[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:]
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    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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