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


                       PROTECTING AMERICANS WITH
                        PREEXISTING CONDITIONS

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

                                HEARING

                               BEFORE THE

                      COMMITTEE ON WAYS AND MEANS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            JANUARY 29, 2019

                               __________

                            Serial No. 116-1

                               __________

         Printed for the use of the Committee on Ways and Means


[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
35-633                      WASHINGTON : 2020                     
          
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                      COMMITTEE ON WAYS AND MEANS

                RICHARD E. NEAL, Massachusetts, Chairman

JOHN LEWIS, Georgia                  KEVIN BRADY, Texas
LLOYD DOGGETT, Texas                 DEVIN NUNES, California
MIKE THOMPSON, California            VERN BUCHANAN, Florida
JOHN B. LARSON, Connecticut          ADRIAN SMITH, Nebraska
EARL BLUMENAUER, Oregon              KENNY MARCHANT, Texas
RON KIND, Wisconsin                  TOM REED, New York
BILL PASCRELL, JR., New Jersey       MIKE KELLY, Pennsylvania
DANNY K. DAVIS, Illinois             GEORGE HOLDING, North Carolina
LINDA SANCHEZ, California            JASON SMITH, Missouri
BRIAN HIGGINS, New York              TOM RICE, South Carolina
TERRI A. SEWELL, Alabama             DAVID SCHWEIKERT, Arizona
SUZAN DELBENE, Washington            JACKIE WALORSKI, Indiana
JUDY CHU, California                 DARIN LAHOOD, Illinois
GWEN MOORE, Wisconsin                BRAD R. WENSTRUP, Ohio
DAN KILDEE, Michigan                 JODEY ARRINGTON, Texas
BRENDAN BOYLE, Pennsylvania          DREW FERGUSON, Georgia
DON BEYER, Virginia                  RON ESTES, Kansas
DWIGHT EVANS, Pennsylvania
BRAD SCHNEIDER, Illinois
TOM SUOZZI, New York
JIMMY PANETTA, California
STEPHANIE MURPHY, Florida
JIMMY GOMEZ, California
STEVEN HORSFORD, Nevada

                     Brandon Casey, Staff Director

                 Gary J. Andres, Minority Chief Counsel


                            C O N T E N T S

                               __________

                                                                   Page

Advisory of January 22, 2019, announcing the hearing.............     2

                               WITNESSES

Karen Pollitz, Senior Fellow, Kaiser Family Foundation...........     6
Andrew R. Stolfi, Insurance Commissioner and Administrator of the 
  Division of Financial Regulation, Oregon Division of Financial 
  Regulation.....................................................    17
Rob Robertson, Chief Administrator/Secretary-Treasurer, Nebraska 
  Farm Bureau Federation.........................................    27
Keysha Brooks-Coley, Vice President of Federal Advocacy, American 
  Cancer Society, Cancer Action Network (ACS CAN)................    34
Andrew Blackshear, Patient and Volunteer, American Heart 
  Association....................................................    47

                       SUBMISSIONS FOR THE RECORD

Kaiser Family....................................................   164
American Speech-Language-Hearing Association (ASHA)..............   170
Michael G. Bindner, Center for Fiscal Equity.....................   173
Association for Community Affiliated Plans (ACAP)................   177

 
                       PROTECTING AMERICANS WITH
                         PREEXISTING CONDITIONS

                              ----------                              


                       TUESDAY, JANUARY 29, 2019

                     U.S. House of Representatives,
                               Committee on Ways and Means,
                                                    Washington, DC.

    The Committee met, pursuant to call, at 10:00 a.m., in Room 
1100, Longworth House Office Building, Hon. Richard E. Neal 
[Chairman of the Committee] presiding.
    [The advisory announcing the hearing follows:]

ADVISORY FROM THE COMMITTEE ON WAYS AND MEANS

                                                CONTACT: (202) 225-3625
FOR IMMEDIATE RELEASE Tuesday, January 22, 2019 
FC-1

                  Chairman Neal Announces a Hearing on

                       Protecting Americans with

                         Preexisting Conditions

    House Ways and Means Committee Chairman Richard E. Neal today 
announced that the Committee will hold a hearing on Protecting 
Americans with Preexisting Conditions. The hearing will take place on 
Tuesday, January 29, 2019, in the main Committee hearing room, 1100 
Longworth House Office Building, beginning at 10:00 a.m.
      
    In view of the limited time available to hear witnesses, oral 
testimony at this hearing will be from invited witnesses only. However, 
any individual or organization not scheduled for an oral appearance may 
submit a written statement for consideration by the Committee and for 
inclusion in the printed record of the hearing.
      

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:

      
    Please Note: Any person(s) and/or organization(s) wishing to submit 
written comments for the hearing record must follow the appropriate 
link on the hearing page of the Committee website and complete the 
informational forms. From the Committee homepage, http://
waysandmeans.house.gov, select ``Hearings.'' Select the hearing for 
which you would like to make a submission, and click on the link 
entitled, ``Click here to provide a submission for the record.'' Once 
you have followed the online instructions, submit all requested 
information. ATTACH your submission as a Word document, in compliance 
with the formatting requirements listed below, by the close of business 
on Tuesday, February 12, 2019. For questions, or if you encounter 
technical problems, please call (202) 225-3625.
      

FORMATTING REQUIREMENTS:

      
    The Committee relies on electronic submissions for printing the 
official hearing record. As always, submissions will be included in the 
record according to the discretion of the Committee. The Committee will 
not alter the content of your submission, but reserves the right to 
format it according to guidelines. Any submission provided to the 
Committee by a witness, any materials submitted for the printed record, 
and any written comments in response to a request for written comments 
must conform to the guidelines listed below. Any submission not in 
compliance with these guidelines will not be printed, but will be 
maintained in the Committee files for review and use by the Committee.
      
    All submissions and supplementary materials must be submitted in a 
single document via email, provided in Word format and must not exceed 
a total of 10 pages. Witnesses and submitters are advised that the 
Committee relies on electronic submissions for printing the official 
hearing record.
      
    All submissions must include a list of all clients, persons and/or 
organizations on whose behalf the witness appears. The name, company, 
address, telephone, and fax numbers of each witness must be included in 
the body of the email. Please exclude any personal identifiable 
information in the attached submission.

    Failure to follow the formatting requirements may result in the 
exclusion of a submission. All submissions for the record are final.

    The Committee seeks to make its facilities accessible to persons 
with disabilities. If you require special accommodations, please call 
(202) 225-3625 in advance of the event (four business days' notice is 
requested). Questions regarding special accommodation needs in general 
(including availability of Committee materials in alternative formats) 
may be directed to the Committee as noted above.
      
    Note: All Committee advisories and news releases are available at
    http://www.waysandmeans.house.gov/

                                 

    Chairman NEAL. The Ways and Means Committee will now come 
to order. I want to thank everyone for their presence here 
today for the Ways and Means Committee's first policy hearing 
in the 116th Congress. A warm welcome to the new Members of the 
Committee on both sides of the aisle. I am honored this morning 
to be the 67th Chairman of the House Ways and Means Committee. 
We take this position, history, and prestige of the Committee 
all quite seriously.
    I look forward to considering policies that will have a 
positive impact on the future of our Nation and all American 
families. Today we will discuss an issue that affects nearly 
every American family: Preexisting conditions and their impact 
on healthcare coverage. Over 130,000 Americans have a 
preexisting condition, and protecting them goes to the core of 
safeguarding healthcare for all Americans.
    What insurance companies consider to be preexisting 
conditions can be anything from asthma to cancer to even 
pregnancy. Before the Affordable Care Act, which is the current 
law of the land, Americans faced significant hardship when 
trying to purchase adequate healthcare coverage. Insurance 
companies could refuse coverage altogether, charge excessive 
fees, and place dollar limits on the amount of care that 
Americans might receive. Insurers could even discriminate 
against patients with common healthcare issues such as diabetes 
or high blood pressure.
    When the ACA became law, new safeguards went into place to 
put a stop to these practices. Our healthcare system's 
protections really matter for American families' peace of mind, 
and certainly for their pocketbooks.
    My colleagues on the other side from time to time have 
offered a different view. Despite their repeated claims to 
support the protections for healthcare for people with 
preexisting conditions, their actions have directly 
contradicted the statements. They are currently leading ongoing 
efforts to undermine or eliminate the current law's protections 
for Americans with preexisting conditions. This is the wrong 
course of action.
    The Trump administration's efforts to chip away at the law 
and 18 Republican attorneys general who are actively trying to 
sabotage the law through the courts understand what they can't 
do legislatively they will attempt to do judicially. As one of 
the first actions in the 116th Congress, my colleagues and I 
are moved to intervene in the GOP lawsuit and defend the 
current law's preexisting conditions safeguards.
    I am pleased to join attorneys general from Massachusetts 
and other Democratic attorneys general who are defending 
consumers in fighting for Americans with preexisting 
conditions. Let me be clear: The ongoing effort to sabotage the 
healthcare system is having a direct impact on the finances of 
Americans across the country, and it is creating uncertainty 
for one-fifth of the U.S. economy. Four million Americans have 
lost health insurance since President Trump took office. That 
is 4 million Americans who previously had insurance and now 
must pay their medical costs fully out-of-pocket or delay 
needed medical care. And earlier this month, this 
Administration took action to reduce the tax credits by $900 
million while raising the out-of-pocket maximums by an 
additional $400 per family.
    I want to take a minute to share a story about one of my 
constituents who has been personally impacted by the 
preexisting condition protection. Michael Finn is 48 years old 
and a State representative from West Springfield, 
Massachusetts. He was diagnosed with type 2 diabetes 2 years 
ago when he was 46. He was a borderline diabetic for at least 
10 years before that, even though his condition went 
undiagnosed.
    Mike is married with three children under the age of 10, 
and he is grateful to the ACA for allowing him to keep 
receiving treatment, medication, and care, even though he has a 
preexisting condition. His wife is a stay-at-home mother, and 
Mike is the sole breadwinner in the household. If he were 
unable to work or unable to receive insurance assistance to 
help cover healthcare costs, he and his family don't know what 
they would do.
    We need to embrace policies that protect people like Mike. 
The law is currently clear. But there is an opportunity to 
build upon it and stop the ongoing sabotage. I have seen in 
Massachusetts that we can work together across party lines to 
make sure Americans have coverage and to protect families from 
financial ruin. Recall that 100 percent of the children in 
Massachusetts are covered and 97 percent of the adults. We need 
more of that reflection here in Congress, and I hope this 
hearing will be the beginning of that process.
    I am pleased our witnesses could join us today to share 
their professional and personal experiences and thoughts on how 
protections for people with preexisting conditions are 
essential. Our witnesses know that these safeguards can be the 
difference between getting needed medical assistance and 
foregoing necessary treatments or the difference between 
accessing affordable care and losing a lifetime of savings just 
to stay alive.
    These protections mean the world to people, and they are 
the law of the land. I am glad we will have an opportunity this 
morning to discuss them.
    And, with that, let me recognize the Ranking Member, Mr. 
Brady, for his opening statement. Mr. Brady for 5 minutes.
    Mr. BRADY. Thank you, Chairman Neal, for convening this 
important hearing today.
    Without question, while America's health system boasts 
remarkable innovation and highly trained professionals, it 
faces many challenges, the greatest among them: The high cost.
    Americans agree. In a recent Gallup Poll, almost 70 percent 
of Americans say healthcare has major problems, and nearly that 
many say rising insurance premiums are their biggest concern. 
It is clear the status quo of America's healthcare isn't 
working. When Democrats pushed through a healthcare bill, 
written behind a closed door, filled with special interest 
provisions, and with no Republican support, President Obama 
made many unkept promises to the American people, including the 
reform we are proposing will provide you more stability and 
more security. When it comes to healthcare costs, the words 
``stability'' and ``security'' are the last to come to mind.
    It has been 10 years since the ACA was passed by Democrats 
only, and yet healthcare still remains the top worry of 
American workers and businesses. We have to do better. For 
Republicans, what we hope will happen today is an honest 
conversation, one on how we can create a healthcare system that 
is more compassionate, more convenient, and less costly.
    And to begin, there are a few things that I would like to 
make clear. First is this: Of course, Republicans support 
protections for people with preexisting conditions. We included 
these protections in our House-approved alternative to the ACA. 
Section 137 of the American Healthcare Act said clearly: 
Nothing in this Act shall be construed as permitting healthcare 
insurance issuers to limit access to health coverage for 
individuals with preexisting conditions.
    Furthermore, Republicans guaranteed there can be no 
lifetime limits on healthcare costs. It is important if you 
have a child with an expensive disease or you face one 
yourself. We make sure young people can stay on their parents 
plan until they are age 26. And then again, on day one of this 
Congress, Republicans offered and unanimously supported an 
amendment on the House floor stating our unwavering support for 
protecting patients with preexisting conditions. This means 
guaranteeing no American purchasing healthcare as an individual 
can be denied coverage, denied renewal, or charged more because 
they have a preexisting condition.
    These protections, by the way, have long been guaranteed 
for 93 percent of the Americans who get their healthcare at 
work or through the government. They should be guaranteed for 
individuals as well. And if you remember only one thing we say 
today, remember this: We have to do more than protect 
healthcare; we have to work together to make it affordable. The 
ACA is failing too many Americans who face soaring costs, 
skyrocketing deductibles, and few choices of local doctors and 
hospitals. It really is time for a fresh start, this time with 
both parties working together creating truly affordable 
healthcare focused on patients, not on Washington.
    This Committee advanced many bipartisan healthcare reforms 
last Congress that expanded health savings vehicles for 
families, protected the most fragile among us in Medicare, 
rolled back some of ObamaCare's most egregious taxes, and 
looked for ways to increase innovation. So let's work together 
this Congress to build on these initiatives.
    I think there are many commonsense areas where we can work 
together, Mr. Chairman, from price transparency, to spurring 
innovation, lowering drug prices, addressing surprise billings, 
and removing the regulatory barriers to improve patient care.
    The final point I would like to make is this: What 
Republicans don't support, as well as the majority of 
Americans, is the status quo. I know many of my Democrat 
colleagues may want to relitigate the past today; we will be 
glad to because the ACA has become too expensive to use for so 
many Americans and so many Texans. So expensive, in fact, twice 
as many Americans have found a way to get out of ObamaCare than 
those who chose it. Twice as many got out of it--out from under 
it because they couldn't afford it and they couldn't use it.
    So what will benefit us is to focus on the future. Today 
let's turn a new leaf, beginning the work folks back home sent 
us here to do: Work together to help make healthcare less 
expensive and easier to use. We owe that to our families and to 
our businesses.
    With that, thank you, Chairman Neal.
    Chairman NEAL. Thank you, Mr. Brady.
    And, without objection, all Members' opening statements 
will be made part of the record.
    Let me now introduce our distinguished panel of witnesses 
for the opportunity to discuss many of the important questions 
for protecting coverage for preexisting conditions.
    First, I would like to welcome Karen Pollitz, a Senior 
Fellow at the Kaiser Family Foundation and, for those of you 
with long memories, a former staffer for our longtime colleague 
Mr. Levin of Michigan, who recently retired from Congress.
    Next is Andrew Stolfi. He is the Insurance Commissioner and 
Administrator from my friend Earl Blumenauer's State, Oregon. 
He is in the Oregon Division of Financial Regulation.
    Rob Robertson from the State of Adrian Smith's, Nebraska. 
He is the Chief Administrator/Secretary-Treasurer of the 
Nebraska Farm Bureau Federation.
    Keysha Brooks-Coley, Vice President of Federal Advocacy at 
the American Cancer Society, Cancer Action Network, will share 
with us why these protections are so critical for Americans 
living with cancer and cancer survivors.
    And, finally, Andrew Blackshear, a constituent of Mr. 
Thompson and one of the 133 million Americans with a 
preexisting condition. His story highlights the dangers of 
short-term limited-duration healthcare plans that have been 
promoted by the Trump administration.
    Each of your statements will be made part of the record in 
its entirety. I would ask that you summarize your testimony in 
5 minutes or less. And to help you with that time, there is a 
timing light that you might take note of at your table. When 
you have 1 minute left, the light will switch from green to 
yellow and then finally to red when the 5 minutes are up.
    Ms. Pollitz, please begin.

          STATEMENT OF KAREN POLLITZ, SENIOR FELLOW, 
                    KAISER FAMILY FOUNDATION

    Ms. POLLITZ. Thank you, Mr. Chairman, and Ranking Member 
Brady, and Members of the Committee. Good morning.
    Mr. Chairman, most people are healthy most of the time, but 
when we need care, it can get expensive. Figure 1 in my 
statement shows that each year about 20 percent of people 
account for 80 percent of all health spending, while the 
healthiest half accounts for just 3 percent of health spending. 
That chart is just a snapshot, though. Over time, our health 
status changes, and eventually, at some point, we will all get 
sick or hurt or pregnant and need costly care at least for a 
while. So we buy health insurance in case we get sick, not in 
case we stay healthy.
    Before the Affordable Care Act, the individual insurance 
market didn't always work for people once they got sick. People 
with preexisting conditions could be turned down or charged 
more. About 27 percent of nonelderly adults each year have a 
condition, such as cancer, diabetes, or pregnancy, that would 
have made them uninsurable in this market.
    Also, people healthy enough to get nongroup coverage 
couldn't be sure it would work for them once they got sick. 
Policies typically didn't cover key benefits, such as 
prescription drugs, mental health, or maternity care. And if 
people made large claims, they could find it hard to stay 
covered. Renewal premiums could skyrocket. Insurers also 
engaged in post claims underwriting, investigating a condition 
to see if it existed even undiagnosed before the policy, and if 
so, denying claims for the preexisting condition.
    Premiums on average were cheaper before the ACA. But there 
was a lot of variation around that average. And the cheapest 
premiums were only available to people while they were young 
and healthy. The ACA made a lot of changes. It required 
insurers to take everybody and offer policies that cover 
essential health benefits at premiums that don't vary based on 
health status. To make that affordable, the ACA added 
subsidies. Last year, more than 9 million people bought 
nongroup policies with the help of premium tax credits.
    Subsidies also stabilize the market, helping people buy 
regardless of health status, and they effectively absorb 
premium increases from year to year for people who are 
eligible. Of course, nearly 4 million other unsubsidized 
individuals were enrolled in ACA policies last year, mostly 
bought outside of the marketplace. And, for them, rising 
premiums are harder to afford and enrollment by unsubsidized 
individuals has been declining.
    Why are premiums rising? Uncertainty is the key underlying 
reason. Insurers didn't know how to price for this in market 
when it opened. Most set premiums low and lost money in the 
first 3 years. Rates then increased substantially in 2017, a 
one-time correction, according to insurer rate filings, but 
then new sources of uncertainty arose.
    The Trump administration ended payments to insurers for 
cost-sharing subsidies they are required to provide through the 
marketplace. Insurers responded with so-called silver loading, 
raising the premiums for silver plans twice as much in 2018 as 
for bronze and gold plans. For 2019, for the first time we saw 
national average premiums for the benchmark marketplace plan 
decline by about 1 percent. Even so, premiums this year are 
higher than they would have been by about 6 percent due to two 
new factors: Repeal of the ACA individual mandate penalty and 
competition from short-term policies.
    Short-term policies are exempt from ACA market rules. They 
will deny coverage to people who are sick. They will terminate 
coverage for people when they get sick. And typically they 
covered fewer benefits. They are also cheaper, but only for 
healthy people. Competition by short-term plans threatens 
stability of the ACA risk pool. Initially that threat was 
limited because regulations required the term of short-term 
policies to be short, less than 3 months; they weren't eligible 
for subsidies; and they didn't satisfy my mandate, so people 
who bought these to save money were at risk owing a tax 
penalty.
    But now the mandate penalty is gone. The new Trump 
administration regulations allow short-term policies to last up 
to 12 months. And other guidance on ACA waivers now give States 
a path to promote the sale of these policies and even shift 
some Federal subsidy dollars to them.
    How markets might evolve under these and other changes 
remains to be seen. Further steps to divide the risk pool can 
make cheaper options available to some people while they are 
healthy, but that strategy won't increase choices for people 
who have health conditions, and it will increase premiums for 
the ACA-compliant plans on which they rely.
    Protections for people with preexisting conditions have 
become a defining feature of the ACA, and they enjoy strong 
public support, our polling shows, by Democrats and 
Republicans, and by people with preexisting conditions, and 
those who haven't developed them yet. Most Americans want 
health insurance to work for people when they get sick.
    Thank you, and I am happy to take your questions.
    [The prepared statement of Ms. Pollitz follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    

                                 
    Chairman NEAL. Thank you, Ms. Pollitz.
    Now we would like to recognize Mr. Stolfi. Would you please 
begin?

   STATEMENT OF ANDREW R. STOLFI, INSURANCE COMMISSIONER AND 
 ADMINISTRATOR OF THE DIVISION OF FINANCIAL REGULATION, OREGON 
                DIVISION OF FINANCIAL REGULATION

    Mr. STOLFI. Chairman Neal, Ranking Member Brady, Members of 
the Committee, thank you for inviting me today for this 
important discussion. My name is Andrew Stolfi, and I am the 
Insurance Commissioner and Administrator of the Oregon Division 
of Financial Regulation.
    Since Oregon implemented the major provisions of the 
Affordable Care Act, more than 340,000 Oregonians have gained 
health insurance, and our uninsured rate has dropped from a 
high of more than 17 percent to about 6 percent. Today more 
than 3.7 million Oregonians, 94 percent of the State, are 
covered by health insurance, and our goal is to maintain 
coverage for 99 percent of adults and 100 percent of children.
    Governor Brown's vision and our goal is not just a number; 
it is for all Oregonians to have quality, affordable 
healthcare, regardless of who they are or where they live. The 
ACA has greatly advanced this goal, and we urge this Congress 
to protect the gains that have been made while continuing to 
work toward bending the cost curve for consumers.
    Oregon's health insurance market has traditionally been 
competitive and offered choice. We have also been a leader in 
implementing progressive consumer-focused health reforms. 
However, despite our best efforts, our uninsured rate in 2009 
was higher than the national average at more than 17 percent. 
Oregonians seeking insurance in the individual market also 
experienced high rates of denials based on preexisting 
conditions. In 2007, the denial rate was about 30 percent.
    And when an individual policy was issued, it could exclude 
or limit coverage in a myriad of ways. The ACA helped change 
all of this, particularly for those with preexisting 
conditions. More than 1.6 million American Oregonians with 
preexisting medical conditions are protected from coverage 
denials or limitations. Pregnant mothers know they can get the 
care they and their babies need. And children with 
developmental disabilities can get all the essential therapy 
they need to grow to their fullest potential.
    We have individual health policies offered by at least two 
carriers in each of our counties and are one of the first 
States to implement our reinsurance program that has kept 
individual insurance rates about 6 percent lower than they 
would be without. These numbers reflect the work that has been 
done in Oregon to provide stability to the State's health 
insurance market. Unfortunately, other numbers demonstrate the 
harm recent Federal actions have caused.
    Federal rule changes to short-term limited-duration plans 
and association health plans, along with zeroing out of the 
individual mandate penalty have raised 2019's individual health 
insurance rates about 7 percent. Cutting off funding for cost-
sharing reductions has added another 7 percent to 2019 silver 
rate plans, meaning that rates in Oregon in 2019 are between 7 
and 14 percent higher than they could have been without 
unnecessary and avoidable Federal uncertainty.
    The true harm, however, would come if challenges to the ACA 
were successful and we lost the consumer protections it created 
for people with preexisting conditions. These protections 
require a comprehensive set of interlocking laws that work 
together like spokes in a wheel. For an individual with a 
preexisting condition, these spokes fit together like this: 
Guaranteed issue lets you buy a policy you need. Community 
rating prevents you from being charged more just because of 
your condition. Guaranteed renewability prevents an insurer 
from canceling your policy if you use its benefits. A ban on 
preexisting condition exclusions ensures that your policy 
covers the treatment you need. Preventive services can keep 
your problem from getting worse. Essential health benefits 
ensure that all the treatments you need are covered, and a ban 
on annual and lifetime dollar limits protects you from 
crippling out-of-pocket expenses when you use your essential 
benefits.
    Oregon's experience pre-ACA shows why each of these 
elements are essential and work together to protect individuals 
with preexisting conditions. In 2009, we technically had some 
protections for individuals with preexisting conditions, 
however, within these meager protections, insurers had ample 
room to limit their risk exposure and control costs.
    A pregnant woman could be denied coverage. Treatment for a 
preexisting condition could be limited. Miniscule benefit 
limitations could be imposed, and necessary prescription drugs 
were not required to be covered. For those with preexisting 
conditions, you were lucky if you were even given the choice to 
take an insurer's limited terms.
    In conclusion, the ACA has helped to provide Oregonians and 
their families with access to comprehensive healthcare. It has 
greatly reduced our uninsured population, created tens of 
thousands of new jobs, and saved hospitals hundreds of millions 
a year in uncompensated care. More people are healthier than 
they would be without it.
    Unfortunately, uncertainty at the Federal level has 
threatened our work and unnecessarily added cost to the system. 
Access to affordable healthcare is important for everyone, and 
it is time we stop dismantling the gains we have made and focus 
more on innovative solutions to control cost and maintain a 
stable health insurance market.
    Under Governor Brown's leadership, we will continue to 
protect consumer's access to healthcare through the ACA. We 
will continue to build on our successes, fight to increase 
access, and search for ways to make insurance affordable for 
everyone.
    [The prepared statement of Mr. Stolfi follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    

                                 
    Chairman NEAL. Thank you.
    Now I would like to recognize Mr. Robertson. Please, begin.

   STATEMENT OF ROB ROBERTSON, CHIEF ADMINISTRATOR/SECRETARY-
           TREASURER, NEBRASKA FARM BUREAU FEDERATION

    Mr. ROBERTSON. Yes, good morning, Congressman Neal, 
Congressman Brady, and Members of the Ways and Means Committee. 
I am Rob Robertson, Chief Administrator for the Nebraska Farm 
Bureau. We are pleased today to share with you some challenges 
we see in the individual health insurance markets and also some 
steps that Nebraska Farm Bureau took to protect those Americans 
with preexisting conditions.
    I have dedicated my entire life to helping farmers and 
ranchers, and I just honestly couldn't believe what I saw 
during the summer of 2018. We held listening sessions with our 
farmer and rancher members, and they, literally, got up in 
tears talking about their challenges of how they are coping 
with the health insurance markets and the individual market. 
And the emotional stories were many. I mean, farmers and 
ranchers and spouses got up and said, you know, I am forced to 
work off the farm because of the high cost of health insurance.
    We heard about farm and ranch families not taking out any 
health insurance and then having major medical bills during the 
year. We heard that the highest living expense for the farm is 
health insurance. The stories were all over the board. We heard 
common reports of annual premiums being $30,000 to $35,000 to 
$36,000 a year. That is $3,000 a month. And I am sure 
Congressman Adrian Smith heard similar stories throughout his 
travels in Nebraska as well.
    But what makes matters worse is farmers and ranchers, more 
than any other sector or occupation in the country, are more 
affected by the high cost of the individual health insurance 
markets than any other sector because the lion's share of 
farmers and ranchers are self-employed. And if you are self-
employed, you generally buy on the individual market where the 
costs are high and you are not able to be a part of a large 
group. This is not a partisan issue. This is not a political 
issue. This is an issue of hardship. And we need to fix these 
individual markets and try to find some ways to protect 
preexisting conditions at the same time.
    Because of these issues with our members, the Nebraska Farm 
Bureau took matters into our own hands. In 2017, we began to 
establish an association health plan with our organization. By 
the fall of 2018, we implemented and started enrollment. It 
never would have happened without the wonderful partnership we 
had with the insurance carrier Medica, based out of 
Minneapolis, Minnesota. They partnered with us, and the plan 
offered a more affordable health insurance product, which on 
average was 25 percent less than the individual marketplace for 
members of our large group in our association health plan. It 
covers preexisting conditions. And let me repeat that: It 
covers all members regardless of their health status in our 
association health plan. And it was ACA compliant.
    The plan is what our members wanted and is what we 
delivered. In creating the association health plan, we deeply 
believed it was imperative to cover preexisting conditions, and 
that is what we did. Let me be clear: That is not an attack on 
the ACA; that is a companion to the ACA by providing our 
members with another insurance option.
    And our results: Coming out of the first year, we had 
almost 700 members sign up for the association health plan; 
they saved millions of dollars in premium costs; and then we 
continue to hear a lot of interest this coming year for sign-up 
for the next enrollment period, starting in 2019 for the 2020 
year. From a policy standpoint, one of the best ways we can 
protect Americans with preexisting conditions is to enhance the 
ability of individuals to ban together, pool their risk, and 
form large groups that are fully insured. That is what the AHP, 
our association health plan, did.
    In our case, many of our members are self-employed. The 
only way we were going to be able to form this association 
health plan was because of the new association health plan 
regulation issued by the Department of Labor last summer. If it 
wasn't for those new regulations, we would not have an 
association health plan for our members.
    Let me share a quick example with you on the impact this 
association health plan had on members. Our first enrollees out 
of the gate, a husband and wife who farm together near 
Fairbury, Nebraska, in 2018, their annual cost on the 
individual market was $25,000. They are told in 2019 it was 
going to be $26,000 a year. Under our plan in which they signed 
up, it was $19,000. They saved $7,000, and that is real money.
    How do we get this discounted rate? You know, farmers and 
ranchers are now a part of a large group, rated as a large 
group. And when you rate as a large group, you can spread the 
risk out, you can lower administrative costs, and you can do a 
little bit more with pricing in terms of risk-adjustment 
factors.
    My testimony provides a lot of eligibility criteria on how 
to be a part of our association health plan. In general, you 
have to be in a similar line of business to be a part of that, 
so we designated and targeted farmers and ranchers and 
agribusinesses, and it is ACA-compliant on what it covers.
    Our organization represents farmers and ranchers with an 
average age approaching 60. We strongly support the 
continuation of health plans that cover preexisting conditions. 
The key is to provide innovative policy solutions to allow for 
those types of things like the association health plans to be a 
part of how we cover preexisting conditions. Hopefully, our 
plan works. And I appreciate the time from the Committee today, 
and I will be happy to answer any questions.
    [The prepared statement of Mr. Robertson follows:]
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    Chairman NEAL. Thank you, Mr. Robertson.
    Let the Chair recognize Ms. Brooks-Coley. Please, begin.

  STATEMENT OF KEYSHA BROOKS-COLEY, VICE PRESIDENT OF FEDERAL 
 ADVOCACY, AMERICAN CANCER SOCIETY, CANCER ACTION NETWORK (ACS 
                              CAN)

    Ms. BROOKS-COLEY. Good morning, Chairman Neal, Ranking 
Member Brady, and Members of the Committee. I am Keysha Brooks-
Coley, Vice President of Federal Advocacy for the American 
Cancer Society, Cancer Action Network, the nonpartisan, 
nonprofit advocacy affiliate of the American Cancer Society.
    We appreciate the Committee holding today's hearing to 
examine how policymakers can build on critical patient 
protections in the ACA and make sure people continue to have 
access to quality, affordable health insurance. Nearly 16 
million Americans have a history of cancer and another 1.8 
million will be diagnosed with the disease this year. For these 
individuals, your family, friends, and many of your 
constituents, access to affordable health insurance is a matter 
of life and death.
    The American Cancer Society research shows that uninsured 
Americans are less likely to get screened for cancer and more 
likely to be diagnosed at an advanced stage. Yet, prior to the 
ACA, a cancer diagnosis or other serious illness was often the 
exact reason why these individuals were uninsured. Insurance 
companies could deny coverage to someone simply because they 
had or had survived cancer. They could abruptly revoke health 
coverage after someone was diagnosed. They could charge 
exorbitantly high premiums to purchase coverage. In other 
words, people who needed health coverage the most could not get 
it.
    Before the enactment of the ACA, the American Cancer 
Society's national call center heard from recently diagnosed 
cancer patients daily who were unable to get coverage because 
of their disease or who had lost coverage as a result of their 
diagnosis. It was stories like these about cancer patients from 
across the country that moved ACS CAN and other advocacy 
organizations to engage in the policy debate about access to 
care. Passage of the ACA significantly helped cancer patients 
and others with serious conditions.
    People can no longer be denied coverage because of a 
preexisting condition. They no longer face arbitrary lifetime 
or annual caps on their cancer care. And more Americans are 
able to access meaningful health coverage, either through 
marketplace plans, which currently serve 10 million people, or 
through Medicaid expansion, which currently provides coverage 
to 17 million people.
    These patient protections are at the core of the ACA and 
must be maintained. Unfortunately, recent policy changes are 
putting many of these most essential protections at risk, 
specifically the expansion of short-term health plans and the 
drastic reduction in navigator funding. Last year, the 
Administration issued a final rule to expand access to short-
term limited-duration health insurance. These plans do not have 
to abide by key consumer protections, they can discriminate 
based on preexisting conditions, charge higher premiums to sick 
people, and exclude certain benefits based on health history. 
This means they could cover everything except cancer care.
    Expansion of these plans does not help consumers; it puts 
them at increased risk. While these plans are often touted as 
lower cost alternatives, they are only less expensive upfront 
because they don't cover necessary care.
    Finally, ACS CAN is concerned about the drastic reductions 
that had been made to navigator and enrollment education 
funding. Shortened enrollment periods, fewer resources for 
outreach and education, and less funding for consumer 
navigators directly impacts the number of individuals who 
enroll in marketplace coverage.
    Beyond shoring up existing patient protections, there are 
also ways Congress can strengthen the ACA, many of which I 
detail in my written testimony, but a few I will mention now. 
Fixing the so-called family glitch would allow more families 
the opportunity to access affordable comprehensive healthcare. 
Eliminating the so-called subsidy cliff by creating partial 
subsidies for individuals with incomes above 400 percent of the 
Federal poverty level would also go a long way to improve 
affordability of coverage.
    Mr. Chairman, thank you again for the opportunity to 
testify today. We urge the Committee to find bipartisan 
solutions that ensure individuals with preexisting conditions 
are protected from discrimination, that essential health 
benefits are maintained, and that coverage is made affordable 
for individuals.
    We look forward to working with you to build upon the 
foundation of the ACA and strengthen healthcare coverage for 
millions of Americans living with a serious illness such as 
cancer. Thank you.
    [The prepared statement of Ms. Brooks-Coley follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    

                                 
    Chairman NEAL. Thank you, Ms. Brooks-Coley.
    Mr. Blackshear, you are recognized, would you please begin.

STATEMENT OF ANDREW BLACKSHEAR, PATIENT AND VOLUNTEER, AMERICAN 
                       HEART ASSOCIATION

    Mr. BLACKSHEAR. Chairman Neal, Ranking Member Brady, 
Members of the Committee, my name is Andrew Blackshear. I have 
been a volunteer with the American Heart Association since 
2017. Thank you for the opportunity to testify today about the 
lifesaving importance of quality, affordable insurance coverage 
for people with preexisting conditions.
    I was a healthy 27-year-old in 2015 when my health took a 
turn for the worse. I was at home after a long night of 
restaurant work, and as I leaned over to untie my shoes, I felt 
some chest pain. The pain continued the next day, and I came 
down with a severe fever. My fever kept climbing over the next 
few days, eventually going above 103 degrees, all the way up to 
103.6.
    I was worried I would lose my job if I didn't get back to 
work. So, on my first night back, I collapsed on the floor of 
the restaurant in response to a fluid buildup between my heart 
and the pericardium, the sac that surrounds the heart, a 
condition that I later learned was called cardiac tamponade. 
The fluid buildup was making it much harder for my heart to do 
its job. I didn't know it at the time, but I learned later that 
I had contracted an infectious fungal disease while driving 
through California's San Joaquin Valley in August weeks before 
this.
    The condition, known as valley fever, was caused by 
inhaling fungal spores that are released from the dry soil. It 
was likely that just by breathing the air coming through my car 
vents my lungs had become infected. When the spores 
disseminated through my lung tissue, I developed fungal 
pericarditis, and it almost took my life.
    Treating my condition was a huge challenge. Over the next 
few weeks, my blood tests and symptoms only got worse. Soon I 
needed emergency open heart surgery to remove the fluid around 
my heart. While fighting for my health, I was also fighting for 
the care that I needed. I had purchased a short-term health 
insurance plan after aging out of my parents' plan when I 
turned 27.
    Shortly after the fungal infection was diagnosed, medical 
bills started piling up. I knew my short-term plan had a high 
deductible, so during the time of my echocardiogram, I paid the 
$5,000 deductible. But then I started receiving letters from 
the insurance company asking me for more information and 
demanding that I prove my heart problems weren't caused by a 
preexisting condition. I kept getting the same letter over and 
over saying the insurance company wouldn't pay my nearly 
$200,000 in medical bills until I could show them that I didn't 
have a preexisting condition.
    Still recovering from my first operation, I had to go to 
every doctor I had ever seen, all the way back to a 
pediatrician, to collect the information my insurer was 
demanding. The company finally agreed to pay for my care after 
I requested the State of California help me take them to court. 
When open enrollment began in November of that year, it was 
amazing. I enrolled in a plan, started paying my premiums, and 
continued to see my same doctors, but there was a big 
difference. My ACA plan did what it was supposed to do: It paid 
for my doctors' bills instead of punishing me for being sick. 
No more calling around to my old doctors' offices. No more 
collecting and sending in paperwork to this company. And no 
more anxiety for my family over whether I could afford to get 
better.
    Weeks after my first operation, I then had a tender 
stomach, extreme fatigue, swollen ankles, and trouble 
breathing. I flew to Minnesota to be seen at the Mayo Clinic 
and was diagnosed with constrictive pericarditis and heart 
failure. My left and right ventricles were failing. I underwent 
my second open heart surgery to remove the sac around my heart 
completely. This is called a pericardiectomy.
    I felt so much better after the second surgery. And with 
comprehensive coverage, I knew I wouldn't be bankrupted because 
I had gotten sick. Thanks to the Affordable Care Act, today I 
have no medical debt and I am healthy. But I will always be 
without a pericardium, so having health insurance that covers a 
preexisting condition remains a necessity to me.
    As a heart disease patient and volunteer with the Heart 
Association, I urge lawmakers to make sure preexisting 
conditions are covered. No one should face the prospect of 
being unable to afford the care that they need to stay alive. 
Thank you again for focusing on this critical issue.
    [The prepared statement of Mr. Blackshear follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    

                                 
    Chairman NEAL. Thank you for that very important and 
powerful testimony, Mr. Blackshear.
    We will now proceed under the 5-minute rule with questions 
for our witnesses. I will begin by recognizing myself for 5 
minutes. But before asking the witnesses my questions, I would 
like at this time to yield 2 minutes to our colleague, 
Representative Gwen Moore, for the purpose of outlining her own 
experience, but most importantly, for the first time having 
done this publicly, for her constituency.
    Ms. Moore, you are recognized for 2 minutes.
    Ms. MOORE. Thank you so much, Mr. Chairman. And I am so 
glad to be here. And when I say that I am glad to be here, I 
mean I am glad to be here. Literally, instead of yielding me 
time, you could be delivering kind words at my memorial 
service.
    In the spring of 2018, I joined an exclusive club of 
millions of Americans with the cursed C-disease: Cancer. A 
disaster that guarantees discrimination in the insurance 
marketplace; for many, a death sentence. Specifically, I have 
been diagnosed with small cell lymphocytic lymphoma, a 
manageable cancer with proper surveillance and treatment.
    Right now I am in great health with an excellent prognosis 
of living with this disease, but throughout the spring and 
summer of 2018, I spent a lot of time on a gratitude tour of 
being grateful for medical research, having insurance, and, 
most importantly, thanking God for the ACA provisions. No, I am 
not one of the 20 million low-income people that we are going 
to lay down our lives to protect, but I am one of the people 
that, before the ACA provisions, could have been subject to 
medical underwriting instead of community rating, making it 
unaffordable, with no coverage of essential health benefits. 
And with all the labs that I went to and all the visits to try 
to pin down this diagnosis depending on early intervention, 
none of that could have happened if they had imposed lifetime 
limits on my care and imposed caps on the out-of-pocket costs, 
if the ACA had imposed caps on that. Worse, they could have 
just denied me completely because of my preexisting condition.
    We have talked a lot about this costing too much or being 
too expensive. What does a life cost? Let me just say that I 
pay $15,000 a month for medicine. Who can afford that? And what 
am I worth?
    I yield back.
    Chairman NEAL. Thank you very much for that important 
testimony. I think your story highlights how, in considering 
how to strengthen and protect consumer protections for 
Americans with preexisting conditions, we must stand in the 
shoes of those facing hard decisions about their healthcare and 
work to make sure that they know their health insurance will be 
there when they need it and for what they need.
    Now, let me return to the start of our questioning to the 
story I shared in my opening statement because each of us knows 
someone who had delayed getting healthcare only to be diagnosed 
with a chronic condition. Mike and his family benefit every day 
from the ACA.
    Ms. Pollitz, before the ACA, what would have happened to 
the likelihood of Mike Finn and his family being able to get 
and keep an insurance plan that meets the needs of a diabetic 
as well as three young children? What kind of obstacles would 
they have faced in trying to get meaningful affordable care?
    Ms. POLLITZ. Mr. Chairman, diabetes is one of the 
conditions that, through our research, we demonstrated was a 
declinable preexisting condition. So the individual market 
would not have been an option for that family or at least for 
the child with diabetes, with the exception of a few States 
before the ACA, including Massachusetts, which required 
coverage to be offered on a guarantee issue basis. And so that 
was the largest barrier to getting coverage in a nongroup 
market.
    In other plans, before the ACA, there could be temporary 
preexisting condition exclusion periods. So if you took a new 
job with a new health plan, there might be a waiting period as 
long as a year before the diabetes would be covered. Under a 
prior Federal law, HIPAA, people did have to get credit for 
prior coverage under other plans, so that when they switched 
jobs, they wouldn't continuously incur new preexisting waiting 
periods, but any break in coverage of 2 months or longer would 
end that protection, and then people might again face job lock 
or difficulty getting private insurance coverage for a 
preexisting condition.
    Chairman NEAL. Thank you, Ms. Pollitz.
    Ms. Brooks-Coley, I am sure that patients that you have 
represented have experience with high-risk pools, can you 
please share your thoughts about patient experiences with high-
risk pools?
    Ms. BROOKS-COLEY. Thank you, Mr. Chairman.
    An individual who has cancer has--they have experienced 
issues with high-risk pools. Some of the concerns that patients 
have experienced is not having access to actual services that 
they need, making sure they have access to preventable 
screenings that we know are lifesaving. Making sure that 
individuals have access to actually real coverage they need 
that is not too expensive, and is available when they need it.
    We know that high-risk pools are not always the most 
comprehensive coverage, especially if you have a serious 
illness, such as cancer, and need access to very costly 
treatments as well as therapies.
    Chairman NEAL. Thank you.
    And, with that, let me recognize the Ranking Member, Mr. 
Brady, for 5 minutes.
    Mr. BRADY. Mr. Chairman, thank you.
    And thank you to each of the witnesses for your compelling 
testimony. Your belief and support for preexisting conditions 
is one of the reasons why Republicans fully support these 
preexisting conditions and no lifetime caps and making sure you 
can't be denied coverage and making sure young people can stay 
on their parents' plans. All that is critical.
    But we have to do more than just protect preexisting 
conditions; we have to make healthcare more affordable. In 
Texas, I cannot tell you how many of my constituents tell me 
they can't afford the ACA. The monthly costs are far too high. 
And, secondly, the out-of-pocket cost--it can be $10,000. Who 
can use that healthcare insurance? And then often they can't 
even see their local doctor or go to the local hospital.
    I am so glad that the Cancer Society is here because, in 
Houston, you know, maybe this is one of the reasons, you know, 
three Texans eligible for ObamaCare got out from under it, 
rejected it, for everyone that uses it. We have very few 
choices. Cost went down. That is the good news. But in the 
Houston region, for example, if you are a mom in Conroe, Texas, 
struck with breast cancer, if you are a father with prostate 
cancer, if you are someone with a blood cancer in Huntsville, 
we have MD Anderson Cancer Center, one of the finest cancer 
centers in the world. You can't go there if you're on ACA--if 
you have a private plan, you can. If you are on the ACA, you 
have to settle for less. Even if you can see MD Anderson, the 
best cancer doctors in the world for you, you are denied 
coverage under the ACA.
    I am convinced we can do better to make healthcare more 
affordable and have access that patients need. I do believe 
that the Trump administration made some key moves over the last 
year, that have been almost a lifeline for some Americans who 
can't afford the Affordable Care Act. One is, for the first 
time, the average benchmark premium for the nearly 40 States 
that use Healthcare.gov, instead of doubling since ObamaCare 
came into place, for the first time ever, those rates 
decreased, including those in our State of Texas, where rates 
are down 2 percent. They decreased.
    Second, we now have, and I am pleased to say, we are 
actually starting to see more insurers and more choices in our 
State than before because, in too many counties in America, it 
was take it or leave it. You take that ACA plan or nothing at 
all, and that is not fair.
    And then, when the individual mandate penalty was repealed, 
I think Speaker Pelosi predicted millions of Americans would 
face lifesaving choices, but in truth, nearly 97 percent of 
those on the ACA have re-enrolled. The biggest challenge we 
face--one of the reasons in Oregon two out of three people 
eligible for ObamaCare aren't signing up--is the cost, and that 
is what I worry about the most.
    Mr. Robertson, you were very careful in not criticizing the 
Affordable Care Act, and I think that is a great approach here. 
But what I heard you say was that these association plans and 
what you have developed for your members is because you can't 
afford the other ACA options available, and you had to find a 
better approach. As we think about the future of healthcare for 
the 7 percent of Americans we are focused on here that don't 
get it at work or from the government, do you consider this, 
what you have for your members, to be junk plans or something 
inferior, or something that really meets the needs of your 
members?
    Mr. ROBERTSON. It is the latter. It really meets the needs 
of our members. And think about it: Everybody--most people in 
this room probably are part of an employer group, but if you 
are an individual self-employed farmer or rancher, you are not. 
So the association health plans allow you to form a bona fide 
large group, which allows you to spread out the risk. We are in 
this for the long term because we want to reduce costs because 
the cost from the ACA in the individual market, when you are 
there solely, is very, very high.
    Mr. BRADY. You know, if I recall, was Nebraska one of the 
States that the ACA also created co-ops, you know, in 
healthcare to try to lower costs by sort of taking the public 
option? But if I recall, in many States, those co-ops failed 
and left a lot of Nebraskans and others in a real lurch. Did 
that contribute to the need to find something that actually 
works for your members?
    Mr. ROBERTSON. Yeah, absolutely. Just 2 or 3 years ago 
there were a lot of co-ops that formed. A couple of them, they 
all were going great guns the first year out, and then year 2 
and 3, they all went belly-up, and that left many of our 
Nebraskans, particularly farmers and ranchers, searching for 
the right policies and affordable policies, which there are 
hardly any.
    Mr. BRADY. Thank you, Mr. Robertson.
    Chairman NEAL. Thank you, Mr. Robertson.
    With that, let me recognize the gentleman from Georgia, Mr. 
Lewis, for 5 minutes.
    Mr. LEWIS. Thank you, Mr. Chairman, for holding this 
hearing. As I said to you, I think this is a good place to 
start. Healthcare is a right; it is not a privilege. And all of 
us--all Americans have a right to quality healthcare. I want to 
thank our colleague and friend, Gwen Moore, for sharing her 
story. It is not easy.
    Mr. Blackshear, thank you for sharing your story with us. 
It must be difficult to come and testify in public about such a 
difficult and personal experience. I think you are very brave. 
Please, would you share more about how you felt when you 
learned that your insurance would not protect you?
    Mr. BLACKSHEAR. Yes. Thank you for the compliments, as 
well. I was very worried. My whole family was worried. You 
know, these bills were stacking up. I knew I never had a heart 
problem. Everybody in my family knew I never had a heart 
problem. So I knew their attack wasn't justified at all, but I 
continued to jump through hoops until I found a way out by 
finding someone from the State to fight for me. Just a lot of 
anxiety built up in my family while I was sick over these 
bills.
    Mr. LEWIS. But it is good that you didn't give up.
    Mr. BLACKSHEAR. No, I would never give up.
    Mr. LEWIS. You didn't give in.
    Mr. BLACKSHEAR. No, never.
    Mr. LEWIS. You kept the faith.
    Mr. BLACKSHEAR. Uh-huh.
    Mr. LEWIS. You kept fighting.
    Mr. BLACKSHEAR. I kept fighting.
    Mr. LEWIS. What would you say to others that may share your 
concern and conditions?
    Mr. BLACKSHEAR. Yeah, to them personally, I would say: You 
know, if you are in that type of situation, keep fighting for 
what you deserve. And another thing, I don't even think we 
should be in a position where we have to fight in those 
situations.
    Mr. LEWIS. Thank you, Mr. Chairman.
    I yield back.
    Chairman NEAL. Thank you, Mr. Lewis.
    With that, let me recognize the gentleman from California 
for 5 minutes, Mr. Nunes.
    Mr. NUNES. Thank you, Mr. Chairman.
    I want to thank all the witnesses here for testifying. And 
I want to make sure that everyone knows that everyone up here 
supports protections for preexisting conditions, always have, 
always will. Nobody up here believes that insurance companies 
should be able to jerk customers around, drop their coverage, 
and charge more when they get sick.
    It is really this long debate on ObamaCare that Democrats 
have consistently used protections for people with preexisting 
conditions as a justification for the law and the creation of 
two new entitlement programs. They have $750 billion in 
Medicare cuts with ObamaCare, and a trillion dollars in tax 
increases.
    ObamaCare was supposed to solve these problems but, in 
fact, has, in most cases, made them worse. So I understand we 
have a political theater here in Washington and have hearings 
like this, but I think we should be careful so that we are not 
stoking fear that someone is going to lose their insurance. We 
really have a responsibility to come up with a better 
healthcare system because ObamaCare wasn't the solution.
    Republicans have put solutions on the table in the past, 
and we will continue to do that. I would love to work with my 
colleagues on finding ways to fix our healthcare system. For 
example, we know that the Medicare trust fund begins to go 
broke just after 2020. The year 2024 is what they say today; it 
could be even sooner than that. So we have a lot of challenges 
ahead of us, and hopefully we can work together. And I think 
what it takes first is to admit that ObamaCare was not the 
solution. Maybe there is a better solution, but right now, it 
is not the solution.
    Mr. Robertson, one of the things that you have done very 
successfully with the Nebraska Farm Bureau is you have thought 
outside of the box. You have created a new program that is 
working in your State. Do you have some examples, without 
naming names, of course, but maybe give some examples of folks 
who have enrolled in your plan that maybe weren't able to get 
on the ACA, who are now getting healthcare coverage? Do you 
have some personal examples of this?
    Mr. ROBERTSON. Yeah, I sure do. We have a member of our 
board of directors that did not participate in the ACA last 
year and signed up for the association plan this year and saved 
$7,000, $8,000, and so that is a question--they had an 
alternative plan, but it wasn't near ACA-compliant and didn't 
cover preexisting conditions. But now they are covering all of 
those conditions at a lower cost than what it would have been 
on the individual market with ACA.
    So, in my mind, that is a win. Not a week went by without--
or a day go by during signup where we heard stories of our 
members saving thousands of dollars by joining our association 
health plan.
    Mr. NUNES. And, roughly, how many folks do you have in your 
plan now?
    Mr. ROBERTSON. Nearly 700 members.
    Mr. NUNES. Nearly 700. And they have to be Farm Bureau 
members.
    Mr. ROBERTSON. They have to be Farm Bureau members by July 
1 of that preceding year because we wanted a 6-month waiting 
period because we didn't want the next hundred Farm Bureau 
members to need knee replacements. So that was important.
    Mr. NUNES. Uh-huh. And what is the average age? You 
mentioned the average age in your testimony, but could you 
repeat that again. What is the average age of the folks that 
are in your plan?
    Mr. ROBERTSON. We were seeking that information out from 
our insurance partner yesterday. I think because of some HIPAA 
laws, we don't have that, but we are guessing it is in the low 
50s. Typically the younger producers might have been eligible 
for more subsidies on ACA, and so they took the subsidy ACA 
route rather than our association health plan route. So we 
think it is a little bit weighted toward the older end.
    Mr. NUNES. Do you have an average price for the plan, and 
can you walk us through the different types of plans that you 
are offering?
    Mr. ROBERTSON. Yeah. Prices vary for age and geography. And 
we had six products that were offered underneath the plan that 
we sponsored. And the average prices are anywhere from, we 
think, $18,000 to $25,000 a year, and, again, that sounds like 
a lot, but when you are paying $36,000 a year, that is a 
savings. That is real-time savings.
    Mr. NUNES. Well, congratulations on thinking outside of the 
box and coming up with plans, and I think we can learn a lot 
from your work, and I appreciate you being here today.
    Mr. ROBERTSON. Thank you.
    Mr. NUNES. Thank you, Mr. Chairman.
    Chairman NEAL. I thank the gentleman. The gentleman from 
Texas, Mr. Doggett, is recognized for 5 minutes.
    Mr. DOGGETT. Thank you. How appropriate and important it is 
that we are focusing on healthcare and preexisting conditions 
as the first formal hearing of this new and much-improved 
Congress. In understanding where we go forward, it is important 
to understand the path that has led us to today. And that path 
is 8 years of Republican persistence in trying to destroy the 
Affordable Care Act and its protection for preexisting 
conditions. Trying again and again and again, dozens and dozens 
of times, to repeal the Affordable Care Act and its protection 
for preexisting conditions, and failing on those efforts. Then 
moving to try to weaken and undermine the Affordable Care Act 
in any way that they possibly could.
    One thing that has been missing from that path is the 
replace part of repeal and replace. Not once was any 
comprehensive alternative to the Affordable Care Act and its 
protection for preexisting conditions ever presented for a vote 
in this Committee or any other one. It is great to hear that 
they want to work with us, and I hope that they do, in moving 
to a better place and correcting some of the obvious 
deficiencies of the Affordable Care Act. But it would be even 
better had they advanced a comprehensive replacement, if they 
had one, for a vote and action over the course of the last 8 
years.
    On Inauguration Day, not even getting to the inaugural 
dances, President Trump decided to join their effort to destroy 
the Affordable Care Act, and he issued an Executive order on 
that day to tell all Federal agencies to do everything they 
could to undermine the Affordable Care Act. And the most recent 
example of that is what is clearly collusion. It is collusion 
between an indicted Texas attorney general who sought to 
destroy protection in the court for preexisting conditions and 
the Trump administration, which, instead of defending that 
protection for the Affordable Care Act, decided they would just 
lay down and play dead. And had it not been for the important 
intervention of attorneys generals from States across the 
country to defend the Affordable Care Act, there would have 
been no contest over this total capitulation by the 
Administration.
    Republicans can tell us that they believe in preexisting 
conditions, but this is more than passing some sense of 
Congressional resolution, it is a matter of structuring a way 
of accessing healthcare that does protect without exorbitant 
premiums those many Americans, almost half of Texans, who have 
preexisting conditions.
    Perhaps the most troubling aspect, in fact, of preexisting 
conditions, maybe the most overriding preexisting condition in 
America today, is amnesia, the political amnesia of those who 
have forgotten what it was like before the Affordable Care Act 
and how it was that those who would get a diagnosis of a 
serious disease would also be getting an effective diagnosis of 
financial ruin if there was no protection for them before the 
Affordable Care Act.
    The Affordable Care Act is far from perfect. One of the 
areas that I hope our Committee will focus on is how we get an 
answer on the question of prescription price gouging, the need 
for Medicare and negotiation, and the need for more competition 
to reduce those costs.
    But, Ms. Brooks-Coley, I would ask you one question. Across 
my area, I have been to so many Relay for Life events where 
cancer survivors come out and people from the community come 
out to support the American Cancer Society, and one of the 
statistics that I remember from those gatherings is the 
indication that if you don't have insurance--and, of course, in 
a State like mine in Texas with an indicted attorney general 
who keeps fighting Medicaid expansion, we have more uninsured 
than just about any place in the country, probably just about 
any place in the industrialized world--that you have a 60-
percent greater chance of dying with cancer if you lack 
insurance than if you have access, such as through the 
Affordable Care Act. Is that still the case?
    Ms. BROOKS-COLEY. Thank you for the question, Congressman. 
That actually is a 2017 statistic from our Cancer Journal, and 
it is a really important statistic that we actually cite 
oftentimes when we are having conversations about why patients 
with preexisting conditions have access to coverage.
    American Cancer Society research has shown that access to 
coverage and your ability to have health insurance is a 
deciding factor, if you have a serious illness like cancer, of 
what your diagnosis stage would be, as far as when your cancer 
is found, what your treatment outcomes will be, the quality of 
what those treatment options will be, as well as survival 
rates. And speaking to your direct question, survival rates are 
directly linked to an individual's ability to have access to 
affordable, quality, and comprehensive healthcare.
    Mr. DOGGETT. Thank you.
    Chairman NEAL. I thank the gentleman. I thank the 
gentleman. With that, I would like to recognize the gentleman 
from Florida, Mr. Buchanan, for 5 minutes of inquiry.
    Mr. BUCHANAN. Thank you, Mr. Chairman, for this hearing. I 
also want to thank all of our witnesses.
    First, I want to say that I, myself, and I know 
Republicans, support preexisting conditions, but I wanted to 
mention something else. Being someone that has been in business 
for 30 years, this is always my favorite time of the year, the 
beginning of the year. We have a new Congress. A lot of us are 
new on this Committee. I would challenge all of us to find a 
way that we can work together. These are big issues.
    My big, most passionate thing I am passionate about is the 
rising cost of healthcare. I read in the paper, USA Today--and 
I have thrown this out before, but a year ago, it struck me so 
much--that 62 percent of Americans don't have a thousand 
dollars in the bank. They are living paycheck to paycheck. And 
when I thought about that, for someone that has been in 
business 40 years, many years before I got here, we paid for 
everybody's healthcare for 20 years.
    And then the next 20 years, the costs continue to go up, 
not just in terms of ObamaCare, but in terms of the costs going 
up. We have to find a way to bend the curve on costs because it 
is bankrupting, in my mind, the middle class, and we talk a lot 
about the middle class.
    I would just tell you I met, you know, met with a lot of 
people, over in Florida, anyway, about healthcare costs. One 
gentleman said to me that he is paying--the company is paying 
$700, he is paying $700 a month out of his pocket for a family 
of five, a young family, and then he has an $8,000 deductible. 
So as they have children, it cost $8,000 a year that is having 
to come completely out of pocket.
    Another gentleman, Roberto, has an Italian restaurant, that 
he has had, and he was telling me that his healthcare cost is 
something you mentioned, $3,000 a month. So it is clearly 
affecting everybody.
    And my point is that cost is getting pushed to the middle 
class. That is why they don't have any money, you know, at the 
end of every week, or at the end of every month, because they 
are having to pay more themselves from that standpoint.
    I think there has been probably some good ideas in terms of 
Oregon and Massachusetts. We should look for the best 
practices, the best ideas, and find a way to bend the cost of 
healthcare costs. That is what we should be doing, not playing 
the blame game. We are here today, let's find a way with a new 
Congress, to move forward and start having an impact.
    I think the spending last year or this year is $3.5 
trillion that we spent on healthcare. There has to be ways we 
can find more efficiencies by working together. So my focus is 
on how do we bring the costs down?
    Ms. Pollitz, let me ask you, what is your suggestion for 
this Committee in terms of how we can work on a bipartisan 
basis to start lowering the costs? What would be some of the 
things that you might suggest?
    Ms. POLLITZ. Well, Mr. Buchanan, I work for the Kaiser 
Family Foundation, and we actually don't make policy 
recommendations, but we do provide information. We have a lot 
of information on our website and on our partner website, the 
Kaiser-Peterson Health Tracking site, that provides a lot of 
data on healthcare costs and where they are rising and why they 
are rising. And I think we would be very happy to sit down with 
you or any other Members and kind of review that information 
for you and suggest other things.
    Mr. BUCHANAN. My thought is, how do we start vetting the 
curve on the costs?
    Mr. Robertson, you mentioned--and I chaired our chamber in 
our area, in Sarasota, Florida, there is 2,400 members in 
there. Now, 80 percent of the members are 15 employees or less, 
exactly what you are talking about. It looks like you have 
about a 25 percent, 30 percent savings, through this 
association concept, which we weren't able to put in place in 
our chamber. We tried, but for whatever reasons, outside groups 
had more influence, but is it your sense you are going to be 
able to hold on to the savings that you have so far?
    Mr. ROBERTSON. Yeah, we really do. I mean, it all depends 
on how the history looks of the whole group, of the association 
health plan in the first year out. We don't have experience on 
this group yet, but we sense we will. And as the group gets 
larger, which we are getting a lot of interest--more members 
signing up this year--as the group gets larger, just because of 
the fact it is larger, you can spread more of the risks and the 
costs out with the whole group. And so we hope that 25 percent 
becomes 30 percent, 35 percent reduction from the----
    Mr. BUCHANAN. You mentioned that they all have preexisting 
condition coverage, right, as a part of that package? So you 
didn't drop any of that out to get to the savings?
    Mr. ROBERTSON. No, no, the savings are just related to how 
large groups are rated, basically.
    Mr. BUCHANAN. Thank you, and I yield back.
    Chairman NEAL. I thank the gentleman.
    With that, let me recognize the gentleman from California, 
Mr. Thompson, to inquire for 5 minutes.
    Mr. THOMPSON. Thank you, Mr. Chairman, and thank you to all 
the witnesses who took time to be here today for this very 
important hearing.
    I voted for the Affordable Care Act, a bill that was not 
written in the back room, a bill that was written in full 
public with hearings, amendments, hearing from witnesses, and I 
did that because I believe every American should have access to 
quality, affordable healthcare, including Americans with 
preexisting conditions. And it has worked.
    In my district alone, the uninsured rate dropped from a 
full 10 percent, from 15.9 percent in 2013, to 5.9 percent in 
2017. And that is, in large part, because folks with 
preexisting conditions had access to a healthcare market that 
they didn't before.
    And you heard from my constituent, Mr. Blackshear; he was 
one of those people who gave an outstanding explanation of his 
personal situation. Every one of us have heard from 
constituents in our district. Every one of us can talk about an 
example to this. The last time we met, I shared with this 
Committee the fact that my sister-in-law, who is a dental 
hygienist married to a young minister, couldn't afford 
healthcare in their State of Florida. Both were starting out in 
their business, and it wasn't until the ACA was passed did she 
have access to healthcare. And it was shortly after that, that 
she was diagnosed with a very serious cancer. She has undergone 
some pretty extreme procedures for that. She is home. She is 
doing well.
    And the number one concern that she has is, now that she 
has a preexisting condition, will she be able to continue to 
have healthcare. She is scared to death that somehow she is 
going to lose that if the ACA goes away. And that is not what 
we should be doing. We should make sure that this is, in fact, 
the law of the land, because it is the ACA that made that 
possible.
    And, Mr. Robertson, I want to thank you for your testimony 
and particularly the point that you made on a couple of 
occasions, and that is that your Farm Bureau policy is ACA-
compliant. That is an important factor. Because if it weren't 
for that, it could very easily be another junk policy, that 
takes your members' premiums, and they are there for you every 
step of the way, unless you become injured or you become ill. 
So it was the ACA that provided that protection.
    Mr. Blackshear, you purchased your short-term healthcare 
policy a few months before you fell ill. The following November 
you said that when open enrollment hit, you purchased a plan 
through Covered California, our marketplace for the ACA. Can 
you describe how the patient experience changed on a day-to-day 
basis after you purchased a plan through Covered California?
    Mr. BLACKSHEAR. Yes. Basically, just the anxiety, that was 
the huge thing. Being sick, you know, and especially severely, 
in heart failure, seeing bills that aren't being paid, and I am 
having to run errands. It was pretty difficult. So I would say 
the biggest thing is just the anxiety surrounding it, you know, 
that wondering, I am paying my premiums, but are they going to 
help me out, you know.
    Mr. THOMPSON. And we have heard a lot from the dais today 
from our colleagues on the other side who keep raising the 
issue of the cost of healthcare through the Affordable Care 
Act. Talk a little bit about what you pay and the difference 
between what you pay for your ACA policy and your short-term 
policy that didn't provide you the care that you needed.
    Mr. BLACKSHEAR. With no income change, my short-term plan 
was $160 to $180 premium per month. And then surprisingly, when 
I got on the ACA, it went down to $70 a month.
    Mr. THOMPSON. This was after you were diagnosed with a very 
serious healthcare issue?
    Mr. BLACKSHEAR. Yes, yes.
    Mr. THOMPSON. Thank you very much.
    Mr. Stolfi, you talked about your Oregon plans. In 
California, we recently passed legislation prohibiting these 
short-term, junk plans. Has Oregon done something similar?
    Mr. STOLFI. Thank you, Representative, for the question. In 
2017, our legislature passed a law limiting short-term plans to 
what was then the Federal requirement of 3 months. It was a 
policy decision made at the time, and we are very happy with 
that decision.
    Mr. THOMPSON. And all the plans that you sell are compliant 
with the ACA?
    Not that you sell, but the State--that's sold in the State?
    Mr. STOLFI. Well, the short-term plans are not required to 
be compliant, which is the problem with them.
    Mr. THOMPSON. Thank you very much. I yield back.
    Chairman NEAL. I thank the gentleman.
    With that, let me recognize the gentleman from Nebraska, 
Mr. Smith, for 5 minutes.
    Mr. SMITH OF NEBRASKA. Thank you, Mr. Chairman. I 
appreciate the opportunity to have this hearing and bring some 
attention to the fact that there is a lot of common agreement 
in terms of preexisting conditions. Actually, what we as 
Republicans have proposed previously and actually voted on, and 
I do want the record to reflect that we did vote on an 
alternative that would have, I think, proven very effective to 
consumers to be able to have options and actually to afford 
health insurance.
    It concerns me greatly when we see an increase in premiums 
to levels that are--I never even thought imaginable before we 
even had that vote back in 2009 and 2010.
    And so, as we process this--and Mr. Buchanan certainly 
pointed out how important it is that we work together to find a 
way forward so that the American people will not be harmed, 
because let me be very clear, many Nebraskans have been harmed 
by the heavy hand of the Federal Government saying that they 
have been helping them, and that the government has helped in 
ways that many Nebraskans would tell me they have actually been 
harmed. So I do have some questions.
    Ms. Brooks-Coley, you referenced exorbitant premiums that 
were paid before the ACA came about. What would you list as an 
example of an exorbitant premium?
    Ms. BROOKS-COLEY. From the cancer perspective, one of the 
concerns that our patients had before the ACA, and before the 
important patient protections included in the law, was the fact 
that our patients had to oftentimes pay more for their care. 
Sometimes they had insurance plans that did not actually cover 
cancer treatment and had to pay exorbitant prices to actually 
access lifesaving chemotherapy, radiation, and other 
treatments.
    So those exorbitant prices, that even if they had coverage, 
may not have actually covered the actual care that they needed, 
were extremely harmful.
    If you look now at the Affordable Care Act and the patient 
protections and the essential health benefit requirements that 
are in the law, our patients don't have to worry about those 
costs, and they are paying their premiums and paying for the 
expenses that they have with the understanding, though, that 
they won't be hit with exorbitant costs that could impact them 
and their family members.
    Mr. SMITH OF NEBRASKA. So a high-risk pool, you are telling 
me, would pay a higher premium before the ACA. Is that correct?
    Ms. BROOKS-COLEY. I am sorry, Congressman.
    Mr. SMITH OF NEBRASKA. A high-risk pool that would have 
covered preexisting conditions, even before the ACA, are you 
saying that those premiums would have been higher than others?
    Ms. BROOKS-COLEY. I was speaking specifically to the fact 
that there may have been services they had to pay for out of 
pocket that weren't covered by those plans.
    Mr. SMITH OF NEBRASKA. Okay, all right. And thank you.
    I am concerned that some of the high-risk pool premiums 
that were around prior were higher, but now we see more people 
paying similar premiums, as Mr. Robertson pointed out. Even the 
roughly $19,000 premium per year, that is still a lot.
    Ms. BROOKS-COLEY. Right.
    Mr. SMITH OF NEBRASKA. And so that is why I hope we can 
work together on a way forward to bring that down. Because even 
if there are preexisting conditions that are covered in a 
mandatory fashion, if the premium is out of reach for a rate-
payer and they can't afford it, there is not a lot to do about 
that. And it is certainly unfortunate because it ultimately 
reduces access. I mean, we see that even folks in California 
who qualify for an ACA plan, only 40 percent opt for that plan. 
And I think we need to get to the bottom of why and how that 
has come to be the situation.
    I think of Pam in my district, who liked her plan before 
all of this came about. She had a plan that she liked. It 
covered her preexisting condition. She was canceled and that is 
unfortunate. She lost coverage through no fault of her own four 
times because the government said they were trying to help her, 
and that should be unacceptable to us as policymakers.
    And certainly we want the American people to have more 
choices for coverage. And I am glad that the Nebraska Farm 
Bureau has at least given another choice to its members because 
we have seen choices diminish, certainly in Nebraska, since the 
ACA came about.
    Thank you, I yield back.
    Chairman NEAL. I thank the gentleman.
    With that, let me recognize the gentleman from Connecticut 
to inquire for 5 minutes, Mr. Larson.
    Mr. LARSON. I thank you, Mr. Chairman, and I thank you most 
of all for something that Mr. Buchanan said--this is the start 
of a new Congress and a commitment to have public hearings and 
to have them often and to go to regular order. And I would 
point out to my colleagues on the other side, and I often 
wonder when they say ``ObamaCare'' if they mean it in the same 
way that we do in terms of Obama truly caring about the people 
of this country. I will give them a pass and say that is what I 
think they mean on this and not the derisive nature that 
oftentimes--that it takes.
    What we are going to need here on this Committee is the 
kind of format that Mr. Neal has indicated this Committee is 
going to be dedicated to, and that is to have public hearings 
as we did during the Affordable Care Act, and make sure that 
everybody has an opportunity to go back and forth.
    Our colleagues on the other side, it doesn't seem that 
there is much disagreement between us with preexisting 
conditions. We should, therefore, all be able to reach a 
conclusion rather quickly.
    I want to ask the panelists real quickly. All of you as you 
have sat here today, you all agree that there should be no 
limit, that anyone who has a preexisting condition ought to be 
able to get an insurance policy, correct? Is there anyone who 
would disagree?
    Does anyone disagree, of our panelists, with what Mr. Lewis 
had to say, that because of the nature of health insurance--Mr. 
Robertson, you have seen it up front with farmers. All of you 
have experienced it in one form or another. Should it be a 
right? Can I see a show of hands? Should it be a right, yes? 
You all believe that it should be a right, as Mr. Lewis has 
pointed out.
    What we have here is an infrastructure problem, and what we 
find in Congress when we have an infrastructure problem, even 
though currently our national infrastructure, Mr. Blumenauer 
would tell you, has a D-minus rating by engineers, et cetera; I 
would say our overall health infrastructure--and by that, I 
mean our own personal health and well-being--is an 
infrastructure problem.
    And in both cases, what Congress has to do is come together 
and talk about what is necessary to improve that 
infrastructure. And it is not roads and bridges in this case, 
but it is arteries and disease and preexisting conditions. But 
like all of these, they come at a cost. And so while Congress 
may strongly agree about the need, when it comes to paying for 
it, that is where the disagreements come in. And that is the 
bottom line here.
    Mr. Robertson, you have talked about pooling resources and 
everybody coming together. What a great thing. A colleague of 
ours here, Brian Higgins, has come up with an idea, and I want 
to quickly ask you this. What about if we were to have 50-year-
olds be able to buy into a Medicare system? A Medicare system 
that the Kaiser Family Foundation said that if a 60-year-old 
bought into the plan, it would be 40 percent less than the 
Affordable Care Act gold plan. Is that something you could 
agree with?
    Mr. ROBERTSON. Well, it depends. I mean, there is a lot of 
value to pool individuals together.
    Mr. LARSON. Precisely. And----
    Mr. ROBERTSON. But if you don't address the cost side of 
that equation----
    Mr. LARSON. Sure. But let's say if it was age 50 years old, 
again, and you could buy into a program which would make it 
revenue neutral but would look at the older end of the people 
that you cover from, say, 50 to 64, they would get a break, and 
the Medicare group would be much younger, as well. Also, the 
younger group would become 27 to 49, driving, as you know, 
insurance down dramatically.
    Mr. ROBERTSON. Right. Again, there is value with pooling 
resources, but until you address the other side of the equation 
on cost of providing healthcare, somebody has to pay for those 
plans.
    Mr. LARSON. Exactly. And so what would you suggest?
    Mr. ROBERTSON. There are a lot of things that I think have 
not been looked at yet by Congress and policymakers, but there 
are some--I think, some market innovation programs that can be 
looked at to make a health insurance system work.
    Mr. LARSON. We are running out of time, but if you would 
submit those to us we would be happy to take a look at them.
    But thank you for your testimony. I want to thank all the 
panelists. I yield back.
    Chairman NEAL. I thank the gentleman, and let me recognize 
the gentleman from Texas, Mr. Marchant, to inquire for 5 
minutes.
    Mr. MARCHANT. Thank you, Chairman Neal. Congratulations on 
your Chairmanship. I am looking forward to working with you and 
with our leader, Mr. Brady, on finding some solutions that will 
positively affect my constituency. I want to echo Mr. Brady's 
statements and make sure that my constituents back home know 
that I support protecting access for all patients with 
preexisting conditions.
    We all agree that protecting these individuals is 
necessary, and I will look forward to working on policy 
solutions that address the uncertainty that surrounds these 
individuals. Sadly, current law is riddled with problems that 
make it a litigator's dream and a patient's nightmare.
    So I will ask the panel--and I have heard each of your 
stories and what you do. I would like to ask you a very 
specific question, though, and if it doesn't apply to you, just 
say, it doesn't apply to me and I don't have an answer for you. 
But what law or laws would you propose Congress pass that the 
President could sign, that would give individuals with 
preexisting conditions the certainty that they need when it 
comes time to utilize their coverage?
    Ms. Pollitz.
    Ms. POLLITZ. I am sorry? The certainty to utilize their 
coverage?
    Mr. MARCHANT. Yep.
    Ms. POLLITZ. I am not sure what you mean by that.
    Mr. MARCHANT. Make a claim, have it paid.
    Ms. POLLITZ. Getting the claim paid?
    Mr. MARCHANT. Yes, ma'am.
    Ms. POLLITZ. I mean, the ACA does require that people have 
access to insurance regardless of their preexisting conditions. 
It does require that insurance provide essential benefits, at 
least in the individual and small group market, and it provides 
subsidies to make all of that work.
    Mr. MARCHANT. So you would propose no new law to change 
what is on the books now?
    Ms. POLLITZ. I wouldn't propose laws one way or the other. 
I am just saying there is that law. As I think the Members have 
discussed today, not everybody gets coverage under the ACA. 
Particularly, it is difficult for people who don't qualify for 
subsidies.
    There are other limits. We haven't talked too much today, 
for example, about--well, actually, I think Mr. Brady brought 
up network adequacy, and whether the plans that are there for 
people then cover a sufficient number and distribution of 
doctors and hospitals. I think it is fair to say implementation 
of network adequacy standards under the ACA hasn't gotten very 
far. The Obama administration, toward the end, began to ask----
    Mr. MARCHANT. But my question was about preexisting----
    Ms. POLLITZ. But now the Trump administration isn't even 
looking at that anymore.
    Mr. MARCHANT. My question is about preexisting conditions. 
This is the purpose of the hearing.
    Mr. Stolfi.
    Mr. STOLFI. Thank you, Representative. I would say that a 
prior Congress has already passed, and the President has 
already signed, a piece of legislation that protects people 
with preexisting conditions, the Affordable Care Act. And as 
far as helping those individuals further when it comes to the 
costs that they are faced with, and all individuals, actually, 
with coverage, work can be done on, as one of the panelists has 
mentioned, the cliff.
    So individuals at and over 400 percent of the poverty 
level, helping those individuals get more subsidies to help. 
Cost-sharing reductions could be funded so that we could see 
rates come back down----
    Mr. MARCHANT. That would be addressing preexisting 
conditions?
    Mr. STOLFI. People with preexisting conditions and people 
without. So every person with insurance would benefit.
    Mr. MARCHANT. Okay, thank you.
    Mr. Robertson.
    Mr. ROBERTSON. Well, I am here talking about the 
association health plans, and I think more laws and regulations 
to improve and reform association health plans would be very 
helpful to help cover preexisting conditions.
    Mr. MARCHANT. Ms. Brooks-Coley.
    Ms. BROOKS-COLEY. Thank you, Congressman. The American 
Cancer Society, Cancer Action Network supported the Affordable 
Care Act for that very reason, because of the patient 
protections that are included in the law, that made sure that 
patients who had serious illnesses such as cancer, and had 
preexisting conditions, had access to the coverage that they 
need.
    Mr. MARCHANT. Thank you.
    Mr. Blackshear.
    Mr. BLACKSHEAR. With a policy question like this, I would 
refer you to speak with the people that I work with in the AHA.
    Mr. MARCHANT. Okay. Thank you.
    One of the real-life situations that some parents in my 
district face are children that are privately covered on their 
parents' insurance plans now, but their disabilities and their 
sickness will go much past the 27-year-old limit. And they fear 
that eventually, when they pass away or their coverage goes 
away, there is a retirement, that when they have to switch that 
child to Medicaid, that the preexisting condition or the level 
of care will not be adequate or compare to the level of care 
that they are getting on the private insurance. Does anyone 
have a comment about that?
    Chairman NEAL. The gentleman's time has expired.
    Mr. MARCHANT. Thank you.
    Chairman NEAL. Let me recognize the gentleman from Oregon, 
Mr. Blumenauer, to inquire for 5 minutes.
    Mr. BLUMENAUER. Thank you, Mr. Chairman. I appreciate our 
having this discussion today and I think it is appropriate to 
start out. Although I must confess that I would think my good 
friend from Texas, the Ranking Member, would be embarrassed to 
critique the Affordable Care Act process, the dozens of 
hearings, the work that went on, to the--I don't even know how 
to describe jamming through the largest transfer of wealth in 
American history without a hearing, with people not knowing 
what was in it to this day.
    When the history is written of what happened in the--in 
this last decade, that claim will be laughable. And I hope we 
can get past it.
    Mr. Chairman, one of the things I think is important, two 
of the witnesses, Ms. Pollitz and Mr. Stolfi, pointed out that 
we have legislation now that reaches the requirement for 
preexisting conditions. The only problem in terms of gaps is 
that there is not adequate funding for subsidies and they are 
chipping away at some of the things that are going on. We have 
it now.
    Now, notwithstanding legislation that my Republican friends 
passed to try to give themselves a fig leaf before the last 
election, what they did is not sufficient, is not as good as 
the Affordable Care Act. They can say that they want to do 
that, but it didn't speak to the interaction of all of the 
pieces. That is why they never passed legislation and enacted 
into law something to replace the Affordable Care Act. They 
couldn't do it and meet those standards.
    Or, as the President of the United States said, healthcare 
is complicated. Who knew? Who knew? But the fact is, what you 
came up with is not as good as what we had, and if we would 
have been working together for the last 6 years to refine and 
enhance the Affordable Care Act, coverage would be better, 
costs would be lower, and we could move on to other areas that 
we agree need help.
    Now, Mr. Stolfi, you have, in your testimony, impacts of 
what happened with the Republican Congress and the 
Administration that have driven up costs, not reduced them but 
driven them up. Do you want to point to your testimony? I think 
people missed that, that the things the Republicans have done 
and the Administration is pursuing, according to your 
testimony, has harmed people in my State.
    Mr. STOLFI. Thank you, Representative, for the question. 
Yes. So we are calling it Federal uncertainty, but it is a 
contribution of a number of factors. It is the short-term 
limited duration plan changes, association health plan changes, 
zeroing out of the Federal mandate, the Texas lawsuit, and the 
loss in marketing dollars to promote open enrollment at the 
exchanges. All of these things have a real-life impact on 
people.
    In Oregon, they have influenced the rates that people are 
paying in 2019, by increasing those rates between 7 and 14 
percent over what they otherwise could have been, without this 
unavoidable Federal uncertainty.
    Mr. BLUMENAUER. Thank you. The witnesses have pointed out, 
there have been some problems earlier. Getting a massive 
proposal in place, insurers made bids that weren't accurate, 
and it took them a couple of years to be able to get it right. 
That is not something that should be surprising for something 
that is dealing with this much of the economy. It will take 
time to get it right.
    But what has happened is that, while they are working to 
get it right, my Republican friends and the Administration have 
created greater uncertainty, getting rid of the mandate and 
having problems in terms of cost-sharing reductions. Things 
that were envisioned in the bill that were part of making it 
work properly, unnecessarily put this uncertainty in a business 
that doesn't thrive on uncertainty. They are risk adverse. They 
want good information.
    Mr. Chairman, I appreciate our having a discussion like 
this today. I think as we go through, we will find areas that 
we don't need that make it worse. We ought to take a bill that, 
as enacted, is providing what people want for preexisting 
conditions, not chip away at it, but refine it.
    Thank you, Mr. Chairman.
    Chairman NEAL. I thank the gentleman for his inquiry. And 
now let me recognize the gentleman from New York, Mr. Reed, for 
5 minutes.
    Mr. Reed not being here, let me recognize Mr. Kelly for 5 
minutes.
    Mr. KELLY. Thank you, Mr. Chairman, and thanks for having 
this hearing. And to all the witnesses, thanks for taking time 
out of your private lives to come here.
    This hearing today is about preexisting conditions and what 
is covered and what is not covered. But most importantly, while 
it is called the Patient Protection Affordable Care Act, the 
most obvious part of it is the ``Affordable'' Care Act.
    I don't know how many Members sitting up at the dais today 
actually buy health insurance. I am still in the private sector 
and we do provide employer-sponsored healthcare and pensions, 
by the way. I think one of the biggest challenges is how do you 
afford to do that, especially if you are a small employer. And 
I think that is where we come in with the association health 
plans.
    And I think, Mr. Robertson, that is the key to how even 
small employers can offer a benefit to their associates that 
lets them compete in an open market for talent, part of that 
being benefit programs.
    In Pennsylvania, by the way, there is a company in 
Fairview, Pennsylvania, which is just outside Erie, and I 
represent them--there is new ownership, 13 employees. The owner 
wants to provide health insurance for his employees, but can't 
afford the rates for them.
    Now he wants to join an AHP through his business 
association with the manufactured business association in Erie, 
but the Governor of Pennsylvania says ``no, no, you can't join 
an AHP; Pennsylvania isn't providing that.'' And I have to tell 
you, we hear all this back-and-forth about what we do. We have 
always supported preexisting conditions. It is just flat out 
what we do because we believe in that.
    Being an employer, I believe in that because of the people 
that I work with every day for mutual success. And to try to 
develop some type of a plan that says, ``no, they don't want 
this,'' that is not true. I think what all of us want is 
something that is truly affordable.
    Ms. Brooks-Coley, you know I am a Hyundai dealer. Hyundai 
Motor America Hyundai dealers have something called the Hyundai 
Hope on Wheels. We just finished our 20th anniversary, and 
through Hyundai dealers and Hyundai Motor America, have 
contributed $125 million to the research for pediatric cancer. 
So there is nobody in America that says, ``nah, they don't 
deserve it'';'' nah, we can't go down''; ``too expensive.'' 
``Too expensive'' is true because sometimes your heart is 
willing but your wallet is weak; you don't have the resources 
to do it.
    But, Mr. Robertson, I want to get to you because there is 
an answer for people who want to provide healthcare. And they 
want to provide it for their associates. But if you are 
eliminated from doing that--and I think you covered it very 
clearly. One of the ways we develop healthcare programs is 
through what, age and geography, which is a little bit 
different than the way I would think about it. But I would 
think risk is probably something that should be figured in 
there, too.
    And I am not saying people with preexisting conditions 
shouldn't be covered, but it has to be factored in.
    Tell me, how else would a small employer be able to get the 
same benefits as a large group for the rates that they need to 
have, in order to remain competitive, and in their line of 
business or their competition, to find talent out there, and 
wanting to take care of those people?
    Mr. ROBERTSON. Well, I think it is problematic for 
individuals or small employers. Again, it is all economics. 
Size matters. If you can pool a larger group, you can address 
the preexisting conditions, but because you are in a larger 
group, you can spread out the risk. And so if you are a small 
employer, a farmer/rancher, and if you are only yourself, it is 
hard to deal with the risk.
    But we can address preexisting conditions if you allow the 
individual and small markets to pool together all their 
resources and risk. That is the way to do it. It is pretty 
simple.
    Mr. KELLY. It is pretty simple, and the reason that it can 
be affordable is because you widen the universe of who is 
paying premiums.
    Mr. ROBERTSON. Correct. I mean, large employers do it 
today. It is pretty simple. You widen the pool and you can 
lower administrative costs. You can lower other associated fees 
with that large group. Right now, we are trying to force the 
small and individual group to cover preexisting conditions. 
That is why the costs have gone up on the premiums, to where 
they are $30- to $36,000 a year for farmers and ranchers of 
Nebraska. We have to pool them up and----
    Mr. KELLY. Let me ask you this, because we are all agreeing 
on the same thing, right? We want preexisting conditions 
covered. We want to make sure that employers can offer this.
    Why would they want to exclude the association health 
plans? For what reason? What would be the purpose of doing 
that? Because basically with the Affordable Care Act, they 
wanted more people paying in that were actually filing claims. 
So it is the same principle. Why are AHPs under fire right now, 
with no, you are not allowed to have those? For what reason?
    Mr. ROBERTSON. I don't know. I think that is the best 
reason to move forward, to cover preexisting conditions because 
you are using market forces with insurance companies to spread 
those risks to cover preexisting conditions. That is what needs 
to happen.
    Mr. KELLY. And I want to encourage you to keep going. I 
know the farmers in Nebraska appreciate what you are doing. I 
have to tell you, Manufacturers Associates in Erie have over a 
thousand members in that plan. What a shame to have to tell 
those people now, you can't participate on a level you can 
afford; we are going to force you into some other market. That 
is not what America is; that is not what we have ever been. We 
are about innovation. So I thank you for your time here.
    Mr. Chairman, thank you, and I yield back.
    Chairman NEAL. Thank you, Mr. Kelly, and with that, let me 
recognize the gentleman from Wisconsin, Mr. Kind, to inquire 
for 5 minutes.
    Mr. KIND. I thank you, Mr. Chairman. I want to thank you 
for holding such an important hearing for our initial kickoff 
as a Committee, and I want to thank the witnesses for your 
testimony. And I am so happy to hear such wide, bipartisan 
support for the need to protect individuals with preexisting 
conditions. It is just fundamental in our healthcare system. I 
am glad to see that consensus developing.
    Mr. Robertson, let me ask you, and listen, I am an owner of 
a family farm myself in a large, rural, Western Wisconsin 
district. We rotate corn and beans, have some beef cattle, and 
so I am operating in farm circles quite a bit. And I am glad to 
hear that you are coming up with a solution in Nebraska with 
these AHPs that are addressing one of the shortfalls, quite 
frankly, that existed under the Affordable Care Act. That is 
those individuals trapped in the individual marketplace that 
are not qualifying for premium tax credits to lower their 
healthcare costs. You are trying to address it right now with 
the AHPs.
    Clearly, it is not something that is prohibited under the 
ACA, because the Nebraska AHP is ACA-compliant, which is all 
that we have been asking. The concern with the AHPs, though, is 
if it wasn't ACA-compliant, they would be offering junk plans 
that wouldn't cover very much and, therefore, offering them 
cheaper, and it would strip a lot of the younger, healthier 
people and gravitate to those plans with the more comprehensive 
coverage that virtually all of us ultimately need at some point 
in our life.
    But let me ask you a couple of questions, because I am 
dealing with the same issue in Wisconsin. The average farmer's 
age in Wisconsin is 60, 61, like you said it was in Nebraska. 
Are you worried with the health pool that you have established 
with the AHP, with the average age about 60 and the fact that 
as we grow older, we consume more healthcare, healthcare gets 
more expensive, and what that is going to do with your premiums 
in the future, with that aging population within your health 
plan?
    Mr. ROBERTSON. No, no, we are not. I mean, we built this 
plan to last for a long time, the next 5 or 10 years. And so we 
built it to be ACA-compliant, and we think as we grow the pool, 
we hope this thing becomes not just 700 members, but it becomes 
3-, 4-, 5,000 Farm Bureau members.
    Mr. KIND. Are you also worried about maybe the 
extraordinary event that might happen with some of your 
members, whether it is cancer or something else, with the 
extraordinary costs that might come with one or two individuals 
contracting cancer and having to deal with those expenses, what 
that might do with the AHP premiums in the future?
    Mr. ROBERTSON. Yeah, I mean, that is always a concern 
because you have to have an association health plan that 
remains solvent. And so there is that concern out there. But, 
again, the track records will show, with all these large 
employers, the larger the group, the more you can address those 
types of large events.
    Mr. KIND. And I think there is great agreement on that 
point. It was just interesting, because I did encounter this 
article of the World-Herald Bureau, written by Joseph Morton, 
talking about the Nebraska AHP.
    And, Mr. Chairman, I would ask unanimous consent to get the 
article included in the record at this time.
    [The information follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    

                                 
    Mr. KIND. But in it Mr. Jeff Bartsch, who is Medica's Vice 
President, who is offering the health plan for you, was asked 
how the initial premiums were established, and he was quoted as 
saying, ``We had an opportunity to just assess who the 
potential association members would be, and their health risk 
is lower than the remaining individual market, and that is why 
you are seeing some better premiums being offered.''
    But he also pointed out there are over 90,000 people in 
health insurance exchanges under the ACA in Nebraska who are 
still in that pool, and the vast majority of them are receiving 
premium tax credits to lower their costs.
    I know in Wisconsin--I don't know what it is in Nebraska--
but 87 percent of the participants in the ACA health insurance 
exchange in Wisconsin are qualifying for these premium tax 
credits, substantially reducing their costs, and that is why so 
many have signed up for it.
    But Mr. Bartsch also went on to say that the association, 
in our mind, is really targeting, again, either people who have 
left the market already, or those people who are still in the 
market but don't receive a premium tax credit. So that is the 
issue, really, the roughly 5, 6 percent of the overall 
population of the country. Mr. Bartsch, that is just a small 
overall portion of the overall population that fits that 
definition.
    And that is one on which I hope that we could find some 
bipartisan agreement. How do we address that small portion of 
the American population stuck in the individual marketplace, 
not qualifying for premium tax credits?
    I know Mr. Neal and others of us have offered legislation 
to address that by expanding these premium tax credits to cover 
more individuals. That is another way of addressing it.
    But I am just concerned that with demographics, with an 
aging population, extraordinary health events, such a small 
pool of 700 members--you are hoping to grow that--what that 
might do to future premiums.
    Let me finally ask you, do most of your members when they 
hit 65 then transfer into Medicare?
    Mr. ROBERTSON. Yeah. Yeah, they do.
    Mr. KIND. And Medicare is a great program, and they have to 
take all newcomers, whether you have a preexisting condition or 
not. Medicare is able to spread that risk out.
    Do you have a prediction that if there was an early buy-in 
option to Medicare, that is budget neutral, that some of your 
members might find that an attractive option?
    Mr. ROBERTSON. I do not. No, I am just here on the 
association health plans. I appreciate that----
    Mr. KIND. Fair enough. Fair enough.
    Mr. ROBERTSON. But on your point, on the Federal poverty 
level, we even saw those members who are in the 250 to 400 
percent Federal poverty level--actually, our Farm Bureau plan 
competed with that tax credit, and we were able to pull some of 
those away from that premium subsidy. So that was good news we 
saw.
    Mr. KIND. That is good. We will watch it very closely. 
Thank you. Thank you all.
    Chairman NEAL. I thank the gentleman, and with that I would 
like to recognize the gentleman from Missouri, Mr. Smith. And 
after Mr. Smith inquires, we will move to establish precedent 
on the Committee, having two witnesses on our side for one on 
the other side. With that, Mr. Smith is recognized for 5 
minutes.
    Mr. SMITH OF MISSOURI. Thank you, Mr. Chairman. I look 
forward to working with you and the Republican leader on the 
important business upcoming in this Committee.
    We all agree that protecting access to coverage for 
individuals with preexisting conditions is necessary. I look 
forward to working with you, Mr. Chairman, on solutions that 
offer certainty to our most vulnerable. That being said, the 
status quo is full of problems that have made many patients' 
nightmares become reality.
    In 29 of the 30 counties I represent, Missourians only have 
one insurance provider on healthcare exchanges. Lack of choice 
has skyrocketed costs.
    You know what fails to protect patients with preexisting 
conditions? Deductibles so high that you might technically have 
insurance, but it is effectively meaningless.
    Lack of choice. A noncompetitive marketplace full of 
options that don't meet your needs.
    What will fail to protect patients with preexisting 
conditions? Failing to address Medicare solvency before it 
becomes insolvent in 7 years.
    We have to address costs and increase choices in our 
healthcare system to create a competitive marketplace, so 
consumers can buy insurance that works for them and meets their 
needs.
    I want to share a letter I received from Marian and Greg 
from Ozark County, Missouri, in my district: ``My husband Greg 
and I recently moved to Ozark County from Tennessee. Greg had 
to retire early because of a stroke that he suffered in 2015. 
We are currently on COBRA and are paying a thousand dollars a 
month for basically nothing. We discovered that our county in 
Missouri has only one provider for ObamaCare, and that coverage 
is even more expensive than our COBRA coverage.
    When is Congress going to do something to correct the 
damage of ObamaCare? Getting rid of the mandate was great, but 
that is not enough. And why aren't there high-risk pools or 
some other options for people with preexisting conditions like 
my husband? We don't want to spend all of our savings on health 
insurance premiums, especially if we don't receive any benefit. 
Politicians say that people shouldn't go bankrupt from medical 
bills. I say that people shouldn't go bankrupt from paying 
ridiculously high insurance premiums.''
    I couldn't agree with Marian more and I hope that the 
Chairman will work with us to find policies to lower costs that 
we can advance through, not only this Committee and the House, 
but that can pass the Senate and earn the President's 
signature. I yield back.
    Chairman NEAL. I thank the gentleman. With that, let me 
recognize the gentleman from New Jersey for 5 minutes to 
inquire, Mr. Pascrell.
    Mr. PASCRELL. Thank you, Mr. Chairman. Doing away with the 
mandate and cutting subsidies, et cetera, et cetera, is just 
the beginning of how you try to strangle the Affordable Care 
Act. Let me hope you will write some of these things down, 
because it seems like this is a redo of the last 6 years.
    The ACA has substantially improved access to care and 
financial security. Between 2010 and 2017, the share of 
nonelderly adults with a problem paying a medical bill fell 21 
percent; who didn't fill a prescription, fell 27 percent; who 
skipped a test or a treatment, fell 28 percent; who didn't 
visit a provider when they needed care, and that fell 23 
percent.
    Now, to bolster that, the marketplace consumers are 
satisfied with their coverage. That has gone from 36 percent 
all the way up, now it is at 82 percent in 2017. You have to 
look at these numbers, instead of doing redo's.
    Before the ACA, women could be charged more than men just 
for being born female. Maternity, mental health, and substance 
abuse were routinely not included in insurance coverage. What 
are you talking about, you support preconditions? I must have 
missed a lot of meetings over the last 3 years. And the 
Administration must have missed it all.
    Companies could bill consumers for every last dime with 
virtually no oversight. Someone said before, look at what the 
conditions were in 2010, which brought about this situation. If 
we would have done nothing, if we would have done nothing--and 
you are good at doing that--you criticized us and didn't come 
up with another plan on preconditions. You have to be kidding 
me.
    The fact of the matter is, you voted more than 70 times to 
repeal the protections and take us back to the days of 
uncertain and discriminatory coverage. You did that.
    After years of sabotaging the Affordable Care Act, your 
efforts have served only to make protections afforded to 
Americans and that law all the more popular today. Thank you.
    But the repeated attempts at repealing, gutting, and 
otherwise sabotaging the ACA, have left us with a lot of work 
to do to pick up the slack. The Committee, in particular, 
egregiously gutted provisions of the ACA in the 2017 tax bill 
in December. Remember that? Remember that bill? You didn't even 
have the guts to run on it. You ran away from the bill. A move 
that is projected to cause 13 million people to lose insurance. 
You did it. I didn't do it. No one on this side did it. You did 
it.
    A partisan lawsuit subsequently has tried to dismantle the 
entire ACA, including its protection for preexisting 
conditions, and taking away the few assurances we provide 
Americans in the healthcare marketplace. We must stabilize. No 
one said that the ACA was perfect. No one said that on this 
side. In fact, everybody on this side in the last 6 years have 
offered some kind of situation of amendment to make the ACA 
better. Because we have never had perfect legislation in this 
Committee or any other Committee.
    I just want to ask you one quick question, Karen--Ms. 
Pollitz. Republicans have put forward an expansion of a short-
term, limited duration plan for--it is called a junk plan--as a 
new option to supposedly lower costs for consumers.
    Can you describe the pitfalls of high-risk pools, and have 
they ever worked in the past? And can you describe the problems 
with these junk plans?
    Ms. POLLITZ. I will start with high-risk pools if I could.
    Mr. PASCRELL. Sure.
    Ms. POLLITZ. I actually--yes?
    Chairman NEAL. You will be allowed to finish your answer if 
you make it succinct.
    Ms. POLLITZ. Okay. So high-risk pools were a different way 
of going about this before the ACA in many States, including in 
Maryland where I live. I was actually on the board of our State 
high-risk pool. Insurers were allowed to turn people down 
because of their preexisting conditions and then the State 
would provide a public program, a high-risk pool that would 
offer alternative coverage.
    That is a very expensive proposition, though. If you only 
offer coverage for the people who are sick, who account for 
most of the spending and the risk pool, that will be a very 
expensive program. States that had these programs, by 
definition, lost money on every person that they signed up. 
They were very, very expensive.
    So States, over time, started adopting features to limit 
the cost of programs and to limit the number of people who 
could enroll. So all but one of the high-risk pools excluded 
coverage for the preexisting condition, which made you 
eligible, for 6 to 12 months. They charge premiums higher than 
standard rates, and even still they lost money on average, 
about $5,000 a year per person. So it is another way to do it.
    There are--Medicare, for example, covers people with end 
stage renal disease, so there is a lot of tradition of having a 
public plan take some of the expensive people and make that 
sort of the main way of getting coverage. It is just very 
expensive to do it that way, and without premium financing, 
there has to be other taxpayer financing to make that work.
    In terms of the short-term plans, that is an entirely 
different approach. That is sort of undoing the risk pool and 
saying, we can make cheaper coverage available to people while 
they are healthy but only while they are healthy. And you heard 
from Andrew what happens once you get sick in a short-term 
plan.
    So if you believe that you buy insurance in case you get 
sick, then you want coverage that doesn't stop working once you 
stop being healthy.
    Mr. PASCRELL. Thank you. Thank you, Mr. Chairman.
    Chairman NEAL. I thank the gentleman for his inquiry. With 
that let me recognize the gentleman from Illinois, Mr. Davis, 
for 5 minutes to inquire.
    Mr. DAVIS. Thank you, Mr. Chairman, for calling this 
hearing, and I also want to thank all of our witnesses for 
coming to share with us.
    Much of my focus is on children, because children are such 
an important part of our population and represent so much of 
the future. Children living with disabilities such as autism, 
or ADHD, regularly need therapies or medication to ensure that 
they can attain and retain their maximum functioning.
    Under the ACA, even though children cannot be denied 
coverage, they are charged higher premiums due to a preexisting 
condition. Sometimes therapies and medications required to 
address these conditions are not covered by insurance.
    Ms. Pollitz, how do we ensure that treatments for children 
with disabilities are covered by insurance, and how well are we 
doing with it in the ACA?
    Ms. POLLITZ. Mr. Davis, the--let's see. As you pointed out, 
children with disabilities can't be discriminated against, 
turned down, charged more, or have their preexisting condition 
excluded. The ACA does prior to an acute care coverage benefit. 
So depending on the disability and what it is, there are often 
limits, I think, to what private insurance would cover, which 
is why sometimes people end up turning to the Medicaid program 
which provides a much more comprehensive set of services for 
long-term services and supports.
    And for children, because of the EPSDT benefit, the Early 
Preventive Screening Diagnosis Testing--I forget--it covers 
everything that children need, so that is the most 
comprehensive benefit.
    In terms of two of the conditions that you mentioned, 
autism and ADHD--is that right?
    Mr. DAVIS. Right.
    Ms. POLLITZ. So that is then--the ACA is not so specific in 
that. So there is a standard for essential health benefits that 
applies in the individual and the small-group market, but those 
essential health benefits are categories of services. They, by 
and large, don't include a definition of specific services or 
specific conditions. States are allowed to then add more detail 
to the essential health benefits through the benchmark plan 
that they adopt.
    I think most States have adopted a standard--I don't know 
about Oregon--to cover services and testing and diagnosis 
relating to autism, for example.
    In other plans, including large employer plans, and 
particularly self-funded employer plans, at least with these 
two conditions that you mentioned, there is another law, the 
Mental Health Parity Act, which does require that plans have to 
cover services related to mental health conditions at the same 
level that they do for other medical conditions. I think----
    Mr. DAVIS. Okay. Let me ask you----
    Ms. POLLITZ [continuing]. Insurers can kind of have some 
discretion, though, about determining what counts as a mental 
disorder.
    Mr. DAVIS. Good. Parents around the country regularly spend 
anywhere between $2,000 and $5,000 out of pocket to determine 
whether their child has a disability because insurance may not 
cover the tests required to diagnose or assess these 
conditions.
    Is insurance required to cover the treatment associated 
with preexisting conditions? Shouldn't it also cover the test 
or evaluations required to determine whether a child has a 
particular illness or situation?
    Ms. POLLITZ. Again, in general, I believe insurance is 
required to cover diagnostic services, but insurers have 
discretion to determine what is medically necessary and what 
falls within the scope of their covered services. I am not sure 
if maybe in Oregon there is an example of some----
    So some States are more specific, particularly with respect 
to autism and do require private insurance to cover diagnostic 
services, treatment services. But those State laws would not 
reach large, self-funded, employer plans, and that may be where 
your constituents are finding gaps in their private coverage.
    Mr. DAVIS. Thank you so much for that kind of clarity.
    Thank you, Mr. Chairman. And I yield back.
    Chairman NEAL. I thank the gentleman. With that, let me 
recognize the gentleman from South Carolina, Mr. Price, for 5 
minutes.
    Mr. RICE. That would be Mr. Rice, but you were close.
    Chairman NEAL. Mr. Rice, I am sorry.
    Mr. RICE. No problem, Mr. Chairman.
    The theory of the Affordable Care Act was to provide 
universal coverage for people, including those who had 
preexisting conditions, and that we could keep the costs down 
by adding to the risk pool because people were basically not 
required to buy insurance but penalized if they didn't. And 
also to bring down the health insurance cost.
    As you will recall, the President said, you know, if you 
like your plan, you can keep it, which is clearly a falsehood. 
When he said, if you like your doctor, you can keep him, that 
often proved not to be true. And when he said it would bring 
down the cost of health insurance, in fact, the opposite has 
been painfully true.
    Expanding the insured base was one of the goals, and the 
other goal was to bring the cost down. This first chart here is 
of the insured base, and it clearly shows that before the 
Affordable Care Act, 85 percent of America was covered, either 
by private, employer-held insurance, which is the bottom of 
each bar there. The first bar is 2010; the last is 2017. But at 
the bottom in the blue there is employer insurance.
    And then the--I am skipping the middle, the purple part is 
Medicaid, and then the orange is Medicare, and then the yellow 
is the uninsured population. So the uninsured population has 
shrunk some. It was 85 percent, just before the Affordable Care 
Act hit in 2013; now it is 91 percent.
    So we have insured 6 percent more people. That is good. 
That is a laudable goal. We want to insure as many people as we 
can. But what is the cost of that? Next chart, please. So to 
insure those 6 percent more people, we have--this is insurance 
premiums. The first bar is 2013; the last is 2017. Individual 
market insurance premiums in 2013 were about $225, and today 
they are about $475, which, if you think about that, 85 percent 
of people were covered before the Affordable Care Act.
    We have succeeded in covering 6 percent more people. So the 
cost of that, though, was those 85 percent, who were already 
covered, have to pay more than twice as much to pick up that 
incremental benefit of the 6 percent more people.
    Now, there are different ways to cover those 6 percent more 
people. Most of those people were picked up because we expanded 
Medicaid in most States. And so we just basically said, here, 
here is your free insurance, and we picked those up. We didn't 
have to charge everybody else twice as much to get most of that 
incremental benefit.
    We could have just said, we are going to expand Medicaid, 
forget about the rest of the Affordable Care Act, right?
    Most States had other mechanisms for covering people who 
had preexisting conditions. My State, South Carolina, had a 
health insurance pool. I am curious about Oregon--and, Mr. 
Stolfi, I am going to pick on you, because you are the only 
Insurance Commissioner here. What was Oregon's mechanism for 
covering people with preexisting conditions? Did they have one? 
Did you have none?
    Mr. STOLFI. Thank you, Representative. Oregon did have a 
high-risk pool program.
    Mr. RICE. And could people be excluded from the high-risk 
pool?
    Mr. STOLFI. There were waiting lists for the high-risk 
pool. There were preexisting exclusions for the first--it could 
be up to 6 months.
    Mr. RICE. Okay. But we have open enrollment for a limited 
period of time in ObamaCare, so if you want to sign up in May 
you had a 6-month waiting period anyway, right? So that really 
hadn't changed.
    Now, how much more was the monthly premium in Oregon for a 
high-risk pool, people with preexisting conditions, than for 
other people? Was the premium a whole lot higher? In South 
Carolina I know, because I had two kids that were in our high-
risk pool, I had one that had a heart defect and one that had a 
brain defect, and the premium in South Carolina was about 30 
percent higher. How much higher was it in Oregon?
    Mr. STOLFI. It was capped at 125 percent of the cost.
    Mr. RICE. So it was 25 percent higher, right?
    Mr. STOLFI. Yes.
    Mr. RICE. Okay. Well, today, I am telling you, there it is 
right there, everybody has to pay 230 percent more because of 
ObamaCare. Now, if before ObamaCare the most risky folks with 
preexisting conditions had to pay 125 percent and their 
deductibles had now gone up like five times, I mean, I looked 
at your plan, you had a $750 deductible, a $500 deductible, and 
a $1,500 deductible. Now your average deductible is $4,100.
    So your people with preexisting conditions are now having 
to pay 230 percent more or 130 percent more instead of 25 
percent more, and their deductible is five times as much. Can 
you really look at me with a straight face and tell me that 
those people are better off with ObamaCare than they were 
before ObamaCare? They had lower premiums. They had access to 
coverage. And they had much lower deductibles. Are they really 
better off? Do you really believe that?
    Chairman NEAL. The gentleman will be allowed to finish his 
answer, please.
    Mr. STOLFI. Thank you, Mr. Chairman. Absolutely, the people 
are better off now than they were before. And you touch on a 
point of affordability, which is a very important concept. And 
there is many different ways to look at affordability, and one 
is, you know, for the people that don't have choice. The people 
who have health conditions, how affordable is this coverage for 
them? Before the ACA, this coverage was not affordable for 
people. If they----
    Mr. RICE. It cost half as much. It cost half as much.
    Mr. STOLFI. So we have compared the price right now of an 
average comprehensive healthcare plan that any individual can 
get now to the price that someone would pay in OMEP, and those 
prices are essentially the same. Actually, the OMEP policy is--
--
    Mr. RICE. But the price you are comparing it to is 230 
percent higher than it was before ObamaCare drove it up.
    Mr. STOLFI. So the price differences have actually 
happened, and I can't dispute that. But what is very important 
is that we are not comparing apples to apples.
    Chairman NEAL. The time of the gentleman has expired. We 
move to Ms. Sanchez to be recognized for 5 minutes.
    Ms. SANCHEZ. Thank you, Mr. Chairman. And I want to thank 
all of our witnesses for joining us today.
    I am extremely pleased that we are having this hearing on 
preexisting conditions because it is a reminder of the 
measurable improvements that have been made in the lives of 
millions of Americans since the passage of the Affordable Care 
Act.
    And I have personal experience with this with staff members 
that were employed in my district office. I know for a fact 
that prior to the ACA, insurance companies could deny anyone 
coverage for any reason, and they could also discriminate 
against women and charge us higher premiums simply because of 
our gender, because we are women. That is a practice known as 
gender rating, which I was proud to have championed its demise 
in the passage of the Affordable Care Act.
    In 2009, a study by the Women's Law Center found that 
young, healthy women were charged 84 percent more than 
similarly aged males for plans that didn't even include 
maternity benefits. Insurance companies treated being a woman 
effectively as a preexisting condition. Before the ACA many 
with health insurance who thought they had coverage often found 
themselves denied coverage in their time of need. Many were 
shocked to find that maternity care wasn't covered under their 
plans or they were denied coverage entirely after a pregnancy.
    But it is not just women who benefited from the Affordable 
Care Act. More than 130 million Americans have a preexisting 
condition and are now guaranteed access to coverage and quality 
affordable care when they need it. I am proud to have worked on 
and voted for the Affordable Care Act. And I am frustrated by 
Republican efforts, namely, efforts by this Administration, to 
increase costs and decrease quality. While they love to attack 
the ACA, what they do in response to that is create more 
uncertainty and drive up prices.
    So I am interested, Ms. Pollitz, I have a few things that I 
am interested in asking you whether or not doing these things 
creates more certainty, and thus makes healthcare coverage more 
affordable because these are things that we have seen. Refusing 
to use appropriated money to do advertising, outreach, and hire 
navigators to explain enrollment processes. Do you think that 
creates more certainty and helps lower healthcare costs?
    Ms. POLLITZ. I think that does make it harder for people to 
know all of our polling that we have done every year. Open 
enrollment shows that people don't understand the ACA still, or 
when the dates are. So not having advertising and consumer 
assistance can make it harder for people to sign up. The 
healthiest people are the most likely to stay out.
    Ms. SANCHEZ. Ms. Brooks-Coley, do you think that helps 
create more certainty and lower healthcare costs by refusing to 
use money for the outreach and to hire navigators?
    Ms. BROOKS-COLEY. No. From our perspective, transparency 
and education about plans and what type of coverage an 
individual can purchase is extremely important. And not having 
the funding used for that purpose can lead to patients not 
actually purchasing insurance or understanding what they are 
purchasing.
    Ms. SANCHEZ. Okay. Ms. Pollitz--and Mr. Blackshear has 
personal experience with this, perhaps you would care to chime 
in--allowing these substandard junk plans to be sold on the 
market, do you think that creates certainly and lowers costs?
    Ms. POLLITZ. That has been shown to increase costs. Insurer 
rate filings show that they expect this will cause adverse 
selection, and so raise the average cost of the ACA compliant 
plans.
    Ms. SANCHEZ. Mr. Blackshear.
    Mr. BLACKSHEAR. I just want to say, it literally does 
increase uncertainty.
    Ms. SANCHEZ. Thank you. What about challenging in court 
critical provisions of the ACA such as penalties for those who 
don't get coverage or striking down the individual mandate? Ms. 
Pollitz.
    Ms. POLLITZ. That is another source of uncertainty about 
the future of the ACA.
    Chairman NEAL. Mr. Stolfi, would you agree with that?
    Mr. STOLFI. I would agree, yes.
    Ms. SANCHEZ. Thank you. Finally, Ms. Pollitz, could you 
explain what would happen if we rolled back the preexisting 
condition protections and the gender rating provisions? What 
would happen to those seeking coverage?
    Ms. POLLITZ. Well, that would be kind of going back to what 
the world looked like before 2010. So that women in--certainly 
younger women would pay much more in premiums than younger men 
due to gender rating, and people with preexisting conditions or 
a history of them, would find it much more difficult to find 
coverage in the nongroup market.
    Ms. SANCHEZ. I just want to state for the record in the 
limited time that I have, I had a staff member who worked in my 
district office, the mother of four children, who got cancer, 
and this was prior to the passage of the ACA, and they refused 
her care at a certain point because she had hit her cap. And so 
she was not able to get treatment, and sadly, she passed from 
cancer. That is what will happen if we roll back the 
protections in the Affordable Care Act.
    And, again, I want to thank the Chairman, and I want to 
thank our witnesses.
    Chairman NEAL. I thank the gentlelady. With that, let me 
recognize the gentleman from New York, Mr. Higgins, to inquire 
for 5 minutes.
    Mr. HIGGINS. Thank you, Mr. Chairman. Prior to the 
enactment of Medicare in 1965, 56 percent of older Americans 
could not get coverage because they had the preexisting 
condition of old age. That is when the Medicare program was 
established. Today, 97 percent of older Americans have access 
to good quality healthcare through the Medicare program.
    Preexisting conditions are basically good people that are 
treated differently by private insurance because they were born 
with a genetic mutation that causes or increases the risk of 
disease. Those diseases include childhood cancer, juvenile 
diabetes, kids born with Downs syndrome, and cystic fibrosis. 
Before the Affordable Care Act, almost 50 percent of adults 
between the ages of 50 and 64\1/2\ who tried to buy health 
insurance for themselves and their families were denied because 
of preexisting conditions.
    You can't do that anymore. It is against the law because of 
the Affordable Care Act. My colleagues on the other side keep 
saying that everybody up here supports preexisting condition 
protections. That is not true. Everybody up here does not 
support preexisting condition protections. House Republicans 
between March of 2010 and July of 2017, more than 7 years, 
House Republicans voted 70 times--70 times to repeal and 
replace the Affordable Care Act's preexisting condition 
protections.
    Everybody up here does not support people with preexisting 
conditions. Having failed 70 times, Republicans then advance 
their new plan. The insidious, malicious language in there said 
that a health insurance company had to write a policy for 
somebody with preexisting conditions, but that policy didn't 
have to cover the treatment of a family member, a kid who is 
struck with childhood cancer for that preexisting condition. 
So, no, everybody up here does not support protecting people 
with preexisting conditions.
    Mr. BRADY. Will the gentleman yield?
    Mr. HIGGINS. I will not yield. I will not yield.
    Mr. BRADY. I yield back.
    Mr. HIGGINS. So House Republicans couldn't pass legislation 
to repeal and replace. They couldn't pass their own healthcare 
plan because nobody supported it because nobody believed them. 
So then they went to the States and they said they will do what 
we were unable to do. Twenty States attorneys general joined a 
lawsuit challenging the Affordable Care Act in the preexisting 
condition protections in Federal court. Eleven of those States 
have the highest population of preexisting conditions.
    So the only hope left is the White House, and the White 
House's Justice Department who can come in and save the day. 
They filed an opinion saying that they would not defend the 
Affordable Care Act, and that they opposed and characterized it 
as unconstitutional. They opposed the preexisting condition 
protections of the Affordable Care Act.
    Nobody up here, not one person up here, supports 
preexisting condition protections for the American people. Not 
one person up here. And not one Republican out there either. 
You go ask the States attorneys general in those States that 
have joined together to fight this protection that people 
fundamentally need.
    Here is the bottom line. The Medicare program did what 
private insurance companies had the opportunity to do and 
decided not to, because they don't make a lot of money on 
people who are sick. That is not who we are as a Nation. That 
is why we should allow people to use the leverage of the 
Medicare program to buy-in at their own expense so that they 
can get the protection of preexisting conditions now.
    The private sector has had all kinds of opportunity. And 
the great irony in all of this is that Medicare was established 
as a public program, and guess what, when it was so successful, 
guess who wanted to get involved? Private insurance through 
Medicare advantage.
    Look, I think the choices are pretty clear here, and I 
think that we will have legislation that will affirm that in 
clear and unambiguous language.
    Mr. BRADY. Mr. Chairman, regular order--stay on the time--
--
    Chairman NEAL. I thank the gentleman. His time has expired.
    Mr. HIGGINS. We have preexisting conditions. I yield back.
    Chairman NEAL. With that, subscribing and adhering to what 
is known as the Gibbons Rule, for some of us who have been here 
for a bit, we will recognize the gentleman from New York. And 
the Gibbons Rule simply says people are recognized in the order 
in which the gavel came down if they were seated. Mr. Reed.
    Mr. REED. Well, I thank the Chairman for the recognition. 
And with great respect to my colleague from New York who just 
articulated one of the greatest falsehoods I have ever heard 
uttered in this chamber on the Ways and Means Committee, 
Republicans, and the gentleman, I would hope, would remind 
themselves that they are Members of Congress. And, as a Member 
of Congress, I stand here to articulate as a Republican, and as 
a Member of this dais on the Republican side, that we take yes 
for an answer.
    We support the provision. The provision. Remember, the 
Affordable Care Act was 3,000-plus pages. And the provision 
that we are talking about, the protection of preexisting 
conditions, is something where I say to the American people and 
I say to this dais and I say to my colleagues on the other side 
of the aisle, take yes for an answer. We agree with you. This 
reform is good. This reform will stay as the law of the land.
    And we heard the voice and the fear that was the result of 
the 2018 election where this issue became centerpiece in that 
vernacular and in that debate, that we listen to the American 
people as Republicans. Preexisting conditions will remain the 
law of the land. But we need to do better. And what I would 
articulate to the American people today is that there is a 
fundamental choice that is going to be on display for you for 
the next 2 years.
    The fundamental choice that is carried by my colleagues on 
the other side of the aisle is known as something as simple as 
Medicare for All, single payer healthcare. What that is is 
government controlled, government run healthcare. We as 
Republicans offer you a different vision. We offer you an 
embrace of market pressure to bring healthcare costs down, that 
will also bring health insurance premiums down.
    So, Mr. Blackshear, I heard your story, I heard your 
condition. And maybe if I could articulate something that I 
have seen repeatedly as I have gone across my district and 
across this country and talked to the American people, there is 
a vast misunderstanding in regard to the connection of 
healthcare cost and health insurance premiums.
    I heard your testimony, and if I heard it correctly, you 
said your premiums now are about $70 to $80 a month. Is that 
correct?
    Mr. BLACKSHEAR. That is correct.
    Mr. REED. So that is approximately $1,000 a year. And your 
horrific preexisting condition, your horrific heart condition, 
I read your testimony, and it articulated that you had exposure 
to medical costs of $200,000, and probably those medical costs 
were triple that, quadruple that. It probably cost a million 
dollars for the care that you received.
    And so do you see the issue between $1,000 a year versus 
the cost of care that your horrific condition of $200,000 plus 
causes? And we in the healthcare arena have to have a vehicle 
to take those costs, right, of $200,000 plus for your 
condition, and if you are paying $1,000 a year in premiums, how 
does that cover the two together?
    And I think what Mr. Robertson is offering, from Nebraska, 
is a way to do that. Are you not, sir?
    Mr. ROBERTSON. Yes.
    Mr. REED. And how do you do that?
    Mr. ROBERTSON. Again, by forming an association health plan 
you pool the individual small markets together so basically you 
can cover people with preexisting conditions because your risk 
pool is large enough to do that. That is what large employers 
do today.
    Mr. REED. And that is what employers do. So what it is 
about is taking those costs, right, and trying to share them 
amongst everyone. But most fundamentally, I think what is lost 
in this debate is--did anyone here today testify to any 
mechanisms to bring those healthcare costs of $200,000 down? I 
did not see any of your testimony talking about how to bring 
that $200,000 price tag that Mr. Blackshear was exposed to 
down. Did I see any testimony offered by anyone in here about 
bringing those costs down? Did I miss it?
    And the silence of the dais speaks volumes to the issue 
that we face. Because, Ms. Brooks-Coley, I heard your 
testimony, and we talked about exorbitant prices, and my 
colleagues question to you was about premiums. You didn't talk 
about the premiums, you talked about the prices, and you kind 
of mixed the two together. Did I hear your testimony correctly?
    Ms. BROOKS-COLEY. You are referring specifically to high-
risk pool premiums?
    Mr. REED. He asked you about exorbitant premiums and you 
talked about exorbitant prices. So, to me, that was your 
testimony. To bring prices down is where the focus should be. 
And that is where agreement and common ground could be found.
    With that, I yield back.
    Chairman NEAL. With that, the gentlelady will be able to 
answer.
    Ms. BROOKS-COLEY. Well, the only thing I would say is from 
the cancer perspective. We have concerns about the rising cost 
of premiums as well as the out-of-pocket costs for patients. 
And we agree that affordability is an issue, but you have to 
look at ways to address affordability without addressing and 
harming patient access to comprehensive coverage. You look at 
plans such as short-term limited duration plans and other 
products that aren't comprehensive, and that is where we become 
very concerned.
    Chairman NEAL. Thank you. With that, let me recognize the 
gentlelady from Alabama, Ms. Sewell, to inquire for 5 minutes.
    Ms. SEWELL. Thank you, Mr. Chairman. I want to commend you 
for having our first hearing be about preexisting conditions. 
As has been stated before, preexisting conditions affect over 
half of Americans. And as my colleague, Ms. Sanchez, said, the 
gender rating affected women and made being a woman a 
preexisting condition. I can also tell you that the ACA has not 
only helped us in making sure that insurance companies can no 
longer discriminate against Americans for preexisting 
conditions, but it also decreased the cost of being sick while 
black.
    So as a black woman, I have seen the ACA work both to 
reduce the incidence of gender discrimination but also help to 
reduce some of the barriers to access that often people of 
color have.
    My question really, I guess, is to Ms. Pollitz. Can you 
talk a little bit about the barriers to access to healthcare 
like, for example, not expanding Medicaid? There are lots of 
States like mine, Alabama, that did not expand Medicaid, and 
the premium costs have skyrocketed, not just because of, you 
know, the fact that not as many people are signing up for the 
healthcare insurance, but the fact that so many folks just 
can't afford the premiums and the deductibles.
    Can you talk a little bit about access to healthcare and 
how the ACA has affected that?
    Ms. POLLITZ. Sure. So about 2 million people live in--
adults, below poverty, live in States that have not expanded 
Medicaid. So they don't have any affordable insurance options 
available to them.
    Ms. SEWELL. And isn't it true that by decreasing the 
subsidies, which was one of the ways that my colleagues across 
the aisle sabotaged the ACA, it only exacerbates the problem?
    Ms. POLLITZ. There is actually a proposal the President 
just released in the 2020 benefit and payment parameter rule 
that actually would reduce subsidies under the ACA, just by 
changing the formula that indexes what people have to pay and 
how much in subsidies they get. That is expected to save the 
Federal Government about a billion dollars a year, and----
    Ms. SEWELL. Expanding Medicaid or creating----
    Ms. POLLITZ. No, I am sorry, that is to reduce the ACA 
subsidies. The Administration estimates about 100,000 people 
would lose coverage as a result of that.
    Ms. SEWELL. Well, I know that in my State we don't have--
our farmers struggle oftentimes with finding affordable 
healthcare. In fact, there is a farmer in Nectar, Alabama, Hank 
Adcock, whose story I have shared in this hearing before. He is 
a third generation farmer, has never had health insurance until 
a navigator knocked on his door back in 2015. And, you know, 
had the navigator called it ObamaCare, he said that he probably 
wouldn't have gotten the health insurance. But because they 
said it was the Affordable Care Act and because it was an 
affordable subsidy that he was offered, he took health 
insurance.
    Almost 6 months later, his hand got caught in one of those 
hay bailers and, you know, not only did the Affordable Care Act 
save his hand, it also saved his farm because he had health 
insurance for the first time ever. And so, you know, unlike Mr. 
Robertson, unlike the association plan that you discussed for 
your farmers, we didn't have that option in Alabama. And 
Alabama also did not expand Medicaid, and so, many low income 
workers and hardworking families are struggling just to find 
access. So I really wanted to talk about cutting down the 
costs.
    Wouldn't it be better if we expanded access to coverage 
like you have done in Oregon through your own devices? I wanted 
to talk to Mr. Stolfi about how we can decrease the costs, 
because we have heard a lot about that. How has your State 
decreased the costs and at the same time expanded access?
    Mr. STOLFI. Thank you, Representative. Cost is definitely 
one of the key issues and something that we all should be 
focusing our time and attention on. In Oregon, we have taken a 
couple of approaches--well, there are a couple of major drivers 
of cost. Prescription drugs are a major driver of cost, 
utilization is a major driver of cost. Uncoordinated care and 
unhealthy behavior all contribute to cost. And----
    Ms. SEWELL. I am going to reclaim my time because I only 
have 7 seconds, just to say that your testimony--your written 
testimony goes into detail about that, and I refer us all to 
that.
    I wanted to mention, Mr. Chairman, that the Black Lung 
Disability Trust Fund, which was established 40 years ago and 
pays benefits to coal miners who have had total disability, an 
excise tax on coal that we supported for this fund has expired, 
it expired last year.
    And I just wanted, as a State, Alabama, who has lots of 
coal miners, many of whom are out on disability because of 
that, I would love for this Committee to have a hearing and 
definitely hear from them as to why it is so important that we 
reestablish this excise tax.
    Chairman NEAL. I thank the gentlelady. I will make sure 
that the staff follows up with you.
    With that, let me recognize the gentlelady from Washington 
State to inquire for 5 minutes. Ms. DelBene.
    Ms. DELBENE. Thank you, Mr. Chairman. And thank you to all 
of our witnesses for being with us today. Ms. Pollitz, I want 
to make sure that it is clear what is covered by a qualified 
health insurance plan that is sold on the Affordable Care Act 
exchanges, and what could possibly be missing from a short-term 
limited duration plan.
    And I have a constituent, a nurse in my district. She has a 
young son, Sammy, who has hemophilia, and her employer-
sponsored insurance is very critical. But if she lost her job 
or could no longer work, first of all, would she qualify for a 
special enrollment period?
    Ms. POLLITZ. In the marketplace, yes, she would.
    Ms. DELBENE. Yes. And if during that special enrollment 
period she purchases a plan for her and her son, would all the 
plans sold on the ACA exchanges guarantee coverage for 
hemophilia?
    Ms. POLLITZ. Yes.
    Ms. DELBENE. And if she purchased a short-term limited 
duration health plan, would she be guaranteed coverage for 
hemophilia for her son?
    Ms. POLLITZ. She would not be able to buy that policy for 
her son. She would be turned down.
    Ms. DELBENE. She would not have coverage?
    Ms. POLLITZ. Correct.
    Ms. DELBENE. Yes. If a young man in my district turns 26 
and can no longer stay on his parents' plan, would he also then 
qualify for a special enrollment period? If he has type 1 
diabetes and he goes to buy coverage on the ACA exchange, would 
he have coverage for his diabetes?
    Ms. POLLITZ. Yes, he would.
    Ms. DELBENE. Would he be guaranteed coverage for his 
diabetes if he buys a short-term limited duration plan?
    Ms. POLLITZ. He would not be able to buy one. He would be 
turned down.
    Ms. DELBENE. So another example, say, a graphic designer 
who has lupus decides to quit her job and start her own small 
business. If she buys on the ACA exchange, is she guaranteed 
that her lupus would be covered by that plan?
    Ms. POLLITZ. Yes.
    Ms. DELBENE. And would she have that same guarantee for 
coverage of her lupus if she acquired a short-term limited 
duration plan?
    Ms. POLLITZ. She would not be able to acquire a plan. She 
would be turned down.
    Ms. DELBENE. Finally, the ACA included a provision that 
required all qualified health plans to spend 80 cents of every 
premium dollar on healthcare. If the plan spends less than 
that, they have to return some money to the beneficiary. Does 
short-term plans have that same financial protection for 
consumers?
    Ms. POLLITZ. No, they do not, and they tend to have much 
lower medical loss ratios.
    Ms. DELBENE. Do you have examples of what those might be?
    Ms. POLLITZ. Closer to 50 or 60 percent of premium dollars 
are spent on claims as opposed to administration and profits 
and other----
    Ms. DELBENE. So there is quite a stark difference between 
what qualified plans cover and what short-term limited duration 
plans cover, isn't there?
    Ms. POLLITZ. That is correct.
    Ms. DELBENE. Thank you so much for your feedback.
    And, Mr. Chairman, I yield back.
    Ms. SEWELL [presiding]. The gentlelady yields back. And the 
Chair recognizes Mr. Schweikert from Arizona.
    Mr. SCHWEIKERT. Madam Chairwoman, you look good in that 
seat. All right. Let's actually walk through a couple things. 
First, to our witness from Kaiser, thanks to much of your 
staff. They were incredibly helpful to my office over the last 
couple of years, particularly as we worked on the invisible 
risk pools, and the math. I know what you do datawise is very 
difficult because you do a lot of your data out of survey 
instead of getting actual hard data from insurers and others. I 
am hoping over time we can find a way so you can have even 
crisper data.
    To the gentleman on the end who also has had valley fever, 
you had an undifferentiated case. A couple of us actually chair 
a valley fever task force. Be joyful, we think in 4 to 5 years 
we will have a vaccine out for animals, and then a little while 
after that, for humans. But it has been a fixation for many of 
us from the desert southwest. Most people have no idea about 
the orphan disease, which is this fungi, that affects so many 
people. So I share that with you.
    I am trying to find an eloquent way to say--I am frustrated 
because I know everyone here is sort of speaking from their 
heart and their knowledge-base. Much of my life has actually 
been in the financing side on some of the healthcare, and how 
do you do the actuarial math and how do you make it work.
    A year ago, we actually--not only when you look at our 
Republican legislation, we had in their guaranteed issue, and 
we can all have a conversation on the mechanisms of what is 
guaranteed issue and what is preexisting. They actually sort of 
partially overlap, but there are some structural differences.
    But we also added another $15 billion to buy down in the 
individual risk pool some of the actuarial toxicity, because 
let's face it, it is 5 percent of our population, that is a 
little over 50 percent of all of our healthcare spending, 
because there are brothers and sisters with chronic conditions.
    So here is my argument to my friends on the left, the 
right, and anyone that might be in between. We are having the 
wrong conversation here. Think about what we are doing. We are 
talking about, well, this is preexisting, well, this isn't. 
Well, this is--we can do this with premiums, but we will 
subsidize it more over here. The quick thought experiment, pre-
ACA, after ACA, Republican alternatives, this and that.
    If you were to take all dollars we are spending in our 
society, in our country, all dollars, whether it is coming 
through government, whether it is coming through your insurance 
premium, or out of your pocket, have we done anything to 
actually change the cost curve? All we are really debating here 
is who gets to pay.
    And if you actually go back over the years, you know, going 
back to 1986 when we had sort of guaranteed service at an 
emergency room, or 1996, you know, when we actually did HIPAA, 
which actually had lots of the guarantees and the protections 
or the ACA. We have just been moving around the deck chairs on 
the ship.
    I will ask from my Democrat colleagues, from my Republican 
colleagues, it is time for a radical rethinking of are you 
willing to work with us to break down the barriers to have a 
cost disruption? When this is about to become your primary care 
physician. When the technology--when I can show you the thing 
that looks like a large kazoo that you blow into, it tells you 
if you have the flu, the handheld ultrasound. There is a 
revolution rolling out right now and we have lots of statutory 
barriers at our State levels, our Federal levels, even in the 
original Social Security Act, that will keep technology from 
rolling out, empowering us to take better care of ourselves and 
crash the price of healthcare. And that is the more elegant 
debate here.
    If we can continue this sort of circular logic we are 
having in these debates of well, you support preexisting 
conditions, well, I support preexisting condition coverage. 
Back and forth, and it is great politics. And we are doing 
nothing to crash the price. It is basically your Blockbuster 
video moment. Is there technology rolling out that should help 
us crash the price?
    Now, how many of the smart people sitting here at the dais 
could start to design plans using that technology, using these 
opportunities? And we are going to have to have some really 
difficult conversations of do we have substantial overcapacity 
in physical structures? Well, we have lots of reports. Kaiser 
has actually done a couple of them of the number of hospital 
beds in the Nation that are actually empty and the caring costs 
of those. These are difficult conversations because we love our 
hospitals, we love--but there is technology revolutions around 
us, and unless this Committee and others around us start to 
break down these barriers, we are going to continue in the 
circular logic over and over. There is a chance to do a cost 
disruption. Let's actually start to embrace it and do something 
actually good.
    Thank you, Madam Chairman.
    Ms. SEWELL. The Chair recognizes Ms. Chu from California.
    Ms. CHU. Well, I am particularly concerned about what would 
happen to women's health if we did not have the ACA.
    So, Ms. Pollitz, I am concerned that the actions taken by 
the Trump administration will fundamentally undermine one of 
the ACA's core tenants, the support of cost-free preventative 
health services. And one of the most impactful is that of the 
birth control benefit or the Affordable Care Act's requirement 
that plans must offer no cost contraception coverage.
    Since the ACA went into effect, about 63 million women have 
access to this healthcare benefit. And I feel I must emphasize 
this because it so often gets wrapped up in policy debates that 
people don't consider birth control to be healthcare, but it is 
healthcare plain and simple. But if the case in Texas prevails, 
this benefit, like the rest of the ACA, will be eliminated.
    So, Ms. Pollitz, can you discuss what the situation was for 
contraception coverage prior to the ACA? Were there groups who 
were more likely to not have access to contraception or be 
unable to afford it?
    Ms. POLLITZ. I believe our women's health team has a brief 
on this, which I would be happy to look up and submit for the 
record. In general, the big change with ACA was to require the 
no-cost coverage, so no deductibles, no co-pays apply for FDA-
approved methods of contraception. So that has taken down a 
cost barrier for many women.
    Ms. CHU. Okay. Thank you for that.
    Ms. Brooks-Coley, thank you for testifying today on behalf 
of cancer patients amongst American women. Breast cancer is the 
most commonly diagnosed cancer, and the second leading cause of 
cancer death. In 2016, 3.5 million women in the United States 
were living with a history of breast cancer.
    So, Ms. Brooks-Coley, can you describe the provisions in 
the Affordable Care Act that help women detect breast cancer 
early when it can still be treated, and what would happen to 
women with breast cancer if the ACA were repealed?
    Ms. BROOKS-COLEY. Thank you, Congresswoman. The Affordable 
Care Act made sure that women who actually are diagnosed with 
breast cancer have access to comprehensive coverage. One of the 
things that it also did for all Americans and all women was to 
make sure that preventative services are available to 
individuals for free or little cost.
    We know that important preventative screenings, such as 
mammography and colonoscopy, can be lifesaving tools that allow 
an individual to actually have their cancer diagnosed early, 
where we know then that the diagnosis and treatment can lead to 
better survival rates and better survivorship.
    Ms. CHU. Thank you. I am also concerned about what would 
happen to low income women on Medicaid if the ACA were to end.
    Ms. Pollitz, I am deeply concerned about the Medicaid 
population. Medicaid provides 75 percent of the funding for all 
family planning services, nearly half of all births, and half 
of all long-term care funding, which many frail elderly women 
on Medicaid rely on. Medicaid is a lifeline for millions of 
American women, and Republican actions have put this lifeline 
in jeopardy.
    So, Ms. Pollitz, can you please discuss what the 
implications would be for women in the Medicaid program if the 
entirety of the ACA were to be struck down?
    Ms. POLLITZ. Well, the Medicaid expansion covered adult 
women who were not pregnant or mothers of dependent children, 
and who had income up to 138 percent of poverty. So the 
Medicaid expansion has been the engine of insurance expansion 
in the ACA. And if that were to go away, then millions, 
millions of low income women would lose coverage.
    Ms. CHU. And, Mr. Stolfi, I want to ensure that women would 
not be left unprotected through inadequate junk plans. My State 
of California joined five others in limiting or prohibiting the 
sale of short-term limited duration plans or the junk plans, 
and while they may appear to have lower premiums, many 
consumers find themselves stranded when they don't offer 
coverage for some of the most expensive conditions like 
pregnancy.
    What is some of the additional actions that States like 
California can do to protect consumers, especially women, from 
efforts to undermine the ACA?
    Mr. STOLFI. Well, yes, specifically in regard to short-term 
plans, other States could do exactly what California has done 
and prohibit them. What Oregon has done also is restrict the 
amount of time that they can be sold. Other States have done 
this through regulation. We would appreciate further guidance 
at the Federal level reversing the Federal rule changes. Even 
in States where we have not taken on those changes, it has 
created uncertainty and added costs--unnecessary costs to our 
folks. So we would appreciate more certainty there.
    Ms. CHU. Thank you, I yield back.
    Ms. SEWELL. The Chair recognizes the gentlelady from 
Wisconsin, Ms. Moore.
    Ms. MOORE. Thank you so much, Madam Chair. And, again, I am 
just really glad to be here. I just want to say to our witness 
from the Farm Bureau that I want to commend you for pooling 
together the 700 people in the association to provide them with 
affordable healthcare.
    And while those 700 people can have some reassurances about 
their healthcare, the Affordable Care Act sought to do that and 
did do it for 20 million additional people. It was the very 
same concept of pooling the risk, bringing in young people like 
Mr. Blackshear, who were healthy at the time, having them pay a 
premium so as to lower the cost for everybody.
    And, as a matter of fact, before we started giving it names 
like the Affordable Care Act and so on, and ObamaCare, it was 
RomneyCare. It was the best of market ideas of the insurance 
industry. Get a risk pool. And it was not Medicare for All, it 
was the combination of a social goal of insuring as many people 
as possible with a market driven pathway.
    So for those people who are looking for ideas, let's just 
go back to RomneyCare. Now, I guess the question that I have 
for you, Ms. Pollitz, and keeping in mind the testimony that we 
have heard from Mr. Robertson, if Nevada didn't have affordable 
care, could it be because of some of the things that this body, 
Congress, the Majority under the Republicans, did to undermine 
the affordable healthcare? I am thinking back to the $12 
billion in risk sharing that, you know, while we were trying to 
stand up the Affordable Care Act, there was $12 billion that we 
didn't give to the insurance companies to eliminate that 
uncertainty.
    I am thinking about not expanding Medicaid in places like 
Nebraska, which raised the cost of healthcare to everybody. I 
am thinking about reducing advertising to people. I am talking 
about pushing out these short-term limited duration insurance 
policies, which don't provide minimum care.
    Cutting subsidies they did last year, how have these 
impacted on people to the extent that folks that are in the 
association health plans couldn't find good care, and what is 
the difference between the association healthcare and the 
affordable healthcare?
    And I will yield to you.
    Ms. POLLITZ. The changes that you--the actions that you 
talked about in different ways contributed to kind of an 
artificial increase in the cost of marketplace plans.
    Ms. MOORE. And some insurers just disappearing from the 
marketplace all together.
    Ms. POLLITZ. Correct. That is correct. So the uncertainty, 
as I mentioned in my oral statement, really has been kind of a 
common theme of changes and actions taken that have driven up 
marketplace premiums. Marketplace premiums in Nebraska were 
driven up, for example, silver loading. The benchmark plan in 
Nebraska is dramatic. The benchmark silver plan costs about 40 
percent more than the cheapest gold plan in Nebraska, right? 
That is just an artificial kind of price action that the 
insurers had to take to back up.
    So as long as people are eligible for subsidies, they don't 
feel that, the taxpayer picks that up. And it sounds like many 
of the members in Mr. Robertson's plan are not eligible for 
subsidies, so they would feel the full brunt of this. Just one 
other thing on pooling. It has just come up a couple of times, 
and I kind of wanted to comment on it.
    The pooling itself doesn't make insurance cheaper, it just 
kind of spreads out the costs, it redistributes, so everybody 
kind of pays the same share. If you pull out a small number of 
people from the marketplace who are healthier than average, 
then that also has an upward pressure on the average----
    Ms. MOORE. Thank you so much. Reclaiming my time, I just 
want to go back to the old axiom dating back to 1692, Gershom 
Bulkeley, that says that actions speak louder than words. So 
while we all say we are for protecting preexisting conditions, 
I think that the sabotage we have seen does not hearken well. 
Actions speak louder than words.
    And if we were trying to provide healthcare to people, we 
would not be undermining this market-driven proposal that we 
have, the Affordable Care Act.
    And I yield back.
    Ms. SEWELL. The Chair acknowledges that votes have been 
called to Members. There is only one vote. We are going to 
continue to go. So the Chair recognizes Mr. Wenstrup from Ohio.
    Mr. WENSTRUP. Thank you, Madam Chair, I appreciate it. It 
has been an interesting morning, obviously, and I am glad that, 
I think, deep down we all agree we want coverage for 
preexisting conditions. We have had many little history lessons 
today, true or otherwise. But the fact is that we as 
Republicans have pledged support for coverage for preexisting 
conditions included in our bill.
    I have a family member that has a preexisting condition 
that will need care her entire life. We all get it. There is no 
part about me as a doctor--and, by the way, I came here for 
many reasons. I ran for office for many reasons, but in part to 
stand up for patients. There is no part about me as a doctor 
that doesn't want our fellow Americans to have access to 
quality affordable healthcare, all Americans.
    I want Medicaid to be a better program than it is. I want 
all of our plans to be able to take care of people and have a 
way for people to get into care. And, frankly, I applaud the 
Obama administration because they took the issue on. It should 
have happened sooner. But I don't necessarily agree with the 
direction that it went.
    And, by the way, I heard President Obama one time say he 
was very fond of it being called ObamaCare because it put his 
name with the word care every time someone said it, and I don't 
blame him. It is a pretty good marketing tool. And I hope the 
Members of this Committee will come forward with more to offer 
than just trying to scare Americans with the false claim that 
we don't want people with preexisting conditions to be covered. 
Is that what we are going to sit here and do for the next 2 
years? I certainly hope not.
    The Affordable Care Act has helped some people. That is a 
fact. We get that. For many, it did not. That is also a fact. I 
was in church in a small town in Ohio, the pastor was asking 
for donations to help the poor, and a woman said, ``Pastor, you 
don't know what it is like out here right now. What I am paying 
for healthcare today is through the roof, and God forbid if I 
get sick, because I can't afford that either.'' And that is in 
part because of her deductible.
    A primary care doctor in the same community quit taking 
insurance because if he didn't have to go through the 
rigamarole of insurance, he then could cut his cost. And since 
people are paying out-of-pocket because of their high 
deductible, he cut the price down and he eliminated the 
paperwork. That is what is happening in reality, folks. And you 
can talk about all this here today, but there are flaws in the 
Affordable Care Act that is making it more difficult for 
patients to get care. And at the same time, they are budgeting 
with their healthcare. That is a problem when you put things 
off because you can't afford it because of your high 
deductible. And you can barely afford the premium, if you are 
even getting it because the premium is so high.
    So, yes, they do seek some of these plans where they 
wouldn't take you with preexisting conditions, but then they 
hope they have something just in case, in case there is an 
unavoidable catastrophe. I would like to have all of you back 
here sometime to talk about incentivizing health. What do we 
have in our market today? What do we have in our plans today 
that are incentivizing health, not only for the patient but for 
the physician.
    We talk about lifespan. We talk about how people live 
longer in America, although because of our drug problem that is 
going down, unfortunately, our lifespans. Let's focus on our 
health span. Ms. Pollitz, you talked about treatments. We have 
been great at treating things, but what have we prevented?
    Think about this. Think about who gets rewarded in today's 
system. You know if you are the open heart surgeon that saves 
someone's life, yeah, we want that ability to be there, of 
course, and we want people to have access to that. But do we 
recognize any of the physicians that worked with the patient 
that prevented him from needing the open heart surgery? That is 
where we need to go, folks.
    If you want to talk about a cost curve, start preventing. 
So I hope that we can come back and have solutions for this 
Committee so that maybe we can enhance things that will 
incentivize health in America. That is where we are going to 
save. That is where the cost will go down. And I want that so 
that we will have a robust care system for those that have 
something that can't be prevented. And I would hope that you 
all agree with me on that. This is about patients, not 
politics.
    Let's cut the politics in this Committee and let's focus on 
what is best for patients and people and their families. With 
that, I yield back, and I hope to see you again to discuss that 
issue.
    Ms. SEWELL. To allow Members to vote and to allow the 
witness to take a break, we will have a recess until 1 p.m.
    [Recess.]
    Chairman NEAL [presiding]. Let's reconvene the hearing. And 
I believe that Mr. Boyle is next to inquire. I recognize the 
gentleman for 5 minutes.
    Mr. BOYLE. Thank you, Mr. Chairman. And just to briefly 
follow up on what the gentlewoman from Wisconsin was talking 
about in terms of the roots of the Affordable Care Act, 
RomneyCare, I would just point out, the first time I ever heard 
the concept was from a professor, he was a fellow at the 
Heritage Foundation named Stewart Butler, who was one of the 
founding fathers of this idea. The Heritage Foundation is not 
exactly known for its bleeding heart liberalism. And then the 
roots of the Affordable Care Act were originally introduced in 
the Senate by Bob Dole and 17 Republican Senators.
    Unfortunately, when President Obama and the Democratic 
Congress championed it, suddenly the view on the other side 
changed. But having just spent or endured the last 8 years of 
an attempt to repeal the Affordable Care Act, and having seen 
that defeated legislatively, I am very concerned that what 
couldn't be achieved legislatively now might be achieved 
judicially.
    We had very recently an activist judge in Texas strike down 
the Affordable Care Act, even though the Supreme Court had 
affirmed the Affordable Care Act a number of years ago. So 
could you talk to me, and I will turn to Ms. Pollitz, if you 
could--if the 18 States attorneys general are successful 
ultimately in their lawsuit and higher courts affirm the lower 
courts' ruling and provisions of the Affordable Care Act are 
scrapped, what would that mean for those who currently 
absolutely need a policy that they have gotten from the 
Affordable Care Act to live or have certain protections in 
their already existing private plan that came about because of 
the Affordable Care Act, such as the one on preexisting 
conditions?
    Ms. POLLITZ. Well, so that would roll the clock back to 
pre-2010. The Federal law prohibition on discrimination against 
preexisting conditions would go away. In a number of States 
that prohibition has been enacted in State law, so at least for 
people in State-regulated policies that would continue, but the 
Federal subsidies would also go away, and that is what really 
helps keep the market stable.
    States that tried, before the ACA, to prohibit 
discrimination based on preexisting conditions without 
subsidies found that there were adverse selection and there 
were rate spiral problems. And then other provisions covering 
kids to 26, the Medicaid expansion for poor adults, and the 
prevention trust fund, the FDA authority to license 
biosimilars, the ACA ended up including a wide number of 
provisions that really affect all Americans.
    Mr. BOYLE. And I am glad that you point that out because 
often coverage of the ACA just focuses on the marketplace and 
doesn't focus on those other provisions. One that you spoke 
about, I just wanted to key in on the Medicaid expansion. That 
was one of the best bangs for our buck, so to speak, in terms 
of expanding coverage to those who didn't have it.
    Now, because of the U.S. Supreme Court decision, States had 
the ability to opt-in or opt-out, so we haven't been able to 
get Medicaid expansion throughout the country. If, ultimately, 
the Affordable Care Act were done away with, what would happen 
to those who got their healthcare through the Medicaid 
expansion since that was one of the biggest boons for us?
    Ms. POLLITZ. Right. So States--let's see. States--well, 
first of all, States would lose the Federal money.
    Mr. BOYLE. Which is currently 100 percent or has it dropped 
to 90 percent?
    Ms. POLLITZ. It is on its way to 90 percent. It is below 
100 percent now and it will be at 90 percent next year. So 
billions of dollars in Federal dollars would go away. But under 
Federal law, Medicaid was a categorical program. And Federal 
matching was only for poor people in certain categories, you 
know, children, pregnant women and so forth. So millions of 
people would lose coverage if that Federal law change were to 
go away.
    Mr. BOYLE. And when we talk about millions of people, it is 
not just the overall number, we are talking primarily about the 
working poor.
    Ms. POLLITZ. Yes.
    Mr. BOYLE. We are not talking about people who are sitting 
at home and doing nothing. These are often people with full 
time jobs that make a little bit too much money to qualify for 
traditional Medicaid, but not nearly enough to afford 
healthcare.
    Ms. POLLITZ. Right. And actually for working poor adults, 
even--well, if they weren't working and they didn't earn 
anything, they weren't eligible for Medicaid before. But most 
of the expansion population, as you pointed out, they are 
working people. They are in minimum wage jobs and they are 
earning less than 138 percent of the poverty level, and they 
would lose coverage.
    Mr. BOYLE. I yield back. Thank you, Mr. Chairman.
    Chairman NEAL. I thank the gentleman. And, with that, I 
would like to recognize Mr. Kildee for the purpose of inquiry 
for 5 minutes.
    Mr. KILDEE. Thank you, Mr. Chairman, for recognizing me and 
for holding this very important hearing. This is obviously a 
subject that is one of the subjects that drew me, and I know a 
lot of the newer Members to this Committee. This is obviously 
quite critical, and the decisions we make have real impacts on 
real people.
    Like a lot of families, like a lot of people, like a lot of 
the people that I represent, preexisting conditions and their 
impact on the ability to receive healthcare is really personal 
to me. Like a lot of the families I represent, like a lot of 
people around this country, I have close family members that 
have pretty significant preexisting conditions.
    Twenty-one years ago my wife was diagnosed with multiple 
sclerosis. Thank God she has been able to receive good care, 
but I can't tell you how many times we have had the 
conversation about what our lives would be like if we were like 
so many other people in this country that have had to try to 
deal with these life-changing experiences, like Mr. Blackshear 
has gone through, without having the benefit of health 
insurance, and without having the assurance that condition will 
not somehow prevent them from receiving important care.
    Like my wife, I have a daughter who is 26 years old, who is 
a type 1 diabetic, who was diagnosed when she was 7 years old. 
I can't tell you again how many times my wife and I had this 
conversation about what will happen when our daughter is gone 
from the nest. Will she ever be able to have a future? It is 
not just about being able to get healthcare.
    So actually having the certainty that you can have 
aspirations, you can dream about your own future, that you can 
plan to be a productive and important part of society, that paw 
that hangs over people without that assurance affects our 
society in ways that I think we often don't even measure.
    So any time there is a threat or an effort to undermine 
that very elegant guarantee that is embedded in the Affordable 
Care Act, we have to take notice. And assurances and pleading 
from folks on the other side who, on one hand, assure us that 
they want to protect those assurances, but support Federal 
litigation that would essentially take that away, is a threat 
to people like me and the people that I represent who have that 
same set of circumstances.
    So family members that are able to purchase healthcare at 
an affordable price, regardless of their circumstances, is 
pretty important. And I wonder, starting perhaps with Ms. 
Pollitz, if you could tell us what options would exist for 
people with preexisting conditions in terms of plan 
availability and cost--I know this may be somewhat redundant, 
but it is important to put this down--what options would be 
available if the Administration's efforts to undermine the ACA 
were to succeed? Where could they go?
    Ms. POLLITZ. Before the ACA, Mr. Kildee, job lock was an 
issue, so people would maybe take a job or stay in a job that 
they would rather leave because of the health benefits. A 
friend of mine jokingly coined the term ``slob lock'' to relate 
to people who maybe stayed in marriages for the health 
insurance or got married for health insurance.
    For young adults--it sounds like our kids are about the 
same age--young adults had the highest rate of uninsurance 
before the ACA because their birthday gift or their graduation 
gift was losing eligibility for their parents' policy, for 
Medicaid. And if they couldn't afford coverage--often they 
couldn't because they weren't making a lot of money yet--then 
they would be uninsured. And certainly if they had a 
preexisting condition, like the ones you talked about, they 
would be uninsurable. So it is materially different now.
    Mr. KILDEE. Thank you.
    Mr. Stolfi, would you comment?
    Mr. STOLFI. Thank you, Representative. I can add two points 
to that. The first--and we saw this prior to the ACA--if you 
were lucky enough to get an individual health plan, that pool 
of people, as they got older, they got sicker; insurance 
companies could decide that they no longer wanted to carry that 
block of people, that pool of people, and could discontinue an 
entire policy, therefore, presenting someone who might have 
developed health conditions with the option of taking another 
policy that insurer offered, which would surely have less 
benefits and more cost, or taking their chances to go through 
medical underwriting again, when, if they have developed a 
condition, it would surely be denied.
    And another thing that happened quite a bit before the ACA, 
there was a lot of uncompensated care. Hospital systems in 
Oregon had hundreds of millions of dollars more uncompensated 
care, which drives up the cost for everyone else.
    Mr. KILDEE. Again, I thank you for your presence here. I 
thank the Chairman for arranging this hearing. It is an 
important moment, and I yield back the balance of my time.
    Chairman NEAL. I thank the gentleman.
    The gentleman from Texas, Mr. Arrington, is recognized to 
inquire for 5 minutes.
    Mr. ARRINGTON. Thank you, Mr. Chairman.
    And to the Ranking Member, it is an honor to serve with 
you, and it is a great opportunity for rural America to have a 
seat at the table where a lot of the big problems that we face 
as a country are being worked out.
    And in rural west Texas, I can tell you, the way we solve 
things is we start by agreeing on a set of facts. And then we 
agree on what success is; we define it so that we are all clear 
when we have achieved it. Otherwise, we wander in the 
wilderness. Because this issue is so highly charged and has 
been politicized and demagogued on both sides, let's, Ms. 
Pollitz, agree on some facts.
    One fact may be that Kaiser is not bringing policy advice 
and recommendations. You are, no doubt, an organization that 
has expertise in healthcare policy information and analysis. Is 
that----
    Ms. POLLITZ. We try, yes.
    Mr. ARRINGTON. Would that be a true statement?
    Ms. POLLITZ. Yes.
    Mr. ARRINGTON. Would you agree that in the implementation 
and over the last several years of the ObamaCare ACA 
implementation, that the cost of care has gone up 
significantly? I use the word ``exponential,'' but--because 
premiums have doubled across the country. Would you say that 
because of the implementation and during the implementation, 
costs have gone up significantly, yes or no? Just yes or no, 
have costs gone up in healthcare since the implementation of 
ObamaCare?
    Ms. POLLITZ. Healthcare costs have gone up----
    Mr. ARRINGTON. Yes. Okay.
    Ms. POLLITZ [continuing]. Although----
    Mr. ARRINGTON. Second, has choice been reduced? My 
understanding is 50 percent of the counties where my fellow 
Americans live only have one insurer. Has their choice in being 
covered by an insurance company and with a certain plan, has 
that been reduced since the implementation of ObamaCare, yes or 
no?
    Ms. POLLITZ. I don't believe so.
    Mr. ARRINGTON. Okay. Now let's talk about this notion that 
Republicans somehow don't support the provisions in the ACA 
that protect people with preexisting conditions. Did your 
organization review and analyze the American Health Care Act? 
That is the Republican reform bill that passed last year out of 
the House but failed in the Senate.
    Ms. POLLITZ. Yes, we did.
    Mr. ARRINGTON. And are you aware that we protected the 
ObamaCare provision regarding people with preexisting 
conditions and, in fact, sort of belted suspenders; we put a 
rule of construction in play that says: Nothing in this Act 
shall be construed as permitting health insurance insurers to 
limit access to health coverage for individuals with 
preexisting conditions. Were you aware of that?
    Ms. POLLITZ. I was aware of that----
    Mr. ARRINGTON. Okay, so, yes.
    Were you aware of that, Mr. Stolfi, that Republicans 
protected that provision of the ACA, because we believed it was 
important?
    Mr. STOLFI. I was aware of that language.
    Mr. ARRINGTON. Yeah, were you aware of that, Mr. Robertson?
    Mr. ROBERTSON. Yes.
    Mr. ARRINGTON. Were you aware of that?
    Ms. BROOKS-COLEY. Yes.
    Mr. ARRINGTON. Were you aware of that?
    You are all aware of it. So this could be a really short 
hearing, Mr. Chairman. We are all in favor of preexisting 
conditions.
    Now let's get on to the real business of solving the 
problem, and in order to do that, like I said, you have to 
define what success is.
    Mr. Stolfi, is there a difference between being covered by 
health insurance and having access to affordable care? Is there 
a difference?
    Mr. STOLFI. There is a----
    Mr. ARRINGTON. Yes or no?
    Mr. STOLFI. Between having insurance and healthcare? Yes.
    Mr. ARRINGTON. Okay. Does everybody on the panel agree with 
that, that there is a difference between being covered, or 
having a health insurance card and having access to affordable 
care? So would the real definition of success for this 
Committee and your sort of advice to us, as people representing 
our fellow Americans, be that we focus on how we make 
healthcare affordable for the American people, especially our 
working and middle-income families? Would you agree? Just nod 
yes if you do.
    So, Commissioner Stolfi, let me ask you a few questions 
about your State in particular. You said that there were 
300,000 new, newly insured people since the ACA's 
implementation, correct?
    Mr. STOLFI. About 350,000.
    Mr. ARRINGTON. How many of those got care through the 
exchange, of the 300,000, versus Medicaid expansion?
    Mr. STOLFI. The majority of the additional----
    Mr. ARRINGTON. The Medicaid expansion. All right. I am not 
going to try to play games with you here. I am just going to 
state the fact--and you can confirm or deny--that 400,000 
people in your State, citizens, fellow--what do you say?
    Mr. STOLFI. Oregonians.
    Mr. ARRINGTON [continuing]. Oregonians were qualified and 
eligible for the exchange. And two-thirds of the 400,000 
decided not to get ObamaCare through the exchange. They decided 
to pay the fine rather than to get care on the exchange. Is 
that correct?
    Mr. STOLFI. I am not certain of those numbers, no, sir.
    Mr. ARRINGTON. I yield back, Mr. Chairman.
    Chairman NEAL. I thank the gentleman. I would say in 
reference to the gentleman's point, the Chair never assumed 
that this would be a short meeting.
    With that, let me recognize the gentleman from Virginia to 
inquire, Mr. Beyer.
    Mr. BEYER. Mr. Chairman, thank you very much. Mr. Chairman, 
I would like to point out that I have been running the family 
business for 45 years, and our healthcare premiums were going 
up 15 percent per year before ObamaCare. And if you do the 
math, that means a doubling in 5 years. A part of what 
ObamaCare was designed to address was the fact that premiums 
were going up very quickly before. In fact, ours did not go up 
any faster after ObamaCare than before, despite the fact that 
coverage was so much greater.
    Mr. Chairman, without objection, I have four letters I 
would like to submit for the record and just briefly describe 
them.
    Chairman NEAL. Without objection.
    [The information follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    

                                 
    Mr. BEYER. The first was--I was one of many Members of the 
House that wrote Speaker Ryan on November 1, 2017, about the 
President's decision to end cost-sharing reductions. We have 
heard so much about the costs of healthcare. Ending the cost-
sharing reductions, which were an integral part of ObamaCare, 
the Affordable Care Act, certainly increased the cost for 
premiums.
    The second was a letter on May 31, 2018, again, from many 
Members of the House, to President Trump, about his signing 
H.R. 1 that functionally eliminated the provision that required 
Americans to purchase health insurance. I believe, Mr. 
Robertson, in your explanation of how the association has 
reduced costs, you said the larger the risk pool, the better.
    Well, the very core of the Affordable Care Act is we have 
the largest risk pool possible, and that is what the mandate 
did. And when the Republican leadership and the President 
eliminated that mandate, obviously we pushed costs up for 
everyone. We took those low-cost young people out of the health 
insurance pool. That is the way insurance works, going back a 
thousand years.
    The third letter, in two versions, October 30, 2018, both 
to the Attorney General and to the President, was about the 
Justice Department refusing to intervene in the lawsuit brought 
by State attorneys general that would nullify preexisting 
conditions protection.
    If my friends on the other side are so committed to the 
protection of the preexisting conditions waiver, the first 
thing we should do is get the Department of Justice and our 
President to stop the lawsuit that would make it irrelevant.
    All of these, by the way, Mr. Chairman, contribute to the 
uncertainty that pushes up premiums. Every time we mess with 
the Affordable Care Act and do something yet again to undermine 
it, we are making premiums go up.
    But, Ms. Pollitz, I have a specific concern for you, 
because I have heard a number of times the quote that nothing 
in this Act shall override the ObamaCare protection for 
preexisting conditions. Isn't there also a provision in the Act 
that allows States to apply for a waiver to get rid of the 
preexisting conditions?
    Ms. POLLITZ. There was, yes, a provision to allow States to 
waive the community rating requirements so that people could be 
charged more based on health status.
    Mr. BEYER. Isn't that functionally the same? When you don't 
waive preexisting conditions, you just make it unaffordable; is 
it not virtually the same thing?
    Ms. POLLITZ. Well, that would have made it harder for 
people with preexisting conditions to afford coverage.
    Mr. BEYER. Like a Mr. Blackshear or like so many of our 
family members that we talked about here today.
    Ms. POLLITZ. Yes.
    Mr. Beyer, that law also substantially changed the 
subsidies, turning them into flat tax credits and smaller tax 
credits so that they would not have had the same stabilizing 
effect. And to the extent that people did drop out of coverage, 
which CBO estimated tens of millions of people would lose 
coverage, that would drive up premiums for people, to the 
extent that people with preexisting conditions stayed, and the 
tax credits would no longer protect them from that premium 
increase.
    Mr. BEYER. It seems like most of the adjustments made in 
the last few years have been to increase the number of people 
with adverse selection being part of the insurance pool and 
reduce the ones that would bring the costs down.
    So we talked about pregnancy as a preexisting condition. 
Maybe someone would like to comment on the fact that because of 
the Affordable Care Act and the pregnancy prevention coverage, 
the contraception coverage, one of the few things we can agree 
on here--the anti-choice versus pro-choice, a woman's 
reproductive rights--is that our abortion rate is the lowest it 
has been since Roe v. Wade, and that there are fewer teen 
pregnancies and unintended pregnancies than there have been in 
decades. Ms. Pollitz, as a researcher, would you agree?
    Ms. POLLITZ. Yes. And access to contraceptive coverage has 
helped. Actually, I was not able to answer the Congresswoman's 
question before, but now only about 2 percent of young women 
end up having to pay out-of-pocket costs for a contraceptive. 
It was much higher before the ACA.
    Mr. BEYER. And, Ms. Brooks-Coley, now that we have this 
waiver of preexisting conditions, the protections, have you 
seen any difference in cancer survival rates, when people are 
not thrown off insurance because they have cancer or can't get 
insurance?
    Ms. BROOKS-COLEY. Congressman, thank you for the question. 
We do have evidence to show that individuals who receive a 
cancer diagnosis, their cancer is being detected earlier, and 
we know that their survival rates and treatment outcomes are 
better because they have access to coverage earlier than they 
did pre the Affordable Care Act passing.
    Mr. BEYER. Thank you very much.
    Mr. Chair, I yield back.
    Chairman NEAL. I thank the gentleman.
    The gentleman from Pennsylvania, Mr. Evans, is recognized 
for 5 minutes to inquire.
    Mr. EVANS. Thank you, Mr. Chairman.
    I would like to follow up with Mr. Arrington's statement 
and allow you, Ms. Pollitz and Mr. Stolfi, to respond to what I 
think you wanted to say, what you wanted to add in addition. 
That is the impression I got. So you have your opportunity, 
both of you, to kind of give some response in terms of 
protecting people with preexisting conditions. So whoever wants 
to start.
    Ms. POLLITZ. Well, I guess in response to the question 
about rising premiums versus rising costs, the national health 
expenditure data show that, actually, healthcare costs per 
capita have risen at a lower rate since the enactment of the 
ACA.
    In the 1990s, the average annual rate of increase in per-
capita healthcare costs was about 5 percent. In the 2000s, it 
was 6 percent, and since the ACA, it has been 4 percent. So, 
still rising, but at a slower rate, kind of a bend in the 
curve. And we see similar changes in the rate of out-of-pocket 
per-capita spending since the enactment of the ACA.
    Mr. EVANS. Commissioner.
    Mr. STOLFI. Thank you, Representative Evans. I could just 
add to that to follow also what Representative Beyer said about 
costs rising, this is not a new phenomenon. In the individual 
market in Oregon before the Affordable Care Act, in 2008 and 
2009, we saw rate increases that were greater than the rate 
increases we saw in 2018 and 2019. There was 21 percent and 17 
percent, if I have those numbers correct.
    So this is not a new phenomenon, but also, as 
Representative Beyer pointed out, the products are 
fundamentally different. So the products that people have now, 
the protections that individuals have now are much more 
comprehensive and worth much more than they were before the 
Affordable Care Act.
    Mr. EVANS. So, in other words, they weren't protected then?
    Mr. STOLFI. Much less so than they are now.
    Mr. EVANS. Okay. Mr. Chairman, being that I am new to this 
Committee but obviously not new to life, the President of the 
United States came to Philadelphia August of 2016, and this is 
the exact quote he said. He was specifically talking to the 
black community. He said: ``What the hell do you have to 
lose?''
    The reason I asked the question is, in the past 2 years, 
the Trump administration has drastically underfunded outreach 
and education initiatives. What I am interested in, could you 
please discuss the linkage between risk pools, outreach, and 
health disparities? Can you respond to that aspect?
    Ms. POLLITZ. I think--we still have a continuing health 
disparities problem due to many factors. But it is also true 
that extending coverage does help to address that because it 
gives more people at least a ticket to healthcare. They may 
encounter other barriers after that, but we have seen--we have 
seen dramatic increases--or decreases, rather, in uninsured 
rates, particularly among minorities, and so that has a 
positive effect in improving access to care.
    Mr. EVANS. So minorities have something to lose?
    Ms. POLLITZ. Yes.
    Mr. EVANS. Okay. Do you want to comment on that?
    Mr. STOLFI. Representative Evans, I could just add that 
every healthcare consumer is different. Every individual has 
different healthcare needs, a different healthcare IQ, 
different biases, as one Representative noted earlier. And the 
best way to help each individual is to have one-on-one 
counseling, one-on-one education, and that costs money. And 
States like Oregon do spend quite a bit of money training 
advocators, training people to educate and help consumers. It 
is unfortunate when there are cuts to programs such as that.
    Mr. EVANS. Mrs. Brooks-Coley, do you have any comment on 
that?
    Ms. BROOKS-COLEY. I do. Thank you, Congressman. I would 
just make the comment that, from a cancer perspective, racial 
and ethnic minorities continue to have higher cancer rates and 
are less likely to be diagnosed early. So access to coverage 
and access to comprehensive coverage is extremely important for 
that population of individuals.
    Mr. EVANS. I am going to go to Ms. Pollitz real quick. 
There was a report in 2017 coming from your organization that 
said changes in insurer participation in the Affordable Care 
Act relating--was somewhat down. The question I want to ask 
you, can you explain to us how premium tax credits assist in 
keeping healthcare affordable and also help to stabilize the 
insurance risk pool?
    Ms. POLLITZ. Yeah. So premium tax credits are set on a 
formula so that you, as an individual, pay only a certain 
dollar amount toward the benchmark plan. If you are at the 
poverty level, that is about $20 a month. If you are at 150 
percent of the poverty level, that is about $60 a month. That 
is what you pay, and the difference between that and whatever 
the benchmark plan is, is the dollar value of your tax credit.
    So, if premiums go up $100 next year and I am at 150 
percent of poverty, I paid $60 for the benchmark plan last 
year; I pay $60 for the benchmark plan this year.
    The tax credits also help to really cure a lot of adverse 
selection. Normally, especially a low-income person, I would 
have to really ask some hard questions. Can I afford the $60? I 
need a car payment. I am healthy. Maybe I will skip the 
insurance because I need to spend the money somewhere else. So 
the subsidies help people when they sort of evaluate the 
expected cost of care and the cost of insurance. They help kind 
of bring that calculation in line, so that people are much more 
likely to sign up and stay signed up as long as they are 
protected from the full cost of insurance.
    Chairman NEAL. We thank the witness.
    With that, let me recognize the gentleman from Georgia to 
inquire, Mr. Ferguson, for 5 minutes.
    Mr. FERGUSON. Thank you, Mr. Chairman, and I am very 
grateful to be having this hearing. Let me say to each of you: 
Thank you for taking time out of your busy schedules and your 
personal lives to come here and talk about this important 
topic.
    I think it is important that we set that we are doing 
exactly what we are doing today, which is to set the record 
straight on preexisting conditions, our past positions, our 
current positions, and our future positions. And one of the 
things I think that--a Rubicon that we have crossed in this 
country is that we all recognize--Republicans and Democrats, 
Independents; it does not matter--we all believe that our 
fellow Americans should be covered.
    I don't think there is an argument there, and I think that 
every one of us believes that in our heart. I think a lot of 
the argument is about how do we do that. Okay? I think to 
simply say that ``if you are against the Affordable Care Act, 
that you are against preexisting conditions'' is not being 
intellectually honest, particularly with the American people.
    You can be for preexisting conditions and be against the 
Affordable Care Act for other reasons, and that is pretty much 
the position I am in.
    Listen, as a former healthcare provider, I used to fight 
this battle with insurance companies when I would have a 
patient that would come in with a preexisting condition, that 
they said would not be covered, yet they were willing to spend 
countless dollars on another condition that was created by, in 
fact, this existing condition. It made absolutely no sense. And 
we had to go to battle for our patients on a regular basis. And 
this is in the pre-ACA days.
    So there have been a lot of comments about what we had 
before didn't work. True. What we have now is not working 
because one of the challenges that we have had is that we have 
seen real costs rise to everyday Americans.
    You know, you made the comment, Ms. Pollitz, that rates are 
rising at a lower--at a slower rate. Healthcare----
    Ms. POLLITZ. Healthcare costs, not premiums, yeah.
    Mr. FERGUSON. So, you know, if you would like to come down 
to the Third District of Georgia and stand on stage and make 
that comment, I will let you do it by yourself. Because you 
might have some stuff other than words thrown at you. And my 
point in saying that is, I think that in many parts of the 
country, that is not the case. I mean, we have constituents 
that have seen premiums go from $600 a month with a $1,000 
deductible to $2,400 a month with a $6,000 deductible.
    I have a single mom, a former patient of mine, with two 
teenage girls, that simply cannot afford to go to the doctor on 
her insurance plan.
    So I think the thing that we want to get out of all of this 
today and I think the real honest conversation that we have is, 
number one, recognize that we all believe that our fellow 
Americans, and particularly those that are most vulnerable, 
should have access to affordable care, and they should have 
access to affordable insurance. I think it is wrong to state 
otherwise.
    I also think that we need to come together, as a Congress 
and as a Nation, to discuss how to drive down the actual cost 
of care. One of the things that I worry about greatly, in all 
of this, and one of the unintended consequences, or maybe the 
intended consequence, of the ACA is that you are now seeing a 
very rapid, vertical integration of the healthcare delivery 
space. You look at the different players that are in that 
market, and they are all joining hands. And it is becoming 
fewer and fewer players in the marketplace, and there is less 
competition.
    One of the things that I am excited that Mr. Robertson has 
brought is a competitive idea that gives the consumer a 
different choice. So to say that we can't have competition in 
the marketplace or we won't be able to cover our most 
vulnerable, I think, is wrong. I think we are a talented enough 
group of Americans that we can figure out how to do that.
    And let's be honest about the fact that we all believe in 
care for our most vulnerable and those with preexisting 
conditions. But we can all band together to fight to drive down 
the rising costs of healthcare and health insurance so that 
people can actually take better care of themselves and their 
families.
    And, with that, Mr. Chairman, I yield back.
    Chairman NEAL. I thank the gentleman. I thank the gentleman 
for his inquiry.
    With that, let me recognize the gentleman from Illinois to 
inquire for 5 minutes, my friend, Mr. Schneider.
    Mr. SCHNEIDER. Thank you, Mr. Chairman, and I want to thank 
the witnesses first for being here today and sharing your 
perspectives and insights but also for your patience. I know it 
has been a long day, but it is a critically important issue.
    And I think what we have been talking about on this panel 
and what others have said, but it is worth repeating, is we all 
need to be striving--in the richest country in the world, 
everyone in this country should have quality affordable care, 
where they are, where they live, when they need it. And 
healthcare is not something--I heard in a different meeting 
this morning, someone made the comment about Congress, as we 
try to tackle long-term problems, working in 2-year cycles, and 
it is difficult.
    Healthcare is not just a long-term issue; it is a lifetime 
issue for each and every one of us. And it starts at birth, but 
it is something we deal with our entire life.
    And one of the things we have seen is that since the 
Affordable Care Act--Ms. Pollitz, you touched on this--the cost 
of healthcare, of delivery, has not risen at the same rate it 
was before then.
    And, with that, Mr. Chairman, I would like to submit for 
the record a report from the Commonwealth Fund, highlighting 
how ACA reforms have moved to paying for value and beginning to 
address the healthcare costs.
    Chairman NEAL. Without objection, so ordered.
    [The information follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    

                                 
    Mr. SCHNEIDER. Thank you. And we are here today; it is a 
critically important topic, talking about protection for people 
with preexisting conditions. And as I have sat here today 
listening, but also over the course of the year, meeting with 
people, I am reminded of many young people I have met. I think 
of Jared Cooper, who was diagnosed at a young age with type 1 
diabetes and has become a champion, and all the other kids I 
have met with diabetes, a lifetime condition, that, with 
treatment, hopefully they will be able to have a full and 
productive life.
    A young woman, Kendall, who I met when she was in seventh 
grade, was diagnosed when she was 2 years old with leukemia, 
and--it was a burden on the family, but she survived, and will 
always be a cancer survivor. But when I met her--and I saw her 
recently. She is now in ninth grade. This is a young woman who 
is on the soccer team, was a swimmer. She is living the life we 
hope for all of our children, reaching her full potential.
    I met a young woman yesterday, Brie, who was brave enough 
to share with me her experience of dealing with learning 
disabilities, combined with ADHD, which can be a preexisting 
condition that would affect her outcomes, but with the proper 
treatment, she is going to have all the opportunities we all 
want for our children.
    And it is not just young people. Mr. Blackshear, thank you 
for sharing your story and bravely sharing your story. I can 
only imagine what you went through, and it starts with just a 
drive through the desert. You know, you wake up the next day, 
and your life is changed forever. But that diagnosis shouldn't 
be a sentence of financial challenge. It should be something 
that you have the opportunity to consistently pursue--and it 
looks like you might want to say something.
    Mr. BLACKSHEAR. I was just going to say: I agree.
    Mr. SCHNEIDER. But it is not just that, and these are 
things, I think all of us have experience with preexisting 
conditions. My sister is a thyroid cancer survivor, the mother 
of three young children, and doing quite well, but she will be 
dealing with healthcare issues her entire life. My cousin is a 
breast cancer survivor. My great nephew was born 2 months 
prematurely; he will soon celebrate his second birthday.
    These are all things about our healthcare system that make 
the world possible for us to appreciate. They should be open to 
everybody. I didn't mean to give a speech. I really wanted to 
get to a question, and, Ms. Pollitz, I will start with you. I 
just gave a list of friends, neighbors, and family with 
preexisting conditions. If we were to lose the protections for 
these people, broadly speaking, what is the impact, not just on 
these individuals but on our community?
    Ms. POLLITZ. It would make it harder for people, as hard as 
it was before the ACA, to get and stay affordably covered. It 
would just make it harder for people. People, before the ACA, 
sometimes hit bottom and did without, and--so they couldn't get 
treatment for those conditions. Sometimes they had to rearrange 
their lives in extraordinary ways, move or take a job or marry 
or change their income or, you know, do something extraordinary 
in order to be able to stay attached to some other coverage for 
which they were eligible that wouldn't discriminate based on 
their preexisting condition. So this makes other options 
possible for people.
    Mr. SCHNEIDER. Thank you, and I just have a few seconds 
left. But, Mr. Blackshear, you were 27 when you were diagnosed 
with valley fever----
    Mr. BLACKSHEAR. Correct.
    Mr. SCHNEIDER [continuing]. Right? And you said that was a 
couple years ago. I think you shared with us, you have 
healthcare now; it is not a worry. And as you look to your 
future, is it something that you feel you can count on, or is 
it something that still hangs over your head, saying, you know, 
I don't know if I will have it a year or 5 years from now?
    Mr. BLACKSHEAR. I really do hope I can count on it. I 
really do. The conversations we are having, you know, I wish we 
were past this, but they are very important, and I really do 
hope so.
    Mr. SCHNEIDER. Thank you. I hope so, too. I am out of time. 
I will just say this: It has been 10 years we have been 
litigating the Affordable Care Act while healthcare has moved 
forward. Our job as policymakers, I would like to say--is we 
don't get to be ahead of the curve; we have to do everything we 
can to catch up and stay in pace with healthcare--but our job 
is to make sure, Mr. Blackshear, that you don't have to worry 
about this and you can achieve your dreams. Thank you and I 
yield back.
    Mr. BLACKSHEAR. I appreciate it. Thank you.
    Chairman NEAL. I thank the gentleman.
    And, with that, let me recognize the gentleman from 
California, Mr. Panetta, to inquire for 5 minutes.
    Mr. PANETTA. Thank you, Mr. Chairman. I appreciate this 
opportunity and appreciate this type of hearing on such an 
important topic as preexisting conditions. Let me also thank 
all of the witnesses at this point for being here and for your 
endurance this morning and this afternoon.
    But I want to give four of you a break and actually focus 
on Mr. Stolfi and have a conversation with you, if that is 
okay. So the rest of you can either zone out or just take a 
little break.
    I want to talk about the connections between preexisting 
condition protections and the ACA. Okay? I think what you are 
hearing today is that most of us support the protections of 
preexisting conditions. But I think what we need to highlight 
is what exactly people are doing to support it, and that it is 
not necessarily intellectually dishonest. What it is, is an 
actual contradiction. What it is, is an actual inconsistency, 
which I think is something that all of us, as representatives 
of the people, try to avoid, being inconsistent. We want to be 
consistent.
    But it seems that in some of my colleagues' support for a 
couple things, there is some inconsistency. And starting with 
the Texas v. Azar case, a case that was filed to strike down 
all of the ACA, in that you had 20 Republican attorneys general 
who basically wanted to repeal the individual mandate as part 
of the tax law, is what they were arguing because it was zeroed 
out in such that the mandate was no longer constitutional.
    And then, on top of that, you had our Administration, this 
Administration, through the Department of Justice, file a 
separate brief during that case in which they decided not to 
defend the constitutionality of the individual mandate, and 
they agreed that certain provisions of the ACA--guaranteed 
issue, community rating, the ban on preexisting condition 
exclusions, and discrimination based on health status--are 
inseverable, are inseverable, from that mandate.
    Now, to me, supporting the DOJ brief, supporting that case 
by the 20 Republican AGs, seems inconsistent with saying you 
are then for preexisting condition protections. Am I correct?
    Mr. STOLFI. I would agree that it would be inconsistent to 
support protecting people with preexisting conditions and the 
Texas lawsuit at the same time.
    Mr. PANETTA. And why is that?
    Mr. STOLFI. Well, the Texas lawsuit itself is seeking to 
invalidate and dismantle the entire Affordable Care Act.
    Mr. PANETTA. And that includes protection of preexisting 
conditions?
    Mr. STOLFI. Absolutely.
    Mr. PANETTA. Now, what we are also seeing recently is 
certain States are trying to create their own laws, saying: We 
protect preexisting conditions.
    And I will use Wisconsin as an example. But what they are 
doing, though, in trying to protect preexisting conditions, how 
is that possible--how is that possible without the ACA? Can you 
explain that?
    Mr. STOLFI. Well, for one very big reason it would be 
rather difficult without the ACA, because the ACA, one of the 
essential elements of it are the subsidies it provides to 
individuals to afford the insurance that they need to have.
    Mr. PANETTA. Would it also create unbalanced risk pools?
    Mr. STOLFI. Without the ACA, yes.
    Mr. PANETTA. And would it also--I mean, it is basically--it 
wouldn't ensure that certain procedures are covered as well, 
correct?
    Mr. STOLFI. That would be likely, yes.
    Mr. PANETTA. And what about the exclusions on annual or 
lifetime caps?
    Mr. STOLFI. Those would go away in most States, yes.
    Mr. PANETTA. Exactly. So it would be pretty hard to support 
preexisting conditions without supporting the Affordable Care 
Act, correct?
    Mr. STOLFI. It would be difficult, yes.
    Mr. PANETTA. Thank you, Mr. Stolfi.
    I yield back. Thank you, Mr. Chairman.
    Chairman NEAL. I thank the gentleman.
    Once again acknowledging the Gibbons rule. When the gavel 
came down, Mr. Suozzi had been seated, so we will move to him 
for 5 minutes for inquiry.
    Mr. Suozzi.
    Mr. SUOZZI. Thank you, Mr. Chairman. I first want to thank 
you for holding this hearing and thank you again for making 
clear to the Ways and Means Committee that you are going to be 
spending a lot of time on hearings looking at the facts of 
different issues. I think it is a great practice that you are 
making sure we return to. I saw Mr. Reed privately a few 
moments ago. I was hoping he would be here so I could say 
publicly that I want to congratulate him because he stated in 
his very strong comments earlier, that he gets it now. He 
finally gets the fact--and the Republicans that he associates 
with--they get it, that preexisting conditions must be 
protected. They heard the message. It only took years. It only 
took 70 votes. It only took hundreds of millions of dollars of 
campaign commercials. It only took billions of dollars of free 
air time debating these issues. But they finally get the fact 
that we must protect preexisting conditions. I think that is an 
excellent, excellent result.
    Ms. Pollitz, I know you said earlier that you don't 
advocate for policy; you just focus on the facts and what is 
out there, the data. So I wanted to just confirm some things 
with you. Of the 330 million people in America, 160 million to 
175 million are covered by their private employer for their 
health insurance.
    Ms. POLLITZ. Correct.
    Mr. SUOZZI. And about 75 million by Medicaid; 45 million by 
Medicare; and 30 million remain uninsured, 4 million people 
more than it was before this Administration took office. Is 
that correct?
    Ms. POLLITZ. I don't know that the number of uninsured has 
risen quite 4 million in the last 2 years, but it has started 
to tick up again.
    Mr. SUOZZI. Do you have any idea of what that number would 
be, of how many it has gone up by? It is okay. You don't----
    Ms. POLLITZ. I will have to submit a number for you.
    Mr. SUOZZI. And there are about 23 million people that are 
covered in the individual marketplace?
    Ms. POLLITZ. Not that many. It is closer to 15 million that 
are in the individual marketplace.
    Mr. SUOZZI. Okay.
    Ms. POLLITZ. I am sorry. In the individual market, most of 
them in the marketplace.
    Mr. SUOZZI. Is it 15 million?
    Ms. POLLITZ. Total, for the individual market, yes.
    Mr. SUOZZI. So most of the stories that we hear about 
insurers pulling out of the market and about premiums going up 
dramatically, are most of those stories specifically related to 
the individual market?
    Ms. POLLITZ. Yes.
    Mr. SUOZZI. So most of the dissatisfaction with what is 
going on in the marketplace is directly related to the 
individual market?
    Ms. POLLITZ. Correct. And that rise in premiums that was on 
the chart before, that is just for the individual market. We 
don't see that same volatility in the cost of employer plans.
    Mr. SUOZZI. So you are referring to Mr. Rice's questioning 
earlier when he had the charts up, about--he said only 6.6 
percent more people were covered. That happens to be 20 million 
people, which is an awful lot of people whose lives are much 
more improved now that they have access to healthcare, and it 
is a humongous number of people, especially if you are one of 
those 20 million people.
    Ms. POLLITZ. Yes.
    Mr. SUOZZI. But when he talked about the rising of the 
rates in the individual market, much of those rate increases 
would have existed anyway because rates were going up before 
the Affordable Care Act. Of course, they were affected by the 
Affordable Care Act as well, but weren't rates going up anyway?
    Ms. POLLITZ. They were, but the rates weren't the same for 
everybody. So people, as long as they were healthy, could kind 
of move to another plan, resubmit to medical underwriting, 
maybe get another cheap rate. But as soon as you got sick, 
either your rates would go through the roof or you would get 
locked out of that market altogether.
    Mr. SUOZZI. So one of the things that we have discussed 
here today is that the Administration has been pushing these 
short-term plans. And these short-term plans are, in fact, 
cheaper for the people who are buying these short-term plans, 
but one of the reasons they are cheaper is they don't cover 
preexisting conditions. Is that correct?
    Ms. POLLITZ. That is correct.
    Mr. SUOZZI. So one of the points that we are trying to make 
in this testimony today, or this hearing today, is that 
preexisting conditions, when they are not covered, may provide 
you with cheaper rates, but the people who have preexisting 
conditions are very seriously hurt by that and can't afford 
themselves those particular plans?
    Ms. POLLITZ. That is right.
    Mr. SUOZZI. And I just wanted to clarify one thing that 
you--I think it was you that said it earlier. You said that we 
have seen premiums increase over the past year, but we estimate 
that about 6 percent of the increases are due to, one, the 
repeal of the individual mandate, and, two, the okaying of 
short-term plans.
    Ms. POLLITZ. Actually, we saw the 2019 premiums go down a 
little bit this year, by 1 percent, but if not for those two 
other factors, the repeal of the mandate and the expansion of 
short-term plans, we would have seen them go down another 6 
percent. So insurers tell us in their rate filing that even 
though they kind of overshot the mark last year when they 
corrected and so they are kind of lowering their rates, they 
are not going as low as they would have otherwise because they 
are still worried about this other source of uncertainty.
    Mr. SUOZZI. Thank you very much. I yield back my time.
    Chairman NEAL. I thank the gentleman.
    Let me recognize the gentlelady from the State of Florida, 
Mrs. Murphy, to inquire for 5 minutes.
    Mrs. MURPHY. Thank you, Mr. Chairman, and thank you to the 
witnesses for your testimonies.
    Along with Congressman Buchanan, I am one of the two 
Members on this Committee who represents Florida, and according 
to the Kaiser Family Foundation, there are an estimated 3.1 
million people in Florida under the age of 65 who have a 
preexisting health condition, such as cancer or diabetes or 
heart disease. And I can sit here thinking to myself that I 
know at least one family member or friend who has some kind of 
preexisting condition, and I imagine that my constituents 
probably could do that as well.
    And, in fact, according to Kaiser, nearly 3 in 10 
nonelderly adults in my Orlando-area district have a 
preexisting condition. That is one of the most of any major 
metropolitan area in all of Florida. It would have been very 
difficult, and maybe even impossible, for these constituents of 
mine to have obtained health insurance on the individual market 
prior to the passage of the Affordable Care Act in 2010 because 
of the way that the insurance companies screened applicants for 
coverage.
    And the ACA, in addition to empowering States to expand 
Medicaid to more people and creating federally supported health 
insurance marketplaces for individuals and families, 
established robust protections for Americans with preexisting 
conditions within those marketplaces. Specifically, the law 
guaranteed access to insurance regardless of health status. It 
prohibited insurance companies from varying premiums based on 
people's health and required coverage of certain essential 
benefits that are important to a healthy life.
    And thanks to these consumer protections and to the 
availability of the Federal financial assistance for lower 
income individuals, there are now 1.7 million Floridians 
enrolled in a marketplace plan. That is far more than any other 
State.
    And, in other words, you know, despite the misguided 
decision not to expand Medicaid, Florida has benefited a great 
deal from the Affordable Care Act. The State and its citizens 
stand to lose a great deal if the law is repealed by Congress, 
struck down by the Federal courts, or undermined by regulators 
at the Department of Health and Human Services.
    Nonelderly adults with preexisting conditions could once 
again be denied coverage or charged an excessive amount for 
coverage. And while my colleagues on the other side of the 
aisle claim that they support protecting people with 
preexisting conditions, it is my understanding that few, if 
any, of the patient advocacy groups supported their various 
efforts to repeal and replace the Affordable Care Act.
    If their proposals were even adequate at providing patient 
protections, why would the patient groups that purport to help, 
oppose them? My colleagues on the other side can say they 
support people with preexisting conditions all they want, but 
the reality is that they continue to support efforts to 
undermine these protections that Americans want. And I think it 
is well past time that they matched their words with actions.
    So my question is for Ms. Pollitz. At the risk of asking 
you to repeat what you have already said many times today, can 
you explain in just very simple terms what the recent 
legislative, administrative, and judicial efforts to weaken the 
Affordable Care Act would mean for people with preexisting 
conditions in Florida and other States? And can you really 
argue with a straight face that--or can anyone really argue 
with a straight face that my constituents would be in a better 
position now if these efforts were successful?
    Ms. POLLITZ. The recent changes--I won't go through them 
all--have had the effect of increasing premiums artificially, 
for individual health insurance through the marketplace. When 
people are eligible for subsidies, they are protected from 
that. So it is the taxpayers of Florida who pay for that, not 
the insurance enrollees. But there are millions of people 
throughout the United States who aren't eligible for subsidies: 
They earn too much. They are in the family glitch that Keysha 
talked about. There are other reasons why they are not 
eligible. And they bear the full burden. So to the extent that 
they start to fall out of the marketplace, it is more likely 
that the healthier people will let go first, that the people 
who know they are using the coverage will hang on as hard as 
they can, find ways to hang in there, and that kind of drives 
up the cost more because it just means the average cost, the 
morbidity of the risk pool, increases.
    So far the subsidies are kind of the stabilizing factor. 
They are kind of keeping it all together. They are keeping most 
of the people kind of covered in the marketplace. But at the 
margins, people with preexisting conditions are--they are 
having to pay more for ACA coverage because they are not 
protected by the subsidies, and at some point, they may not be 
able to do that.
    Mrs. MURPHY. Thank you. I yield back.
    Chairman NEAL. I thank the gentle lady.
    I recognize the gentleman from California to inquire for 5 
minutes, Mr. Gomez.
    Mr. GOMEZ. Mr. Chairman, thank you so much for organizing 
this important hearing. Healthcare is a very personal issue. 
For me, it was growing up without health insurance, spending 7 
days in the hospital, when I was a kid, with pneumonia and 
almost bankrupting my family. Preexisting conditions don't just 
apply to seniors. They also apply to little kids.
    This individual I want to talk about was about the same age 
as me when I had pneumonia when she was diagnosed with a 
congenital heart disease. Her name is Micah. And I had the 
privilege of meeting her. She is amazing. She introduced 
herself as, first, a Girl Scout--that is very important--a 
figure skating aficionado, and a little lobbyist, because she 
was making her voice heard about the Affordable Care Act and 
what kind of impact it had on her life.
    She might be just a kid, but her and her friends are really 
fighting to make sure the Affordable Care Act is in place. She 
has already had two open-heart surgeries and will need a third 
in the future. And without the ACA, she could lose her 
healthcare due to a serious preexisting condition.
    And it doesn't only--although they might be young, they are 
very aware of how their healthcare, their health, impacts their 
entire family. Because from that moment on, I knew that if I 
went outside to play, when I was a little kid, if I got hurt, 
you know, it would have a big impact on my family because we 
didn't have healthcare coverage.
    Micah and 130 million people with preexisting conditions 
deserve no less than to have an honest conversation about the 
Affordable Care Act.
    The other side of the aisle, I have been listening to them, 
and I must admit, I have been getting kind of, a little bit 
furious, a little hot under the collar here, because it is 
just--all I could think about is whatever--they don't 
understand that the Affordable Care Act works together, as all 
of you know, right? Every piece of it. When it comes to the 
subsidies, outreach, getting the risk pools, the marketplaces, 
the expanding of Medicaid, it all works together.
    And when you don't fight for all of it, but you are saying 
you are for protecting people with preexisting conditions, it 
is not--people who make that argument, I don't believe, are 
sincere. You know, the words I come up with when I hear those 
arguments are hogwash, rubbish, blarney, and just plain 
nonsense.
    You know, if you weren't at a hearing and somebody was 
making that argument, let's say, at your kitchen table, right, 
what would you say to them, that, ``Oh, yeah, I am for 
preexisting conditions, but I am not for subsidies; I am not 
for anything else in the Affordable Care Act''? I would love to 
hear what you would say.
    Ms. Brooks-Coley, what would you say?
    Ms. BROOKS-COLEY. From the cancer perspective, we represent 
a population of people who, before the Affordable Care Act, 
could not access coverage. Oftentimes, they were individuals 
who actually couldn't even get a plan even though they had a 
serious illness such as cancer. So, from our perspective, the 
entire ACA and that infrastructure is what has led to patients 
with serious illness, like cancer, having access to coverage 
and I agree with you that the patient protections, of course, 
which are center of the law and important to us from the 
serious illness perspective, but the entire law does work 
together to make sure people have better access.
    Mr. GOMEZ. Mr. Stolfi, what would you say?
    Mr. STOLFI. Thank you, Representative Gomez. I mean, to be 
honest, I think one of the most challenging things about this 
is how complex the issues are. And it is one of the reasons why 
this hearing is so important today, to talk in great detail and 
to make sure everyone fully understands what it means and all 
of the things that go into protecting people with preexisting 
conditions.
    I mean, I am going to walk away today with, you know, a 
belief that there is a much greater understanding today, about 
what that is. And I think if I were sitting around the table 
with someone, I would spend quite a bit of time talking about 
some rather intricate, somewhat boring, insurance concepts in 
order to make sure they fully understood why every single part 
of it is important.
    Mr. GOMEZ. And I appreciate that. And sometimes in life you 
just have to call out people for saying nonsense, right? And I 
know that they are probably sincere that they want to cover 
people with preexisting conditions, but we passed the 
Affordable Care Act to work as an overall structure. And now 
they are saying, after they basically ruined it, that the 
prices are coming up. So our job in the next Congress and 
moving forward is to fix what they broke.
    Thank you, and I yield back.
    Chairman NEAL. I thank the gentleman.
    And now to recognize the gentleman from Nevada, Mr. 
Horsford, to inquire for 5 minutes.
    Mr. HORSFORD. Thank you very much, Mr. Chairman. Former 
Congressman Mo Udall once said: Everything has been said, but 
not everyone has said it.
    So as the last Member today, I am extremely thankful for 
this opportunity.
    And thank you, Mr. Chairman. It says a lot that you made 
this issue of preexisting conditions and the hearing today the 
first priority of this Committee. So I want to thank you for 
that.
    There are 371,000 Nevadans who would lose coverage in 2019 
if the Affordable Care Act were repealed. Approximately 1.2 
million Nevadans with private health coverage would lose 
guaranteed access to free preventative care like immunizations 
and cancer screenings.
    The impact of the Affordable Care Act is critical. About 
one in two Nevadans, 51 percent, live with a preexisting 
condition, including myself. Because of the ACA, insurance 
companies can no longer deny coverage or charge more because of 
a preexisting condition.
    One of those Nevadans is Joe Molino, who lives in north Las 
Vegas, Nevada. Joe was diagnosed with a rare cancer in 2011, 
called chondrosarcoma of the larynx. On September 13, 2013, Joe 
underwent a 12-hour surgery to remove much of the tumor. He 
awoke with a tracheotomy, which he would have in for months.
    The hole, his stoma, never healed, and he experienced a 
complication called tracheal stenosis, which impacted his 
ability to breathe. These complications kept him from going to 
work, and in February 2014, he was notified by his employer 
that his employee-sponsored healthcare would end. And he could 
not afford a COBRA plan on his disability payment.
    Luckily, he was able to get coverage under Nevada's 
expanded Medicaid program, which I would note was actually 
approved by former Governor Brian Sandoval, the first 
Republican Governor in the country to adopt the Medicaid 
expansion in the country.
    In 2016, with the help of the Medicaid expansion and the 
ACA health plan, he was finally able to get back to work and 
live a fulfilling life.
    So I am committed, as my colleagues are on this side of the 
aisle, to do everything that I can to strengthen the Affordable 
Care Act. This is the central issue that the constituents in my 
district talked to me about over the last few years. So I am 
hopeful now with this new Congress that we will look at ways to 
build on the Affordable Care Act and make healthcare better for 
all Americans.
    But, Ms. Pollitz, I would like to ask you, what are some of 
the improvements that Congress should be considering in order 
to improve affordability and access?
    Ms. POLLITZ. Well, again, Congressman, we don't make 
recommendations. I think there are a number of proposals that 
have been discussed in the course of today's session, including 
expanding subsidies for some or all people who aren't eligible 
for them today; expanding the cost-sharing subsidies so that 
they are more generous; other changes to ensure that the 
Medicaid expansion is available in every State, instead of, you 
know, just the ones that have elected that so far.
    So I think there have been--and, you know, there are 
proposals to undo the Affordable Care Act and go in another 
direction. You know, the Better Healthcare Act is one 
direction. Others are talking about expanding public programs 
in other ways: Medicare, Medicaid eligibility.
    So I think there are a lot of options on the table, and I 
am glad you are working on them.
    Mr. HORSFORD. We will figure it out.
    Ms. POLLITZ. Thank you.
    Mr. HORSFORD. Can you discuss why the end to annual and 
lifetime limits are important to cancer patients and other 
Americans facing complex healthcare needs, please?
    Ms. POLLITZ. Yeah. So there aren't that many people who 
would reach lifetime limits, but actually an old friend of mine 
who was on the board of the Nebraska high-risk pool reached it 
because he had two daughters born prematurely with severe 
congenital conditions, and he hit the million dollar lifetime 
limit on his policy with those girls in less than a year. So it 
does happen. They are the most severe conditions.
    Cancer sometimes can get that high. My cancer treatment was 
never that big, but over a lifetime, it could get there. So 
that protection is there for the most extreme cases and the 
most costly cases, and it is a lifeline for those people.
    Mr. HORSFORD. Thank you very much.
    Thank you, Mr. Chairman. I yield back.
    Chairman NEAL. Mr. Gomez has asked for a brief interlude 
here for a couple of seconds.
    Mr. GOMEZ. Yeah. Mr. Chairman, I forgot to mention I would 
like to submit for the record a statement from Ricardo Lara, 
California's new Insurance Commissioner, on this issue. Thank 
you so much.
    Chairman NEAL. Without objection, so ordered.
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    Chairman NEAL. Over the past decade, this dialogue has 
been, from time to time, pretty contentious. But today I heard 
a lot of Members on the other side of the aisle say they 
support protecting people with preexisting conditions. And I 
welcome this as an opportunity to move forward, and I hope that 
we can work together to make sure that we preserve these 
protections for all Americans, as they have come to rely upon 
them.
    The witnesses today, all of you, you were exceptional. And 
I think that this is the sort of dialogue we could have going 
forward, based upon the testimony you have all offered. It was 
solution-based on how we can proceed in an area where people 
expect us to. So, I want to thank you for your testimony.
    Please be advised that Members have 2 weeks to submit 
written questions to be answered later in writing. Those 
questions and answers will be made part of the formal hearing 
record.
    And, with that, the Committee stands adjourned.
    [Whereupon, at 2:14 p.m., the Committee was adjourned.]
    [Submissions for the Record follow:]
    
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