    insurance policy.
        Thank you, and I yield back.
        Ms. Eshoo. I thank the gentlewoman.
        I now would like to call on Mr. Griffith from Virginia. You
    are recognized for 5 minutes.
        Mr. Griffith. Thank you very much, Madam Chair. I
    appreciate it.
        Here is the dilemma that we have. In my district, which is
    financially stressed in many parts of it--I represent 29
    jurisdictions in rural southwest--always put the pause in
    there--Virginia.
        So when ACA came in so many of my people immediately came
    to me, long before the Trump administration came in, and in
    their minds the ACA was junk insurance, because when they were
    promised that their premiums would go down, they now had
    premiums that were financially crippling.
        When they were promised that they would have better access,
    they now found that they had high deductibles and they now
    found that their copays had gone through the roof.
        So there is no question--I never argued--that the
    preexisting condition was a problem that should have been dealt
    with long before the ACA, and I understand the concerns and the
    frustration that people had who had preexisting conditions, and
    we need to take care of that and we will take care of that.
        I don't see anybody who would argue at this point that we
    shouldn't deal with people with preexisting conditions and make
    sure they have access to affordable healthcare, which is why I
    supported our attempts to get an amendment put in on day one of
    this Congress that would say, get the committees of
    jurisdiction.
        In fact, it referenced the Energy and Commerce Committee--
    this committee--and the Ways and Means Committee to report out
    a bill that took care of all of the concerns we have heard
    today and said it guarantees no American citizen can be denied
    health insurance coverage as the result of a previous illness
    or health status and guarantees no American citizen can be
    charged higher premiums or cost sharing as the result of a
    previous illness or health status, thus ensuring affordable
    health coverage for those with preexisting conditions.
        That is where we are. That is what we stand for. So, you
    know, I find it interesting that this debate has become--you
    know, and I am hearing about junk insurance and how Republicans
    are evil, that they want junk insurance.
        I hear it on a regular basis that my people think that what
    they have got now is junk. It is all they can afford, and it is
    costing them a fortune.
        So, Mr. Roy, what do you have to say about that?
        Mr. Roy. I have found the conversation we have been having
    about so-called junk insurance interesting because nobody seems
    to be asking the question as to why people are voluntarily
    buying so-called junk insurance.
        They are buying it because the premiums are half or a third
    or a quarter of what the premiums are for the Affordable Care
    Act for them.
        Mr. Griffith. And if you can't afford something else, you
    are going to buy something that you can afford. Isn't that
    correct?
        Mr. Roy. A hundred percent. So a plan that has all the
    bells and whistles but it is unaffordable to you is
    effectively, worthless, whereas a plan that may not have all
    the bells and whistles but at least provides you some coverage
    is.
        And the great tragedy of the Affordable Care Act is that we
    did not have to have that dichotomy. We could have had plans
    that had robust coverage for people with preexisting conditions
    and protections for people regardless of health status and yet
    were still affordable.
        I have outlined it both in my written testimony, in my oral
    testimony, and many, many other documents that I have presented
    to this committee in the past, how we could achieve that.
        Mr. Griffith. Now, you would agree with me for those people
    who may have bought the junk insurance without knowing what
    they were getting into that we probably ought to pass something
    that says that the things that aren't going to be covered--if
    you're only getting $20,000 worth of care and then you have to
    take the full bill after that, as Ms. Castor talked about--we
    should have that in bold language on the front of the policy.
        You would agree that we should put some consumer protection
    in that and make sure there is transparency so people are well-
    advised of what they are getting or not getting. Isn't that
    true?
        Mr. Roy. I have no problem with robust disclosure about
    what is in a short-term limited duration plan versus an ACA-
    compliant plan. To a degree, we already have that in the sense
    if you are buying off the ACA plan, I think most consumers know
    that those plans have fewer protections, but more disclosure,
    and more clarity in disclosure would be a good thing.
        Mr. Griffith. Absolutely. I agree with that.
        You know, what is interesting is everybody seems to have
    gone after Judge O'Connor. I don't know him. I haven't studied
    his opinions.
        But I do find this interesting. I thought it was the right
    thing to do. He put a stay on his ruling so it didn't create a
    national catastrophe or suddenly people are having to scramble
    to figure out what to do.
        Mr. Miller, isn't that a little unusual in this day--I
    mean, people have accused him of being biased or having a
    political bent and using his power. But I seem to recall all
    kinds of opinions by judges that I thought were coming from a
    slightly different philosophical bent but who went out there on
    a limb, stretched--pushed the envelope of the law.
        But instead of saying, ``Now, let us wait until the appeal
    is over and make sure this is right before we affect the
    average citizen,'' they just let it go into effect. But Judge
    O'Connor said, ``No, in case this is overturned, I want to make
    sure nobody is adversely impacted'' and put a stay on his own
    ruling.
        Isn't that unusual, and wasn't that the right thing to do?
        Mr. Miller. No, it is not--it is hopscotch. We have had
    some Federal judges who have had nationwide injunctions
    reaching way beyond what you would think would be the normal
    process.
        Mr. Griffith. Yes. I have noticed that.
        Mr. Miller. I think all the parties understood what
    practically was going on here. I would just point out on the
    legalities of this, just to clean up the record, one of the
    things about----
        Ms. Eshoo. Just summarize quickly, because your time is up.
        Mr. Miller. My time is up. OK.
        Mr. Griffith. You could summarize, she said.
        Ms. Eshoo. Quickly.
        Mr. Miller. I will just say, real fast, we left out the
    argument about tax guardrails, which was in Chief Justice
    Roberts' opinion, and Si is exaggerating what is there and
    isn't there.
        The problem is that, when you take it apart, there is
    nothing left behind.
        Ms. Eshoo. OK. I think your time is expired.
        Mr. Miller. It was his testimony, was that this tax didn't
    exist anymore.
        Ms. Eshoo. All right. We are now going to go to and
    recognize Dr. Ruiz from California.
        Mr. Ruiz. Thank you. It is so wonderful to be on this
    committee finally. So thank you to all----
        [Laughter.]
        Ms. Eshoo. He hasn't stopped celebrating.
        Mr. Ruiz. Thank you to all the witnesses for joining us
    today. We have over 130 million Americans that have preexisting
    conditions. The ACA defended full protections for people with
    preexisting conditions, and those are three components.
        One is that insurance companies cannot deny insurance to
    people with preexisting conditions; two, they cannot deny
    coverage of specific treatments related to the preexisting
    condition illness; and three, they cannot discriminate by
    increasing the prices towards people who have a preexisting
    condition.
        Let me give you some examples of some of the benefits and
    hardships that people would face if this lawsuit is completed.
        My district is home to Desert AIDS Project, an FQHC that
    was founded in 1984 to address the AIDS crisis. It is the
    Coachella Valley's primary nonprofit resource for individuals
    living with HIV/AIDS. They have grown to become one of the
    leading nonprofits and effective HIV/AIDS treatment in the
    Nation.
        And the folks at Desert AIDS Project know how to end the
    HIV/AIDS epidemic. Basically, you need prevention and you need
    treatment. They told me that the ACA has been critical in
    providing treatment to the HIV--in order to get the HIV viral
    load at an uninfectious low level.
        So the problems before the ACA was that insurance companies
    didn't used to have to pay for HIV tests, for example, or
    individuals with HIV couldn't get Medicaid coverage until they
    were really sick on full-blown AIDS, many already on their
    death beds.
        Now, because of the ACA, insurance companies must cover
    essential health benefits like HIV tests and antiviral
    medications, which by the way the folks on the other side have
    attempted to repeal.
        Because of the ACA and the Medicaid expansion many HIV-
    infected middle class families now have health insurance for
    the very first time. Unfortunately, I can't say that for HIV
    patients throughout our country including in States like Texas
    that didn't expand the Medicaid coverage.
        And, by the way, this is another example of ACA that those
    on the other side attempted to repeal. Before the passage of
    the ACA, 90 percent of Desert AIDS Project clients did not have
    health insurance, and now, with the ACA, 99.9 percent of
    clients have health insurance coverage in Desert AIDS Project.
        Let me repeat that statistic. Insurance coverage for these
    patients went from only 10 percent to 99.9 percent because of
    the ACA. And yet, the president, while claiming to be committed
    to eliminating the HIV/AIDS epidemic in 10 years, is actively
    taking measures to take away these protections of this very
    population by rolling back the Medicaid expansion and weakening
    and undermining preexisting conditions protections.
        This would be devastating to Desert AIDS Project clients
    and patients, and yet this is just one example of the
    devastation that repeal of the ACA would cause on individuals
    with preexisting conditions.
        Ms. Young, could you discuss the potential impact of the
    lawsuit on individuals with preexisting conditions if the
    district court's decision is upheld?
        Ms. Young. If the district court decision were to be upheld
    as written, it would disrupt the coverage for people with
    preexisting condition in all segments of the insurance market.
        So we talked a lot about the individual market. The core
    protections in the individual market today would be eliminated
    along with the financial assistance that enables them to afford
    coverage and make those markets stable.
        In employer coverage, people with preexisting conditions
    would also face the loss of certain protections. They would
    once again be exposed to lifetime or annual limits and they
    could face unlimited copays.
        Mr. Ruiz. Let me get to another point because, you know, we
    are hearing a lot of political trickery here in the
    conversations. A number of the folks on the other side have
    introduced bills that will pick and choose which one of these
    three components that make up full protections for preexisting
    conditions that they want to have in certain bills.
        For example, one bill says, we want guaranteed issue and
    community rating which will help keep the costs low for
    everybody but don't include the prohibition on preexisting
    coverage exclusions.
        Another bill includes guaranteed issue and the ban on
    preexisting coverage exclusion but does not include the
    community rating, saying, well, let us charge people with
    preexisting more than other folks.
        So they claim these bills are adequate to protect consumers
    with preexisting conditions. Can you explain why these bills
    are inadequate to protect individuals with preexisting
    conditions?
        Ms. Young. Very briefly, requiring insurance companies to
    sell a policy but allow preexisting condition exclusions
    requires them to sell something but it doesn't have to have
    anything in it. It is a little bit like selling a car without
    an engine.
        And allowing unlimited preexisting condition rate-ups tells
    the consumer that they can buy a car but they could be charged
    Tesla prices even if they are buying a Toyota Camry. That is
    not what the Affordable Care Act does. It puts in place a
    comprehensive series of protections.
        Mr. Ruiz. Thank you.
        Ms. Eshoo. Your time has expired. I thank the gentleman.
        I now would like to recognize Dr. Bucshon from Indiana.
        Mr. Bucshon. Thank you, and congratulations on your
    chairmanship. Look forward to working with you.
        I am a physician. I was a heart surgeon before I was in
    Congress, and we all support protections for preexisting
    conditions. Look, I had a couple of patients over the years who
    I did heart surgery on who had--one had had Hodgkin's disease
    in his 20s, and his entire life after that he could not afford
    health coverage, and that is just plain wrong. We all know
    that.
        I had an employee of mine whose wife met her lifetime cap
    because of a serious heart condition and had to ultimately go
    onto Medicaid. That is not right.
        So I think Republicans for many years have supported
    protecting people with preexisting conditions. I think we are
    in a policy discussion about the most appropriate way to do
    that.
        And so I really think what we should be focusing on is to
    make sure that people actually have coverage that they can
    afford--quality affordable health coverage, and under the ACA,
    as was previously described, the deductibles can be very high.
    You couldn't keep your doctor and your hospital, as everyone
    said that supported the ACA, and so we are not meeting that
    goal.
        And now we have heard from the Democrats about Medicare for
    All and their bill in the last Congress, H.R. 676, would have
    made it illegal for private physician practices to participate
    in a Government healthcare program. And by the way, Medicare
    for All doesn't even solve the main problem we have in
    healthcare, which is the huge cost.
        I keep telling people if you continue to debate how to pay
    for a product that is too expensive, you are not going to catch
    up. It doesn't matter who is paying for it. It doesn't matter
    if the Government is paying for it or a partial hybrid system
    like we have now.
        So I am hoping we can have some hearings on how we get the
    cost down, and the insurance problem kind of almost can solve
    itself if we can do that.
        We should be talking about the fact that people with
    preexisting conditions really don't have protections, and it
    doesn't work if you don't have actual access to a physician.
        So Mr. Miller and Mr. Roy--I will start with Mr. Roy--can
    you talk about what could happen in the U.S. if private
    physician practices were not allowed to participate in a
    single-payer program, hypothetically, and would that create
    access issues for patients?
        Mr. Roy. Well, we already have access issues for patients
    in the Medicaid program. A lot of physicians don't accept
    Medicaid----
        Mr. Bucshon. That is correct.
        Mr. Roy [continuing]. Even though they theoretically
    participate in the Medicaid program. That is also an increasing
    problem in Medicare because there are disparities in the
    reimbursement rates between private insurers, Medicare, and
    especially Medicaid.
        And this is one of the other flaws in the ACA, is it relied
    on a program with very poor provider access to expand coverage.
    I think the exchanges at least have the virtue of using private
    insurers to expand coverage rather than the Medicaid program
    with its much lower reimbursement rates.
        Mr. Bucshon. So I would argue that, you know, then if you
    go to a Medicare for All, you have access issues on steroids,
    potentially, and especially if you don't allow private practice
    physicians--what I am saying, nonhospital or Government-
    employed physicians, which is what we would all be--to
    participate in the program, which is actually not what other
    countries do.
        In England, for example, you can have your private practice
    and also participate in the National Health Service.
        Mr.----
        Mr. Miller. You are more likely to have Medicaid for All
    than Medicare for All until you solve the--and say ``Stop, we
    can't deal with that.'' The problem is we would love to give
    away all kinds of stuff. We just don't want to pay for it.
        Now, we can shovel it off into ways in which you get less
    than what was promised and say, ``We have done our job.'' We
    did that to an extent with the ACA. You find the lowest-cost
    way to make people think they are getting something that is
    less than what they actually received.
        That is why the individual market as a whole has shrunk in
    recent years. It is because those people who are not well-
    subsidized in the exchanges are finding out they can't afford
    coverage anymore.
        Mr. Bucshon. So, I mean, and I will stick with you, Mr.
    Miller. Do you think if the iteration of Medicare for All bans
    private practice physicians not to be able to participate that
    we would put ourselves at risk of creating a two-tiered system
    where the haves can have private coverage and there can be
    private hospitals as there is in other countries?
        Mr. Miller. Well, already we have got plenty of tiers in
    our system to begin with. It would exacerbate those problems
    and I don't think we would live with it politically, which is
    why it would probably short circuit.
        But it is at least a danger when people believe in the
    theory of what seems easy but the reality is very different.
        Mr. Bucshon. Yes. I mean, I would have an ethical problem
    as a physician treating patients differently based on whether
    or not they are wealthy or whether or not they are subjected to
    a Medicare for All system, right.
        So, ethically, I can tell you physicians would have a
    substantial problem with that. Other countries kind of do that
    because that is just the way it is there and I think in many
    respects their citizens don't have a problem with it because
    that is just what they have always lived with.
        But I would agree with you that in the United States there
    would be some issues.
        Mr. Roy, do you have any comments on that?
        Mr. Roy. I do. I would just like to add that at the
    Foundation for Research on Equal Opportunity we put together a
    detailed proposal for private insurance for all, where everyone
    buys their own health insurance with robust protections for
    preexisting conditions and health status and robust financial
    assistance for people who otherwise can't afford coverage in a
    way that is affordable, that would actually reduce Federal
    spending by $10 trillion over three decades but would ensure 12
    million more people have access to health insurance than do
    today under current law.
        So there are ways to address the problem of affordability
    and access of health insurance while also reducing the
    underlying cost of coverage and care and making the fiscal
    system more sustainable.
        Mr. Bucshon. Yes. I mean, I think we should be also putting
    focus on the cost of the product itself, right, and the reasons
    why it costs so much are multi-factorial. It is a free market
    system.
        The other thing is, I told my local hospital administrators
    that if we get Medicare for All, get ready to have a Federal
    office in your private hospital that tells you how to run your
    business.
        I yield back.
        Ms. Eshoo. I thank the doctor.
        And last, but not least, Mr. Rush from Illinois is
    recognized for 5 minutes for questioning.
        Mr. Rush. Thank you, Madam Chair.
        Madam Chair, I also want to congratulate you for your
    becoming chair of the subcommittee and----
        Ms. Eshoo. I thank you very much.
        Mr. Rush [continuing]. I have been a Member of Congress for
    quite--for, as you have, for over 26 years, and this is my
    first time being a member of this subcommittee, and I am
    looking forward to working with you and other members of the
    subcommittee.
        I want to--as I recall, when this Affordable Care Act was
    passed, there were millions of Americans who were without
    health insurance totally. They were uninsured. They had no help
    at all, no assistance from anyone to deal with their illnesses
    and their diseases.
        And since the Act was passed, approximately 20 million
    Americans have gained health coverage, including over a million
    in my State, and I don't want to overlook that fact. I don't
    want to get that fact lost in the minutia of what we--of any
    one particular aspect of our discussion.
        In 2016, almost 14,000 of my constituents received
    healthcare subsidies to make their healthcare more affordable.
    One aspect of the ACA that I like is insurance companies must
    now spend at least 80 percent of their premium on actual
    healthcare as opposed to other kinds of pay for CEOs and also
    for an increase of their profits.
        And the insurance rate has increased between--the uninsured
    rate, rather, has increased between the years 2013 and 2017--
    since 2017 in my State.
        Ms. Young, how many Americans would expect to lose coverage
    if this court decision in Texas were upheld?
        Ms. Young. The Congressional Budget Office has estimated
    that repeal of the Affordable Care Act against their 2016
    baseline would result in 24 million additional uninsured
    Americans, and upholding the district court's decision we could
    expect sort of broadly similar results with adjustments for the
    new baseline.
        Mr. Rush. Mm-hmm.
        I want to ask Ms. Hung, you've been sitting here patiently,
    remarkably, listening to a lot of discussion between experts.
    But how do you feel about your daughter? How do you feel? What
    is your reaction to all of this as it relates to the looming
    problem that you have if this case is upheld?
        Ms. Hung. Thank you. No one is going to sit here and say
    that they are not going to protect preexisting conditions,
    right. No one is going to say that. But that is what we have
    seen. That is what families like mine have seen--repeal
    efforts, proposals that don't cover preexisting conditions or
    claim to give a freedom of choice to choose what kind of
    insurance we want.
        Well, the choice that I want is insurance that covers, that
    guarantees that these protections are in place. I don't want to
    sit in the NICU at my daughter's bedside wondering if she is
    going to make it and also then have to decide what kind of
    insurance I am going to buy and imagine what needs that she
    will have in order to cover that.
        So I sit here and say, well, what worked for me is that I
    got to spend 169 days at my daughter's bedside without worrying
    about whether we would go bankrupt or lose our home, and that
    is the guarantee that we need.
        Mr. Rush. Madam Chair, I yield back.
        Ms. Hung. Thank you.
        Ms. Eshoo. I thank the gentleman.
        I now would like to call on another new member of the
    subcommittee, and we welcome her. Ms. Blunt Rochester from the
    small but great State of Delaware.
        [Laughter.]
        Ms. Blunt Rochester. Thank you, Madam Chairwoman.
        First of all, thank you so much for your leadership. It is
    an honor for me to be on this subcommittee. And excuse me, I
    had competing committees for my first day of subcommittees and
    so I have been running back and forth.
        But this is a very important topic, and I want to
    acknowledge Ms. Hung. The last time I saw you we were at a
    press event with then-Leader Pelosi highlighting the Little
    Lobbyists and the work that you do and have been doing, and
    just your support of protecting preexisting conditions for
    children across the country.
        And it is really admirable that you advocate not only for
    your child but for all children across the country and have
    been fighting for decades. And I was hoping that you could talk
    a little bit about the formation of the Little Lobbyists and
    who they are, what it is all about, how it formed.
        Ms. Hung. Thank you, Congresswoman, and thank you for your
    support. I did not set out to start the Little Lobbyists. It
    kind of just happened. We were following the news, where
    families like mine, families with children with complex medical
    needs and disabilities, were very concerned, were very worried.
    And we decided to speak up and tell our stories.
        And I tell my story because I know that many have been
    fortunate to not experience the challenges and hardships that
    we have seen. I also know that many have not experienced the
    joy and gratitude that I had in being Xiomara's mother.
        So I feel a responsibility to uplift these stories that we
    weren't seeing being represented. Now, I have spent more than
    my fair share of time in the hospital. I have witnessed my baby
    on the brink of life and death one too many times.
        I know what is possible with access to healthcare--quality
    healthcare--and I think I can say that I have a profound
    understanding, more than many Americans, how fragile life is,
    and it is with that understanding that I have chosen to spend
    my time raising that awareness.
        I acknowledge my privilege. I acknowledge my proximity to
    Washington, DC, to come here. There are so many stories like
    mine across the country of families who are just fighting for
    their children, who want to spend that time on their kids and
    not worrying about filing for bankruptcy or losing their home
    or wondering if they can afford lifesaving medication.
        Ms. Blunt Rochester. Yes, that was going to be my next
    question. How does this uncertainty affect your family? How is
    it affecting individuals that you work with and are talking to
    and other Little Lobbyists?
        Ms. Hung. It is everything. It is everything. So the
    uncertainty is not knowing. I mean, we don't know what the
    future holds. None of us do. But to add this on top of what we
    are going through, on top of the NICU moms that I know that are
    worrying, who are trying to keep their jobs and trying to be
    there for their children, to add this level of uncertainty on
    top of it is just devastating.
        Ms. Blunt Rochester. I wanted to have your voice heard. I
    know from hearing that we have a lot of great experts and a
    great panel here, and I would like to bring it back to what
    this is all about. Maybe--I don't know if I am the last one
    speaking or--but I wanted to bring it back to why we are doing
    this and why we are here.
        I have served the State of Delaware in different
    capacities, as our deputy secretary of health and social
    services, I have been in State personnel, so I have seen
    healthcare from that perspective and also from an advocacy
    perspective as CEO of the Urban League.
        But hearing your story makes this real for us and is really
    one of the reasons why I wanted to be on this committee. So I
    thank you for your testimony. I thank the committee for your
    expert testimony, and I yield back the balance of my time.
        Ms. Eshoo. Thank you very much.
        I don't see anyone else from the Republican side.
        Mr. Burgess. There's some people coming back, but proceed.
        Ms. Eshoo. OK. All right. We will move on.
        I now would like to recognize the gentleman from
    California, Mr. Cardenas.
        Mr. Cardenas. Thank you, and thank you, Chairwoman Eshoo
    and Ranking Member Burgess, and all the staff for all the work
    that went into holding this hearing of this committee, and I
    appreciate all the effort that has gone into all of the
    attention that we are putting forth to healthcare both at the
    staff level and at the Member level, and certainly for the
    advocates in the community as well.
        Thank you so much for your diverse perspectives on what is
    important to the health and well-being of all Americans.
        I think, while the legal arguments and implications of this
    case are important, I want to take a few minutes to focus on
    the very personal threats posed by these attacks to the
    Affordable Care Act.
        This ruling, if upheld, would take away healthcare for tens
    of millions of Americans, including our most vulnerable,
    especially children and seniors. They are especially at risk,
    and people with preexisting conditions, we would see them just
    be dropped from the ability to get healthcare.
        For some of us, this is literally a life-and-death
    situation and, as lawmakers, I hope that we don't lose sight of
    the fact of how critical this is, and as the lawmakers for this
    country, I hope that we can move expeditiously with making sure
    that we can figure out a way to not allow the courts to
    determine the future and the fate of millions of Americans when
    it comes to their healthcare and healthcare access.
        Also, I want to thank everybody who is here today, and also
    the court's ruling would ideologically and politically, you
    know, follow through with the motivation that I believe close
    to 70 times or so in this Congress there was an effort to end
    it, not mend it, when it comes to the Affordable Care Act, and
    I think it is inappropriate for us to look at in such a black-
    and-white manner.
        There are cause and effects should the Affordable Care Act
    go away. I happen to be personally one of those individuals
    that, through a portion of my childhood, did not have true
    access to healthcare, and it's the kind of thing that no parent
    should go through and the kind of situation that no American
    should ever have to contemplate, waiting until that dire moment
    where you have to go to the emergency room instead of just
    looking forward to the opportunity to, you know, sticking out
    your tongue and asking the doctor questions and they ask you
    questions and they find out what is or is not wrong, and that
    is the kind of America that used to be.
        And since the Affordable Care Act, imperfect as it is, that
    is not the America of today. The America of today means that,
    if a young child has asthma, that family can in fact find a way
    to get an equal policy of healthcare just like their neighbor
    who doesn't have a family member with a preexisting condition.
        So with that, I would like to, with the short balance of my
    time, ask Ms. Hung, could you please expand on the uncertainty
    that you have already described that your family would face
    should this court decision end the Affordable Care Act as we
    know it?
        And then also could you please share with us, are you
    speaking only for you and your family or is this something that
    perhaps hundreds of thousands if not more American families
    would suffer that fate that you are describing?
        Ms. Hung. Thank you. I am here on behalf of many families
    like mine. The Little Lobbyists families are families with----
        Mr. Cardenas. Dozens or thousands?
        Ms. Hung. Thousands, across the country, families with
    children with complex medical needs and disabilities. And these
    protections that we are talking about today, they are not just
    for these children. They are for everyone. They are for
    everybody. Any one of us could suddenly become sick or disabled
    with no notice whatsoever. Any one of us could go suddenly from
    healthy to unhealthy with no notice and have a preexisting
    condition. An accident could happen, a cancer diagnosis, a sick
    child.
        There is no shame in being sick. There is no shame in being
    disabled. Let us not penalize that. There is no shame in
    Xiomara needing a ventilator to breathe or needing a wheelchair
    to go to the playground.
        But there is shame in allowing insurance companies to
    charge her more money just because of it, more for her care,
    and there is shame in allowing families like mine to file for
    bankruptcy because we can't afford to care for our children.
        It is that uncertainty that is being taken away or at risk
    right now. Our families are constantly thinking about that
    while we are at our children's bedside.
        Mr. Cardenas. I just want to state with the balance of my
    time that this court case could be the most destructive thing
    that could have ever happened in American history when it comes
    to the life and well-being of American citizens.
        I yield back the balance of my time.
        Ms. Eshoo. I thank the gentleman.
        I now would like to recognize my friend from Florida, Mr.
    Bilirakis.
        Mr. Bilirakis. Thank you, Madam Chair, and congratulations
    on chairing the best subcommittee in Congress, that's for
    sure--the most important.
        Ms. Eshoo. Oh, thank you.
        Mr. Bilirakis. Mr. Miller, the Texas court decision hinges
    on the individual mandate being reduced to zero in the law. Can
    you explain the court's reasoning in their decision?
        Mr. Miller. Well, I mean, we have to go back to a lot of
    convoluted reasoning in prior decisions in order to get there.
    So this is a legacy of trying to save the Affordable Care Act
    by any means possible, and it gets you into a little bit of a
    bizarre world.
        But if you take the previous opinions at their face--it was
    somewhat of a majority of one by Chief Justice Roberts--he
    basically saved the ACA, which otherwise would have gone down
    before any of this was implemented, by having a construction
    which said, ``I found out it is a tax after all,'' and he had
    three elements as to what that tax was.
        The problem is, once you put the percentage at zero and the
    dollar amount at zero, it is not a tax anymore. It is not
    bringing in revenue. You don't pay for it in the year you file
    your taxes. It is not calculated the way taxes are.
        So that previous construction, if you just look in a
    literal way at the law, doesn't hold anymore. What we do about
    it is another issue beyond that. But on the merits, we have got
    a constitutional problem, and in that sense that court decision
    was accurate. People then say, ``Where do you go next?,'' and
    that is the mess we are in.
        Mr. Bilirakis. Yes. Could legislation be passed that would
    address the court's concern, such as reimposing the individual
    mandate?
        Mr. Miller. All kinds of legislation. You are open for
    business every day, but sometimes business doesn't get
    conducted successfully. There are a wide range of things that I
    can imagine and you can imagine that would deal with this in
    either direction.
        You have to pass something. What we are doing is we are
    passing the buck. We are trying to uphold some odd contraption,
    which is the only one we have got, as opposed to taking some
    new votes and saying, ``What are you in favor of and what are
    you against?'' and be accountable for it and build a better
    system.
        Mr. Bilirakis. Thank you.
        Mr. Roy, you have written extensively on how to build a
    better healthcare system. The goal of the individual mandate,
    when the Democrats--now the majority party--passed the ACA, was
    to create a penalty to really force people to buy insurance.
        Are there alternative ways to provide high-quality
    insurance at low prices without a punitive individual mandate?
        Mr. Roy. Absolutely. So, as we have discussed already and I
    know you haven't necessarily been here for some of that
    discussion, simply the fact that there is a limited open
    enrollment period in the ACA prevents the gaming of jumping in
    and out of the system, and that is a standard practice with
    employer-based insurance. It is a standard practice in the
    private sector parts of Medicare. That is a key element.
        Another key element is to reform the age bands--the 3-to-1
    age bands in the ACA--because that actually is the primary
    driver of healthy and particularly younger people dropping out
    of the market.
        Another key piece is to actually lower, of course, the
    underlying cost of healthcare so that premiums will go down and
    making sure that the structure of the financial assistance that
    you provide to lower-income people actually matches up with the
    premium costs that are affordable to them.
        And a big part of it is, again, making the insurance
    product a little bit more flexible so plans have the room to
    innovate and make insurance coverage less expensive than it is
    today.
        Mr. Bilirakis. All right. Thank you very much.
        I yield back, Madam Chair, the rest of my time.
        Ms. Eshoo. Thank you, Mr. Bilirakis.
        I now would like to recognize the gentleman from Oregon,
    Mr. Schrader.
        Mr. Schrader. Thank you, Madam Chair. I appreciate that.
        I think sometimes we forget that the ACA was a response to
    a bipartisan concern about the construction of the healthcare
    marketplace prior to the ACA.
        It was a pretty universal opinion, not a partisan issue,
    that healthcare costs were completely out of control. Whether
    you were upper middle class or low income or extremely wealthy,
    it was unsustainable.
        And the ACA may not be perfect but, as pointed out at the
    hearings, it gave millions of Americans healthcare that didn't
    have it before. It started to begin the discussion that we are
    talking about here: How do you create universal access in an
    affordable way to every American?
        Certainly, I am one of the folks that believe healthcare is
    a right, not a privilege, in the greatest country in the world.
    We are discussing about different ways to get at it.
        I think one of the most important things that doesn't get
    talked about a lot is the importance of the essential health
    benefits. It gets demonized because, well, geez, ``I am not a
    woman so I shouldn't have to pay for maternity. You know, I am
    invincible. I am never really going to get sick, so I don't
    need to pay for, you know, emergency healthcare.''
        Those things are ancillary. I guess, Ms. Young, talk to us
    a little bit about why the essential health benefits are part
    of the Affordable Care Act, and there have been some attempts
    by the administration and different Members not, I think,
    realizing how important they are with these often, you know,
    cheaper plans. Just get the cost down--they are ignoring maybe
    the health aspects of that. Could you talk a little bit about
    that?
        Ms. Young. Absolutely.
        Prior to the Affordable Care Act, insurers could choose
    what benefits they were going to place in their benefit
    policies.
        The Affordable Care Act essential health benefit
    requirements require that all insurers in the individual and
    small group markets cover a core set of 10 benefits--things
    like hospitalizations and doctors visits as well as maternity
    care, mental health and substance use disorder, prescription
    drugs, outpatient services.
        So, really, ensuring that the insurance that people are
    buying offers a robust set of benefits that provides them
    meaningful protection if they get sick.
        If you return to a universe where an issuer can choose what
    benefits they are going to put inside of a policy, you could
    have an insurance benefit that, for example, excludes coverage
    for cancer services and another policy that excludes coverage
    for mental health needs, and one that excludes coverage for a
    particular kind of drug.
        Mr. Schrader. And that might be in the fine print and
    people may not realize that as they sign up for policies.
        Ms. Young. That is correct, yes. So it would require
    consumers to really pile through the insurance--different
    policies to understand what they were buying.
        It also provides a back-door path to underwriting because
    insurers, for example, that exclude coverage for cancer from
    their benefit won't attract any consumers who have a history of
    cancer, who have reason to believe that they may need cancer
    coverage.
        And so it really takes our insurance market from one that
    successfully pools together the healthy and the sick to one
    that becomes more fragmented.
        Mr. Schrader. Right. Well, and another piece of the
    Affordable Care Act that gets overlooked--and, again, it has
    been alluded to by different Members and some of you on the
    panel--is the innovation, the flexibility--I mean, the Center
    for Medical Innovation, the accountable care organizations.
        Instead of--you know, it seems to me we are focused just on
    cost: How do I itemize this cost? We ask you guys these
    questions--the rate bands and all that stuff. We should be
    concerned about healthcare.
        I mean, the goal here is to provide better health. It's not
    to support the insurance industry or my veterinary office or
    whoever. The goal is to provide better healthcare, and the way
    you do that is by, I think, you know, having the experts in
    different communities figure out what is the best healthcare
    delivery system.
        Do you need more dentists in one community? Need more
    mental health experts in another community?
        I am very concerned that, if the Affordable Care Act is
    undone, that a lot of this innovation that has been spawned,
    the accountable care organizations that are going, would begin
    to dissolve. There would be no framework for them to operate
    in.
        Just recently in Oregon, where I come from, we had a record
    number of organizations step up to participate in what we call
    our coordinated care organizations that deal with the Medicaid
    population and have over 24 different organizations vying for
    that book of business.
        Could you talk just real briefly--I am sorry, timewise--
    real briefly about, you know, what would happen if those all
    went away?
        Ms. Young. As you note, the Affordable Care Act introduced
    a number of reforms and how Medicare pays to incentivize more
    value-based and coordinated care.
        If the district court's decision were to be upheld, then
    the legislative basis for some of those programs would
    disappear and there would really be chaos in Medicare payment
    if that decision were upheld.
        Mr. Schrader. OK. Thank you, and I yield back, Madam Chair.
        Ms. Eshoo. I thank the gentleman.
        I can't help but think that this was a very important
    exchange in your expressed viewpoints and counterpoint to Mr.
    Miller's description of the ACA as an odd contraption.
        I now would like to----
        Mr. Miller. I would respond on that if I had the
    opportunity.
        Ms. Eshoo. I am sure you would.
        Let us see, who is next? Now I would like to recognize Mr.
    Carter from Georgia.
        Mr. Carter. Well, thank you, and thank all of you for being
    here. Very, very interesting subject matter that we have as our
    first hearing of the year. I find it very interesting.
        Mr. Miller, let me ask you, just to reiterate and make sure
    I understand. I am not a lawyer. I am a pharmacist, so I
    don't----
        Mr. Miller. Good for you.
        Mr. Carter. Yes. I don't know much about law or lawyers
    and----
        Mr. Miller. It is a dangerous weapon.
        Mr. Carter. Well, let me ask you something. Right now, this
    court case, how many patients is it impacting?
        Mr. Miller. Well, people hypothetically might react
    thinking it is real, but otherwise, nobody.
        Mr. Carter. But it is my understanding it is still in
    litigation.
        Mr. Miller. Correct. Correct. And it is going to take a
    while, and it is going to end up differently than where it
    starts. But we are doing this, you know, make believe because
    it scores a lot of points.
        Mr. Carter. Well, I--make believe--I mean, we are in
    Congress. We are not supposed to be make believe.
        Mr. Miller. Well----
        Mr. Carter. I mean, I am trying to understand why this is
    the first hearing, when it is not impacting a single patient at
    this time, it is still in litigation, we don't know how it is
    going to turn out, we don't know how long it is going to take.
    Judging by other court cases that we have seen, it may take a
    long, long time.
        Mr. Miller. Well, to be fair, I used to run hearings in
    Congress on staff.
        Mr. Carter. Well----
        Mr. Miller. The majority can run any kind of hearing it
    wants to.
        Mr. Carter [continuing]. We are not here to be fair. So
    anyway, I am trying to figure out why this is the first
    hearing. I mean, you know, earlier the chairman of the full
    committee berates our Republican leader because he asked for a
    hearing on something that he is opposed to and that I am
    opposed to, and I am just trying to figure it out.
        You know, one of the things that we do agree on is that
    preexisting conditions need to be covered. Isn't it possible
    for us to still be working on preexisting conditions now and
    legislating preexisting conditions while this is under
    litigation?
        Mr. Miller. What you need are majorities who are willing to
    either spend money----
        Mr. Carter. Well----
        Mr. Miller [continuing]. Change rules and move things
    around. But that has been hard for Congress to do.
        Mr. Carter. Well, I think that the record will show that,
    you know, one of the first bills that we proposed in the
    Republican Party, in the Republican conference, was for
    preexisting conditions--Chairman Walden. In fact, I know he did
    because I cosponsored it.
        Mr. Miller. Mm-hmm. Yes. It was one of the more thorough
    ones, actually.
        Mr. Carter. It is something that--we have concentrated on
    that. So thank you for that. I just want to make sure.
        Mr. Roy, I want to ask you, did you testify before the
    Oversight Committee recently?
        Mr. Roy. Last week, yes.
        Mr. Carter. What were they talking about in the Oversight
    Committee? What were you testifying about?
        Mr. Roy. Prescription drug prices. The high cost of
    prescription drugs.
        Mr. Carter. Prescription drugs. Go figure. Here we are in
    the committee and the subcommittee with the most jurisdiction
    over healthcare issues, and Oversight has already addressed
    prescription drug pricing?
        Mr. Roy. Well, you have 2 years in this committee, and I
    look forward to hopefully being invited to talk----
        Mr. Carter. Well, I do too. I am just baffled by the fact
    that, you know, drug pricing is one of the issues--is the issue
    that most citizens when polled identify as being something that
    Congress needs to be active on, and I am just trying to figure
    out. In Oversight they have already addressed it.
        Mr. Roy. You know, one thing I will say about this topic,
    Mr. Carter, is that it is one of the real opportunities for
    bipartisan policy in this Congress. We have a Republican
    administration and a Democratic House where there has been a
    lot of interest in reducing the cost of prescription drugs, and
    I am optimistic that we really have an opportunity here to get
    legislation through Congress.
        Mr. Carter. And I thank you for bringing that up because
    Representative Schrader and I have already cosponsored a bill
    to stop what I think is the gaming of the system of the generic
    manufacturers and the brand-name manufacturers of what they are
    doing in delaying generic products to get onto the market.
        So, Madam Chair, I am just wondering when are we going to
    have----
        Ms. Eshoo. Gentleman yield? Would the gentleman yield?
        Mr. Carter. And if I could ask a question.
        Ms. Eshoo. Mm-hmm.
        Mr. Carter. When are we going to have a hearing on
    prescription drug costs?
        Ms. Eshoo. I can't give you the date. But it is one of the
    top priorities of the majority. It is one of the issues that we
    ran on with the promise to lower prescription drug prices. I
    believe that there is a bipartisan appetite for this, and we
    will have hearings and we will address it and we welcome your
    participation.
        Mr. Carter. Well, reclaiming my time. I appreciate that
    very much, Madam Chair, because it is a pressing issue and it
    is an issue that needs to be addressed now and today, unlike
    what we are discussing here today that is not impacting one
    single person at this point.
        So, you know, with all due respect, Madam Chair, I hope
    that we can get to prescription drug pricing ASAP because it is
    something that we need to be and that we are working on.
        And, Mr. Roy, you could not be more correct. This is a
    bipartisan issue. I practiced pharmacy for over 30 years. Never
    did I once see someone say, ``Oh, this is the price for the
    Democrat, this is the price for the Republican, this is the
    price for this person and that person.'' It was always the
    same. It was always high. That is why we need to be addressing
    this.
        So I thank you for being here. I thank all of you for being
    here and, Madam Chair, I yield back.
        Ms. Eshoo. I thank the gentleman.
        I now would like to recognize a new member of the
    subcommittee, Ms. Barragan from California. Welcome.
        Ms. Barragan. I thank you. Thank you, Ms. Chairwoman.
        My friend from Georgia asked why we are having this as the
    first hearing, and I just have to say something because, you
    know, I am in my second term, and in my first term when the
    Republicans were in the majority they spent all of their time
    trying to take away healthcare coverage for millions of
    Americans.
        They talk about preexisting conditions and talk about
    saving people with preexisting conditions. But this very
    lawsuit is going to put those people at stake.
        So why are we having this hearing? Well, because you guys
    have been working to take away these coverages and we are
    trying to highlight the importance of this lawsuit.
        Now, you had 2 years and, yes, you could have started with
    prescription drug prices and reducing those, and that wasn't
    done. So you are darn right the Democrats are going to take it
    up.
        You are darn right that we are going to have hearings on
    this, and I am proud to say that our chairwoman and our
    chairman have been working hard to make sure we are going to
    work to bring down prescription drug prices. But the hypocrisy
    that I hear on the other side of the aisle can't just go
    completely unanswered in silence.
        So, with that said, I am going to move on to what my
    comments have been. I want to thank you all for your testimony
    here today. It has been really helpful to hear us understand
    the potentially devastating impact of this lawsuit and of the
    district court's decision.
        The court's decision would not only eliminate protections
    for preexisting conditions but would also adversely impact the
    Medicaid program and end the Medicaid expansion.
        Now, the Affordable Care Act's expansion of Medicaid filled
    a major gap in insurance coverage and resulted in 13 million
    more Americans having access to care.
        I represent a district that is a majority minority--about
    88 percent black and brown people of color and, you know, black
    and brown Americans still have some of the highest uninsured
    rates in the country. Both groups have seen their uninsured
    numbers fall dramatically with the ACA. You know, between 2013
    and 2016, more than 4 million Latinos and 1.9 million blacks
    have secured affordable health coverage. Ultimately, black and
    brown Americans have benefitted the most from the ACA's
    Medicaid expansion program.
        Ms. Young, I would like to ask, can you briefly summarize
    the impact of the lawsuit on Medicaid beneficiaries and, in
    particular, the expansion population?
        Ms. Young. Medicaid expansion is, as you note, a very
    important part of the Affordable Care Act's coverage expansion,
    and it is benefitting millions of people in the 37 States that
    have expanded or are in the process of expanding this year.
        Medicaid expansion has been associated with better
    financial security, and failure to expand is associated with
    higher rates of rural hospital closures and other difficult
    impacts in communities.
        If this decision were to be upheld, then the Federal
    funding for Medicaid expansion would no longer be provided and
    States would only be able to receive their normal match rate
    for covering the population that is currently covered through
    expansion. That is an impact of billions of dollars across the
    country and a very large impact in individual States.
        States will have the choice between somehow finding State
    money to make up that gap or ending the expansion and removing
    those people from the Medicaid rolls or potentially cutting
    provider rates or making other changes in the benefit package
    or some combination.
        So you are looking at a potentially loss of--see very
    significant losses of coverage in that group as well as an
    additional squeeze on providers.
        Ms. Barragan. Thank you.
        Ms. Hung, how has Medicaid helped your family afford
    treatment, and why is Medicaid and Medicaid expansion so
    important for children with complex medical needs and their
    families?
        Ms. Hung. Medicaid is a lifesaving program. I say this
    without exaggeration. Medicaid is the difference between life
    and death. It covers what health insurance doesn't cover for a
    lot of children with complex medical needs.
        Notably, it covers long-term services and supports,
    including home and community-based services that enable
    children's independence. For a lot of families who do have
    health insurance like mine, health insurance doesn't really
    cover certain DME--durable medical equipment--certain
    specialists, the ability to go out of State.
        And so that is the difference for a lot of our families.
        Ms. Barragan. Great. Well, thank you all. I yield back.
        Ms. Eshoo. Thank you very much.
        Now, the patient gentleman from Montana, Mr. Gianforte.
        Mr. Gianforte. Thank you, Madam Chair, and thank you to the
    panelists for your testimony today.
        Every day, I hear from Montanans who ask me why their
    healthcare costs keep going up and continue to increase while
    their coverage seems to shrink at the same time.
        While we look for long-term solutions to make healthcare
    costs more affordable and accessible, I remain firmly committed
    to protecting those with preexisting conditions.
        In fact, I don't know anyone on this committee, Republican
    or Democrat, who doesn't want to protect patients with
    preexisting conditions. Insuring Americans with preexisting
    conditions can keep their health insurance and access care is
    not controversial.
        It shouldn't be. We all agree on it. Which brings us to
    today. In the ruling in Texas v. Azar, it has not ended
    Obamacare. It hasn't stripped coverage of preexisting
    conditions, and it hasn't impacted 2019 premiums.
        While we sit here today talking about it, the Speaker has
    moved to intervene in the case and the judge ruling has been
    appealed. The case is working itself through the courts.
        We could have settled this with a legislative solution less
    than a month ago. One of the earliest votes we took in this
    Congress was to lock in protection for patients with
    preexisting conditions.
        Unfortunately, Democrats rejected that measure. And yet,
    here we are in full political theater talking about something
    we all agree on--protecting Americans with preexisting
    conditions.
        We should be focused instead on the rising cost of
    prescription drugs, telehealth, rural access to healthcare, and
    other measures to make healthcare more affordable and
    accessible.
        I hope this committee will hold hearings and take action on
    these issues important to hardworking Montanans. I can
    understand, however, why my friends on the other side of the
    aisle do not want to take that path.
        Some of their party's rising stars and others jockeying for
    Democratic nomination in 2020 have said we should do away with
    private insurance. They advocate for a so-called Medicare for
    All. In reality, Medicare for none.
        Their plan would gut Medicare and the VA as we know it, and
    force 225,000 Montanan seniors who rely on Medicare to the back
    of the line. Montana seniors have earned these benefits, and
    lawmakers shouldn't undermine Medicare and threaten healthcare
    coverage for Montana seniors.
        Since we all agree we should protect patients with
    preexisting conditions, let us discuss our different ideas for
    making healthcare more affordable and accessible.
        We should put forward our ideas: on the one hand, Medicare
    for All, a Government-run single-payer healthcare system that
    ends employer-sponsored health plans; on the other, a health
    insurance system that protects patients with preexisting
    conditions, increases transparency, choice, and preserves rural
    access to care and lowers cost.
        I look forward to a constructive conversation about our
    diverging approaches to fixing our healthcare system. In the
    meantime, I would like to direct a question to Mr. Miller, if I
    could.
        Under Medicare for All, Mr. Miller, do you envision access
    to care would be affected for seniors and those with
    preexisting conditions in rural areas in particular?
        Mr. Miller. Well, that is a particular aspect. I think, in
    general, the world that seniors are currently used to would be
    downgraded. You are taking--spreading the money a little wider
    and thinner in order to help some. This is the story of the
    ACA.
        We can create winners, but we will also create losers. Now,
    the politics as to who you favor sort out differently in
    different folks. It is hard to get a balancing act where
    everybody comes out on top unless you make some harder
    decisions, which is to set priorities and understand where you
    need to subsidize and what you need to do to improve care and
    the health of people before they get sick.
        Mr. Gianforte. So it is your belief that, if this Congress
    were to adopt a Medicare for All approach, seniors would be
    disadvantaged? It will be more difficult to access care?
        Mr. Miller. They would be the first to be disadvantaged, as
    well as those with employer-based coverage because--if you
    swallowed it whole. I mean, there are lots of other problems
    Avik mentioned. It is not just the spending. It is actually the
    inefficiency of the tax extraction costs.
        When you run that much money through the Government, you
    don't get what you think comes out of it.
        Mr. Gianforte. One other topic, quickly, if I could.
    Telehealth is very important in rural areas. It is really vital
    to patients in Montana. How do you foresee telehealth services
    being affected under a single-payer system?
        Mr. Miller. Well, Medicare has probably not been in the
    forefront of promoting telehealth. I think there is a lot more
    buzz about telehealth as a way to break down geographical
    barriers to care, to have more competitive markets.
        And so, if past history is any guide of Medicare fee-for-
    service, it is not as welcoming to telehealth as private
    insurance would be.
        Mr. Gianforte. OK. And I yield back.
        Ms. Eshoo. I thank the gentleman.
        I now would like to recognize the gentleman from Vermont,
    Mr. Welch.
        Mr. Welch. Thank you. I will be brief. Just a few comments.
        I think it is important that we had this hearing. This did
    not come out of thin air. I mean, I was on the committee when
    we wrote the Affordable Care Act. Very contentious. It was a
    party-line vote.
        I was on the committee when we repealed it--this committee
    repealed the Affordable Care Act, and we never saw a bill. We
    never had a hearing.
        And now we have a continuation of this effort by the
    Republican attorneys general to attack it, and we have the
    unusual decision by the administration where, instead of
    defending a Federal law, they are opposing a Federal law.
        So it is why I have been continuing to get so many letters
    from Vermonters who are fearful that this access to healthcare
    that they have is really in jeopardy.
        Loretta Heimbecker from Montgomery has a 21-year-old son
    who is making $11.50 an hour. He has got a medical condition
    from birth, and absent the access to healthcare he wouldn't be
    able to work and the mother would probably be broke.
        I have got a cancer patient, Kathleen Voigt Walsh from
    Jericho, who would not have access to the treatment she needs
    absent this. I mean, Ms. Hung, you really, in your own personal
    presentation, have explained why people who really need it
    would be scared if we lost it.
        And I also served in Congress when the essential agenda on
    the Republican side was to try to repeal it. I mean, it was a
    pretty weird place to be--Congress--when on a Friday afternoon,
    if there is nothing else to do, we would put a bill on the
    floor to repeal healthcare for the sixtieth time. I mean, we
    are just banging our head against the wall.
        So thank you for having this hearing because I see it as a
    reassurance to a lot of people I represent that we mean
    business--that we are going to defend what we have.
        Now, second, on some of the criticisms about this not being
    a hearing on prescription drugs, Mr. Roy, you were in--did a
    great job helping us start the process in Oversight and
    Government Reform.
        But I know our chair of this subcommittee--this is the
    committee where there is actual jurisdiction--is totally
    committed to pursuing this, and I thank our chair.
        And I have been hearing very good things from President
    Trump about the need to do this. So my hope is that we are
    going to get a lot of Republican support to do practical things
    so we are not getting ripped off, as the president has said, by
    us paying the whole cost of research--a lot of it, by the way,
    from taxpayers, not necessarily from the companies--and have to
    pay the highest prices.
        So I am commenting and not asking questions. But I know
    that there has been extensive and excellent testimony. But I
    just want to say to the chair and I want to say to my
    colleagues, Republican and Democrat, if the net effect of this
    hearing is that we are affirming a bipartisan commitment not to
    mess with the Affordable Care Act, then I am going to be able
    to reassure my constituents that their healthcare is safe.
        And if the criticism is essentially we have got to do more,
    we are ready to do more, right?
        Madam Chair, so I thank you for this hearing, and I thank
    the witnesses for their excellent testimony and look forward to
    more down the line.
        Ms. Eshoo. I thank the gentleman for his comments and his
    enrichment of the work at this subcommittee. I think it is
    important to note that, on the very first day of this Congress,
    that House Democrats voted to intervene in this case--the very
    first day of the Congress--as it moves through appeal.
        So we are the ones that are representing the Government,
    and I think that, for my colleagues on the other side of the
    aisle, you may not like my suggestion, but if you are for all
    of these things that you are talking about, write to the
    attorneys general and the Governors that brought the suit and
    say, ``We want it called off. We want to move on and strengthen
    the healthcare system in our country.'' You will find a partner
    in every single person on this side of the aisle.
        With that, I would like to recognize Mr. O'Halleran--what
    State?
        Mr. Burgess. Arizona.
        Ms. Eshoo. Arizona--from the great State of Arizona--who
    is, I believe, waiving on to the subcommittee, and we have a
    wonderful rule in the full committee that, if you are not a
    member of a subcommittee you can still come and participate.
    But you are the last one to be called on. So thank you for your
    patience, and thank you for caring and showing up.
        Mr. O'Halleran. I thank you, Madam Chair. I am also usually
    last in my house also to be called on.
        Thank you, Madam Chair. Although I am not a permanent
    member of the subcommittee, I appreciate your invitation for me
    to join you today to discuss this issue that is so critical to
    families across Arizona, and thank you to the witnesses.
        As some of you know, the district I represent is extremely
    large and diverse--the size of Pennsylvania. Twelve federally
    recognized Tribes are in my district.
        Since I came to Congress 2 years ago, I have been focused
    on working across the aisle to solve healthcare issues. We face
    these issues together because it is one thing that I hear about
    every single corner of my rural district and one of the
    overriding issues in Congress.
        A district where hospitals and the jobs they provide are
    barely hanging on and where decades of toxic legacy of uranium
    mining has left thousands with exposure-related cancers across
    Indian country.
        A district where Medicaid expansion made the difference for
    some veterans getting coverage, some hospitals keeping their
    doors open, where essential health benefits meant some
    struggling with opiate addiction could finally get substance
    abuse treatment.
        I am here because the lawsuit we are discussing today isn't
    about any of those policies and how they save taxpayer dollars
    and protect rural jobs. I am a former Republican State
    legislator. I know that this lawsuit is purely motivated not by
    what is best for the people we are representing but by
    politics.
        Ms. Young, I have three questions for you. The first is,
    the first letter I ever sent as a Member of Congress was a
    bipartisan letter to congressional leadership about dangers of
    ACA repeal on the Indian Health Care Improvement Act, which was
    included in the ACA.
        Madam Chair, I ask unanimous consent to enter my letter
    into the record.
        Ms. Eshoo. So ordered.
        [The information appears at the conclusion of the hearing.]
        Mr. O'Halleran. Ms. Young, can you describe what the fate
    of this law would be if this lawsuit succeeds and what it means
    for Tribal communities?
        Ms. Young. The district court's opinion as written struck
    down the entire Affordable Care Act so it would--even unrelated
    provisions like the Indian Health Care Improvement Act--so, if
    the decision were upheld, then the Indian Health Care
    Improvement Act would no longer have the force of law and the
    improvements included in that law, like better integration with
    the Veterans Health Service and better integration for
    behavioral health and other core benefits for the Indian Health
    Service, would be eliminated.
        Mr. O'Halleran. Thank you, Ms. Young.
        Are cancers caused by uranium exposure considered a
    preexisting condition?
        Ms. Young. I suspect that under most medical underwriting
    screens they would be, yes.
        Mr. O'Halleran. Thank you. And, Ms. Young, over 120 rural
    hospitals have closed since 2005. Right now, 673 additional
    facilities are vulnerable and could close. That is more than a
    third of rural hospitals in the United States.
        If this lawsuit succeeds, do you anticipate rural hospitals
    and the jobs they provide would be endangered as a result of
    fewer people having health coverage?
        Ms. Young. As you know, rural hospitals face a number of
    challenges and a number of difficult pressures. There has been
    research demonstrating that a State's failure to expand
    Medicaid is associated with higher rates of rural hospital
    closures. And so, if the Federal funding for Medicaid expansion
    were removed, then it is likely that that would place
    additional stress on rural hospitals.
        Mr. O'Halleran. Thank you.
        Madam Chair, this is why last year I led the fight to urge
    my State's attorney general to drop this partisan lawsuit. So
    much is at stake in Arizona for veterans, the Tribes, for jobs
    in rural communities like mine.
        I am interested in finding bipartisan solutions to the
    problems we have got, and I will work with anyone here to do
    that. But this lawsuit doesn't take us in that direction. It
    takes us back, and my district can't afford that.
        Thank you, and I yield back.
        Ms. Eshoo. I thank the gentleman for making the time to be
    here and to not only make his statement but ask the excellent
    questions that you have.
        At this time I want to remind members that, pursuant to the
    committee rules, they have 10 business days to submit
    additional information or questions for the record to be
    answered----
        Mr. Burgess. Madam Chair?
        Ms. Eshoo. Yes.
        Mr. Burgess. Could I seek recognition for a unanimous
    consent request?
        Ms. Eshoo. Sure. Just a minute. Let me just finish this,
    all right?
        I want to remind Members that, pursuant to committee rules,
    Members have 10 business days to submit additional questions
    for the record to be answered by the witnesses who have
    appeared, and I ask each of the witnesses to respond promptly
    to any such questions, and I see your heads nodding, so I am
    comforted by that, that these questions that you may receive.
        And I would recognize the ranking member, and I also have a
    list of--to request unanimous consent for the record.
        Mr. Burgess. Oh, I can go after you.
        Ms. Eshoo. OK. The first, a statement for the record from
    the American Cancer Society Cancer Action Network and 33 other
    patient and consumer advocacy organizations; a statement for
    the record from the American Academy of Family Physicians; a
    statement for the record from the American College of
    Physicians; the Wall Street Journal editorial entitled ``Texas
    Obamacare Blunder.'' I think that was referenced by Mr. Lazarus
    earlier today.
        Jonathan Adler and Abbe Gluck, New York Times op-ed
    entitled ``What the Lawless Obamacare Ruling Means''; a brief
    of the amicus curiae from the American Medical Association, the
    American Academy of Family Physicians, the American College of
    Physicians, the American Academy of Pediatrics, and the
    American Academy of Child and Adolescent Psychiatry.
        Isn't it extraordinary what we have in this country? Just
    the listing of these organizations.
        The U.S.A. Community Catalyst, the National Health Law
    Program, Center for Public Policy Priorities, and Center on
    Budget and Policy Priorities; the brief of the amici curiae
    from the American Cancer Society, the Cancer Action Network,
    the American Diabetes Association, the American Heart
    Association, the American Lung Association, and National
    Multiple Sclerosis Society supporting defendants; and a
    statement for the record from America's Health Insurance Plans.
        So I am asking a unanimous consent request to enter the
    following items in the record. I hear no objections, and I will
    call on--recognize the ranking member.
        [The information appears at the conclusion of the
    hearing.]\1\
    ---------------------------------------------------------------------------
        \1\ The amici briefs have been retained in committee files and also
    are available at https://docs.house.gov/Committee/Calendar/
    ByEvent.aspx?EventID=108843..
    ---------------------------------------------------------------------------
        Mr. Burgess. Thank you. First off, thank you for reminding
    me why I have not yet paid my AMA dues this year.
        [Laughter.]
        Mr. Burgess. I have a unanimous consent request. I would
    ask unanimous consent to place into the record the letter that
    was sent by Mr. Walden and myself regarding the Medicare for
    All hearing.
        Ms. Eshoo. No objection.
        [The information appears at the conclusion of the hearing.]
        Ms. Eshoo. The only request that I would make is that maybe
    on your email mailing list that, when you notify the chairman
    of the full committee, that maybe my office can be notified as
    well.
        Mr. Burgess. Welcome to the world that I inhabited 2 years
    ago.
        Ms. Eshoo. That's why I think you will understand.
        Mr. Burgess. I never found out until after the fact.
        Ms. Eshoo. Right. Right.
        Mr. Burgess. But I would take that up with your full
    committee chair. I am sure they will recognize the importance
    of including you in the email distribution list.
        Ms. Eshoo. I thank the gentleman.
        Let me just thank the witnesses. You have been here for
    almost 3 hours. We thank you for not only traveling to be here
    but for the work that you do that brings you here as witnesses.
        Mr. Lazarus says he is retired, but he brings with him
    decades of experience. We appreciate it. To each witness,
    whether you are a majority or minority witness, we thank you,
    and do get a prompt reply to the questions because Members
    really benefit for that.
        So our collective thanks to you, and to Ms. Hung, what a
    beautiful mother. You brought it all. I am glad that you are
    sitting in the center of the table, because you centered it all
    with your comments.
        So with that, I will adjourn this subcommittee's hearing
    today.
        Thank you.
        [Whereupon, at 1:03 p.m., the committee was adjourned.]
        [Material submitted for inclusion in the record follows:]
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