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


    STRENGTHENING OUR HEALTHCARE SYSTEM: LEGISLATION TO REVERSE ACA 
         SABOTAGE AND ENSURE PREEXISTING CONDITIONS PROTECTIONS

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                           FEBRUARY 13, 2019

                               __________

                            Serial No. 116-6
                            
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                            


      Printed for the use of the Committee on Energy and Commerce

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

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
36-502 PDF                  WASHINGTON : 2020                     
          
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                    COMMITTEE ON ENERGY AND COMMERCE

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

                           Professional Staff

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

                       ANNA G. ESHOO, California
                                Chairwoman
ELIOT L. ENGEL, New York             MICHAEL C. BURGESS, Texas
G. K. BUTTERFIELD, North Carolina,     Ranking Member
    Vice Chair                       FRED UPTON, Michigan
DORIS O. MATSUI, California          JOHN SHIMKUS, Illinois
KATHY CASTOR, Florida                BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland           H. MORGAN GRIFFITH, Virginia
BEN RAY LUJAN, New Mexico            GUS M. BILIRAKIS, Florida
KURT SCHRADER, Oregon                BILLY LONG, Missouri
JOSEPH P. KENNEDY III,               LARRY BUCSHON, Indiana
    Massachusetts                    SUSAN W. BROOKS, Indiana
TONY CARDENAS, California            MARKWAYNE MULLIN, Oklahoma
PETER WELCH, Vermont                 RICHARD HUDSON, North Carolina
RAUL RUIZ, California                EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan             GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire         GREG WALDEN, Oregon (ex officio)
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
LISA BLUNT ROCHESTER, Delaware
BOBBY L. RUSH, Illinois
FRANK PALLONE, Jr., New Jersey (ex 
    officio)
                             
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, opening statement...............................     1
    Prepared statement...........................................     3
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     4
    Prepared statement...........................................     6
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     7
    Prepared statement...........................................     9
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................    10
    Prepared statement...........................................    12

                               Witnesses

Katie Keith, Associate Research Professor and Adjunct Professor 
  of Law, Georgetown University..................................    13
    Prepared statement...........................................    16
    Answers to submitted questions...............................   169
Jessica K. Altman, Commissioner, Pennsylvania Insurance 
  Department.....................................................    24
    Prepared statement...........................................    26
    Answers to submitted questions...............................   172
Grace-Marie Turner, President, Galen Institute...................    34
    Prepared statement...........................................    36
    Answers to submitted questions...............................   176

                           Submitted Material

H.R. 1010, To provide that the rule entitled ``Short-Term, 
  Limited Duration Insurance'' shall have no force or effect, 
  submitted by Ms. Eshoo.........................................    96
H.R. 986, the Protecting Americans with Preexisting Conditions 
  Act of 2019, submitted by Ms. Eshoo............................    98
H.R. 987, the Marketing and Outreach Restoration to Empower 
  Health Education Act of 2019, submitted by Ms. Eshoo...........   100
H.R. ___, the Educating Consumers on the Risks of Short-Term 
  Plans Act of 2019, submitted by Ms. Eshoo......................   104
Article of January 31, 2019, ``Ads For Short-Term Plans Lacking 
  ACA Protections Swamped Consumers' Online Searches,'' by Steven 
  Findlay, Kaiser Health News, submitted by Ms. Eshoo............   111
Letter of February 13, 2019, from Joyce A. Rogers, Senior Vice 
  President, Government Affairs, AARP, to Ms. Eshoo and Mr. 
  Burgess, submitted by Ms. Eshoo................................   116
Letter of February 13, 2019, from Michael L. Munger, Board Chair, 
  American Academy of Family Physicians, to Ms. Eshoo and Mr. 
  Burgess, submitted by Ms. Eshoo................................   119
Testimony of Sam Bloechl before Senate Democratic Policy and 
  Communications Committee, August 16, 2018, submitted by Ms. 
  Eshoo..........................................................   121
Letter of February 12, 2019, from Charles N. Kahn III, President 
  and Chief Executive Officer, Federation of American Hospitals, 
  to Ms. Eshoo, submitted by Ms. Eshoo...........................   123
Letter of February 12, 2019, from James L. Madara, Executive Vice 
  President and Chief Executive Officer, American Medical 
  Association, to Ms. Eshoo and Mr. Burgess, submitted by Ms. 
  Eshoo..........................................................   125
Letter of February 12, 2019, from Deborah P. Brown, Chief Mission 
  Officer, American Lung Association, to Ms. Blunt Rochester, 
  submitted by Ms. Eshoo.........................................   128
Statement from the American Lung Association in Support of 
  Legislation Repealing 1332 Guidance, submitted by Ms. Eshoo....   129
News release of February 8, 2019, ``Bill Would Reverse 
  Administration Rule Allowing Short-Term Insurance Plans,'' 
  American Heart Association, submitted by Ms. Eshoo.............   130
News release of February 6, 2019, ``Bill Would Overturn Guidance 
  Permitting States to Undermine ACA Patient Protections,'' 
  American Heart Association, submitted by Ms. Eshoo.............   131
Statement of Association for Community Affiliated Plans by 
  Margaret A. Murray, CEO, February 13, 2019, submitted by Ms. 
  Eshoo..........................................................   132
Statement of America's Health Insurance Plans, February 13, 2019, 
  submitted by Ms. Eshoo.........................................   136
Letter of December 18, 2018, from the Adult Congenital Heart 
  Association, et al., to Secretary Alex M. Azar II, Department 
  of Health and Human Services, et al., submitted by Ms. Eshoo...   142
Letter of February 13, 2019, from Thomas P. Nickels, Executive 
  Vice President, American Hospital Association, to Ms. Eshoo, 
  submitted by Ms. Eshoo.........................................   146
Statement of Families USA by Shawn Gremminger, Senior Director of 
  Legislative Affairs, February 13, 2019, submitted by Ms. Eshoo.   148
Statement of the Coalition to Protect and Promote Association 
  Health Plans, February 13, 2019, submitted by Mr. Burgess......   149
Article ``The Health 202: Association health plans expanded under 
  Trump look promising so far,'' by Paige Winfield Cunningham, 
  The Washington Post, submitted by Mr. Burgess..................   158
Final Vote Results for Roll Call 69, February 9, 2018, submitted 
  by Mr. Burgess.................................................   163

 
    STRENGTHENING OUR HEALTHCARE SYSTEM: LEGISLATION TO REVERSE ACA 
         SABOTAGE AND ENSURE PREEXISTING CONDITIONS PROTECTIONS

                              ----------                              


                      WEDNESDAY, FEBRUARY 13, 2019

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:30 a.m., in 
the John D. Dingell Room 2123, Rayburn House Office Building, 
Hon. Anna G. Eshoo (chairwoman of the subcommittee) presiding.
    Members present: Representatives Eshoo, Butterfield, 
Matsui, Castor, Sarbanes, Lujan, Welch, Kennedy, Cardenas, 
Schrader, Ruiz, Kuster, Kelly, Barragan, Blunt Rochester, Rush, 
Pallone (ex officio), Burgess (subcommittee ranking member), 
Upton, Shimkus, Guthrie, Griffith, Bilirakis, Long, Bucshon. 
Brooks, Mullin, Hudson, Carter, Gianforte, and Walden (ex 
officio).
    Also present: Representatives Schakowsky and Soto.
    Staff present: Jeffrey C. Carroll, Staff Director; Waverly 
Gordon, Deputy Chief Counsel; Tiffany Guarascio, Deputy Staff 
Director; Zach Kahan, Outreach and Member Service Coordinator; 
Saha Khatezai, Professional Staff Member; Una Lee, Senior 
Health Counsel; Jourdan Lewis, Policy Analyst; Alivia Roberts, 
Press Assistant; C. J. Young, Press Secretary; Mike Bloomquist, 
Minority Staff Director; Adam Buckalew, Minority Director of 
Coalitions and Deputy Chief Counsel, Health; Jordan Davis, 
Minority Senior Advisor; Caleb Graff, Minority Professional 
Staff Member, Health; Peter Kielty, Minority General Counsel; 
Ryan Long, Minority Deputy Staff Director; Brannon Rains, 
Minority Staff Assistant; Danielle Steele, Minority Counsel, 
Health.
    Ms. Eshoo. The Subcommittee on Health will now come to 
order.
    The Chair now recognizes herself for 5 minutes for an 
opening statement.

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

    First of all, welcome to the first legislative hearing of 
the Health Subcommittee in the 116th Congress. Last week we 
heard testimony and examined what the devastating effects would 
be if the case Texas v. United States were to stand, most 
especially on those who have preexisting conditions and the 
medically complex children who rely on the Affordable Care Act.
    We also discussed how the Trump administration's sabotage 
of the ACA and the expansion of junk insurance plans are 
driving up cost by diverting the healthy out of the individual 
market and weakening patient protections with preexisting 
conditions.
    Today, the four bills before us address short-term 
insurance plans, waivers to weaken insurance regulations on the 
private market, funding for marketing and outreach, and 
legislation that would require short-term insurance plans to 
carry an advisory informing consumers what the plan does not 
cover and what ACA requirements the plan does not meet.
    It is a top priority of the majority to protect patients 
with preexisting conditions. On the campaign trail and in our 
hearing last week, our Republican colleagues voiced their 
support for preexisting condition protections. They asked for 
specific legislation, and that is what we are here to discuss 
today.
    Our first bill will rescind the short-term limited duration 
insurance for junk insurance policies, regulation the Trump 
administration finalized last August, which expands these junk 
plans from the current 3-month limit, making them available for 
up to 3 years.
    We know these plans do not cover preexisting conditions, 
they do not have out-of-pocket and lifetime limits, and they do 
not protect women from being charged more than men. 
Representative Castor's bill would rescind the rule that 
expanded these junk insurance plans.
    Representative Kuster's bill revokes the Section 1332 
waiver guidance issued by the administration last October, 
which weakens requirements of private insurance plans to 
provide compressive coverage at an affordable price.
    Section 1332 of the Affordable Care Act requires States to 
meet standards for what qualifies as healthcare coverage. The 
Trump administration guidance changes these standards to be 
less comprehensive and less affordable for patients who rely on 
private insurance purchased on the individual market.
    It also allows tax credits, Federal dollars, to be spent on 
these expanded and extended junk plans. My Republican 
colleagues have been highly critical about funding tax 
subsidies to help Americans afford comprehensive health 
insurance but support allowing more people to access Federal 
money for these short-term junk insurance plans that do not 
even cover basic services.
    Representative Kuster's bill rescinds that guidance so that 
all Americans will have health insurance coverage that meets 
the same standards.
    We are also considering the bill authored by Representative 
Lisa Blunt Rochester to restore the marketing and outreach 
funding the Trump administration cut by 90 percent in 2017 and 
banning this funding from being used to advertise the junk 
insurance plans.
    An article published in Kaiser Health News earlier this 
month described how consumers searching online to enroll in 
comprehensive ACA plans are most often redirected to websites 
and brokers selling junk plans without disclosing that the 
coverage will not be comprehensive.
    And I ask unanimous consent to enter this article into the 
record. Hearing no objections, we will do that.
    [The information appears at the conclusion of the hearing.]
    Federal dollars should not support advertising coverage 
that will not protect patients with preexisting conditions.
    The last bill, my legislation, will require junk insurance 
plans to display up front what is and what is not covered so 
that consumers will know exactly what they are buying. My bill 
also requires a disclosure that these plans do not meet the 
Affordable Care Act's requirements for cost sharing and 
lifetime limits and prohibits these plans from being sold 
during the individual market open enrollment.
    I want to be clear about the following. I believe the Trump 
administration's rule that expanded the maximum duration of 
these so-called short-term plans up to a year and allows them 
to be renewed for up to 3 years should be rescinded.
    [The prepared statement of Ms. Eshoo follows:]

                Prepared Statement of Hon. Anna G. Eshoo

    Welcome to the first legislative hearing of the Health 
Subcommittee in the 116th Congress.
    Last week we heard testimony and examined what the 
devastating effects would be if the case Texas vs. United 
States were to stand, most especially on those who have 
preexisting conditions and the medically complex children who 
rely on the Affordable Care Act.
    We also discussed how the Trump administration's sabotage 
of the ACA and the expansion of junk insurance plans are 
driving up costs by diverting the healthy out of the individual 
market and weakening patient protections for those with 
preexisting conditions.
    Today the four bills before us address short-term junk 
insurance plans, waivers to weaken insurance regulations in the 
private market, funding for marketing and outreach, and 
legislation that would require short-term insurance plans to 
carry an advisory informing consumers what the plan does not 
cover and what ACA requirements the plan does not meet.
    It is a top priority of the majority to protect patients 
with preexisting conditions. On the campaign trail and in our 
hearing last week, our Republican colleagues voiced their 
support for preexisting condition protections.
    They asked for specific legislation, and that's what we're 
here to discuss today.
    Our first bill will rescind the short-term limited duration 
insurance--or junk insurance--regulation the Trump 
administration finalized last August which expands these junk 
plans from the current 3-month limit, making them available for 
up to 3 years.
    We know these plans do not cover preexisting conditions, do 
not have out-of-pocket and lifetime limits, and do not protect 
women from being charged more than men.
    Representative Castor's bill would rescind the rule that 
expanded these junk insurance plans.
    Representative Kuster's bill revokes the Section 1332 
waiver guidance issued by the Trump administration last October 
which weakens requirements of private insurance plans to 
provide comprehensive coverage at an affordable price.
    Section 1332 of the Affordable Care Act requires States to 
meet standards for what qualifies as healthcare coverage. The 
Trump administration guidance changes these standards to be 
less comprehensive and less affordable for patients who rely on 
private insurance purchased on the individual market.
    It also allows tax credits--Federal dollars--to be spent on 
these expanded and extended junk plans.
    My Republican colleagues have been highly critical about 
funding tax subsidies to help Americans afford comprehensive 
health insurance, but support allowing more people to access 
Federal money for these short-term junk insurance plans that do 
not even cover basic services.
    Rep. Kuster's bill rescinds that guidance so that all 
Americans will have health insurance coverage that meets the 
same standards.
    We're also considering a bill authored by Representative 
Lisa Blunt Rochester to restore the marketing and outreach 
funding the Trump administration cut by 90 percent in 2017 and 
banning this funding from being used to advertise junk 
insurance plans.
    An article published in Kaiser Health News earlier this 
month described how consumers searching online to enroll in 
comprehensive ACA plans are most often redirected to websites 
and brokers selling junk plans without disclosing that the 
coverage will not be comprehensive.
    I ask unanimous consent to enter this article into the 
record.
    Federal dollars should not support advertising coverage 
that will not protect patients with preexisting conditions.
    The last bill, my legislation, will require junk insurance 
plans to display up front what is and what is not covered so 
that consumers will know exactly what they're buying.
    My bill also requires a disclosure that these plans do not 
meet the Affordable Care Act's requirements for cost-sharing 
and lifetime limits and prohibits these plans from being sold 
during the individual market open enrollment period.
    I've learned over the years that people know very well what 
they pay, but they don't always know what they're buying.
    I want to be clear--I believe the Trump administration's 
rule that expanded the maximum duration of these so-called 
``short-term'' plans up to a year and allows them to be renewed 
for up to 3 years should be rescinded.
    But as long as short-term insurance plans are being sold, 
the American people should know what the policy does not cover 
and that information should be displayed prominently.
    I'm pleased we're discussing legislation today that will 
protect Americans with preexisting conditions and address the 
sabotage of the Affordable Care Act. I hope these bills will be 
an opportunity to work across the aisle to help the American 
people.
    Welcome to our witnesses and we look forward to your 
testimony.

    Ms. Eshoo. I see that I am over my time, and at this point 
I would like to recognize Dr. Burgess, the ranking member of 
the subcommittee, for 5 minutes for his opening statement.

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

    Mr. Burgess. I thank you for the recognition, and today we 
have been convened once again to discuss issues that will not 
improve the affordability of health insurance for Americans.
    Unsustainably high premiums and issues related to silver 
loading are increasingly becoming a reality for families that 
rely upon healthcare.gov for their insurance.
    Yet, the bills before us today will not make a marked 
increase in the availability of reasonably priced plans. I am 
encouraged to see that we are at least discussing some 
legislative ideas today, unlike last week's hearing, which I 
think everyone agreed was an exercise in futility.
    Once again, I would like to make it clear that there is 
bipartisan support for protecting coverage for individuals with 
preexisting conditions. Many on our side have expressed that 
sentiment.
    Certainly, we have people that we know in our families or 
in our--amongst our employers when we--employees when we were--
before we came to Congress or in our medical practices that are 
affected by the status of preexisting conditions.
    But the constituents in my district are struggling to 
afford their health insurance, and I am sure the district I 
represent is not unique in that regard.
    What good is health insurance if you are afraid to use it 
because you cannot afford your deductible? I have a lot of 
people that I represent who cannot afford a flat tire, let 
alone a $6,800 deductible in the bronze plan sold by 
healthcare.gov.
    This is the issue that I would like to see us tackle, and I 
am disappointed that none of the bills before us today will 
move that.
    What I find most troubling about today's hearing is that 
our colleagues are questioning the flexibility that they put 
into their own law. Section 1332 of the Affordable Care Act 
provides States the opportunity to apply for State Innovation 
Waivers.
    These waivers allow States to come up with inventive ways 
to insure their population while safeguarding their access to 
quality insurance. Section 1332 of the Affordable Care Act 
explicitly authorizes the Department of Health and Human 
Services and the Treasury Department to waive certain ACA 
coverage requirements it has written into law.
    To be clear, I did not vote for this law, nor did I receive 
positive feedback from my constituents about the law's 
implementation.
    However, States like Alaska have had success with these 
waivers, which gives States room to repair their markets that 
have been damaged by the Affordable Care Act.
    This hearing is another attempt to distract from the 
Democratic Party's agenda to establish Government-run, single-
payer healthcare. Last week it was said that there are other 
committees in the House that are holding hearings and drafting 
legislation to establish such a plan.
    On February 7th, the magazine Modern Healthcare published 
an article that says a draft version of the House Democrats' 
upcoming Medicare-for-all bill proposes a national system that 
would prepay hospitals with lump sums while keeping fee-for-
service models for individual physicians.
    This news outlet obtained a 127-page draft that was dated 
January 14th, but I have yet to see such a draft. It is 
concerning that the media knows more than the members of this 
subcommittee about the details of this proposal.
    Based on what I have read about the supposed draft, I am 
concerned. I will tell you, as a physician I know that the 
critical doctor-patient relationship is threatened, and I do 
not believe that the Government should hinder a doctor's 
ability to act in the best interest of his or her patient.
    According to the Modern Healthcare article, this proposal 
would implement a global budget and, once that is set, 
hospitals and institutions would need to stick to it for all 
outpatient and inpatient treatment.
    So that is what is truly concerning about this. What 
happens if the budget runs out? Are patients told, well, we are 
sorry we are out of money--maybe you could try this again next 
year.
    This is a recipe for waiting lines. This is a recipe for 
rationing care, and the sooner people understand that the 
better. Meanwhile, there is a greater percentage of Americans 
in employer health coverage than at any time since the year 
2000.
    The number of Americans with employer-sponsored health 
coverage has increased by at least 2.5 million and probably 
much more than that since President Trump took office. Where 
are the CBO coverage figures on the expansion of employer-
sponsored health plans because more people are working now than 
there were before the President took the oath?
    The President's Council of Economic Advisors projects that 
the administration's recent actions will create $453 billion in 
net benefits for consumers and taxpayers over the next 10 
years.
    Again, as a holder of one of the so-called junk policies, I 
had a health savings account before the previous administration 
told me I didn't know what I was doing and couldn't manage it 
and took it away from me.
    I welcome the fact that the administration has provided 
this flexibility, and I will yield back my time.
    [The prepared statement of Mr. Burgess follows:]

             Prepared statement of Hon. Michael C. Burgess

    Thank you, Chairwoman Eshoo. Today, we have been convened 
once again to discuss issues that will not improve the 
affordability of health insurance for Americans. Unsustainably 
high premiums and issues related to silver loading are 
increasingly becoming the reality for folks that rely upon 
individual market insurance, yet the bills before us today will 
not make a marked increase in the availability of reasonably 
priced plans. I am encouraged to see that we are at least 
discussing some legislative ideas today, unlike last week's 
hearing, which nearly all of the witnesses agreed was an 
unnecessary exercise.
    Once again, I would like to make it clear that there is 
vast, bipartisan support for protecting coverage for 
individuals with preexisting conditions. Many of us on our side 
of the dais have experience with preexisting conditions in our 
own families, or providing insurance for the employees of their 
businesses.
    The constituents in my district are struggling to afford 
their health insurance, and I am sure that my district is not 
the only one suffering from sky-high premiums and deductibles. 
What good is healthcare insurance if you are afraid to use it 
because you can't afford your deductible? This is an issue that 
I would like to see us tackle, and I am disappointed that none 
of the bills before us today will move that ball down the 
field.
    What I find most troubling about today's hearing is that 
our Democratic colleagues are questioning the flexibility that 
they put in their own law. Section 1332 of the Affordable Care 
Act provided States with the opportunity to apply for State 
Innovation Waivers. These waivers allow States to come up with 
inventive ways to insure their populations while safeguarding 
their access to quality insurance.
    Section 1332 of the ACA's text explicitly authorizes the 
Department of Health and Human Services and the Treasury 
Department to waive certain ACA coverage requirements. This is 
written into law. I did not vote for the law, nor did I receive 
positive feedback from my constituents about the law's 
implementation; however, States like Alaska have had success 
with these waivers, which give States room to repair their 
markets that have been damaged by the Affordable Care Act.
    This hearing is another attempt to distract from the 
Democratic Party's agenda to establish Government-run, single-
payer healthcare. As I said last week, there are other 
committees in the House that are holding hearings and drafting 
legislation to establish such a plan. On February 7th, Modern 
Healthcare published an article that says ``A draft version of 
the House Democrats' upcoming Medicare for All bill proposes a 
national system that would prepay hospitals with lump sums 
while keeping a fee-for-service model for individual 
physicians.''
    The news outlet obtained a 127-page draft that was dated 
January 14th, but I have yet to see such a draft. It is 
concerning that the media knows more than the members of this 
committee about the details of this proposal. Based on what I 
have read about this supposed draft, I am concerned. As a 
physician, I know howcritical the doctor-patient relationship 
is, and I do not believe that the Government should hinder a 
doctor's ability to act in the best interest of his or her 
patient. According to the Modern Healthcare article, Ms. 
Jayapal's proposal would implement a global budget and once 
that is set ``hospitals and institutions would need to stick to 
it for all outpatient and inpatient treatment.'' That is what 
terrifies me. What happens if the budget runs out? Are patients 
told, ``Sorry, we ran out of money, try again next year?''
    Meanwhile, there is a greater percentage of Americans in 
employer health coverage than at any time since 2000. The 
number of Americans with employer health coverage has increased 
by more than 2.5 million since President Trump took office. 
Additionally, the President's Council of Economic Advisers 
project that the administration's recent actions will create 
$453 billion in net benefits for consumers and taxpayers over 
10 years.
    Again, while I appreciate the effort to consider 
legislation today, I believe that the bills before us do not 
actually address the root of the problems in our healthcare 
system today. I yield back.

    Ms. Eshoo. I thank the ranking member.
    Just something for the record to the ranking member: I 
don't agree with your characterization of the last hearing that 
we had. Everyone does not agree with your characterization. I 
think your side does, but our side doesn't.
    With that, I would now like to recognize the chairman of 
the full committee, Mr. Pallone.

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

    Mr. Pallone. Thank you, Madam Chairwoman.
    Today, this committee begins to fulfill the promise we made 
to reverse the repeated sabotage of our Nation's healthcare 
system by the Trump administration, in addition to make 
healthcare more affordable and to protect the more than 133 
million Americans with preexisting conditions.
    We will be discussing four bills that will make a real 
difference in people's lives. The first bill, introduced by Ms. 
Castor, would reverse the Trump administration's regulation to 
expand junk insurance plans known as short-term limited 
duration health insurance.
    The Trump administration expanded these junk plans from the 
current 3-month term and made these plans available for up to 3 
years. These junk plans are exactly that: junk.
    They discriminate against people with preexisting 
conditions. They set higher premiums for people based on age, 
gender, and health status. They deny access to basic benefits 
like prescription drugs, maternity care, and mental health and 
substance abuse treatment, and they set arbitrary dollar limits 
for healthcare services, leading to huge surprise bills for 
consumers.
    Expanding these junk plans also makes health insurance more 
expensive for people with preexisting conditions by undermining 
the market for comprehensive coverage. The business model of 
the companies that sell these junk plans is to spend as little 
as possible on the health of their enrollees.
    They accomplish this by denying coverage of preexisting 
conditions, kicking people off their health insurance if they 
get sick or seek medical treatment, and pocketing their premium 
dollars as pure profit.
    This profiteering at the expense of people's health is 
simply unacceptable. It is why we passed the Affordable Care 
Act in the first place--to rein in exactly these types of 
abuses by health insurance companies.
    And yet, the Trump administration would give insurance 
companies the green light to once again discriminate against 
people with preexisting conditions.
    Now, Ms. Castor's bill is an important step in 
strengthening the individual market and reversing the harm 
caused by the Trump administration. Ms. Eshoo's bill requires 
these short-term plans to bear a consumer warning.
    As we will hear from our witnesses today, junk plans are 
often deceptively marketed as comprehensive coverage, and 
consumers are not always aware of the fine print. This is about 
a consumer's right to know.
    The bill would require issuers of these plans to display a 
clear, prominent warning advising consumers that the plan does 
not cover preexisting conditions, is temporary, and may not 
cover most healthcare costs, and that coverage can be 
terminated when someone gets sick or seeks medical treatment.
    And I believe this bill works in conjunction with Ms. 
Castor's bill. While consumer disclosure is important, we must 
also prevent all of the problems associated with expanding 
these plans to 3 years.
    We will also be discussing Ms. Kuster's bill to rescind the 
Trump administration's 1332 guidance. Section 1332 of the ACA 
was designed to give States the ability to examine system 
reforms that would improve the well-being of their residents.
    The key word there is improve. States are also required to 
maintain the affordability and comprehensiveness of coverage 
and keep the same number of people insured as under the ACA.
    But the Trump administration's 1332 guidance turns the 
statute on its head, giving States the green light to undermine 
protections for preexisting conditions. The guidance also gives 
States the green light to provide taxpayer subsidies for junk 
plans and reinvigorates ideas from the failed Republican repeal 
bill, such as the flat tax credits that do not keep up with 
rising premiums and shift costs onto working families.
    This guidance is bad for consumers, bad for individuals 
with preexisting conditions, and bad for taxpayers. It exceeds 
the administration's authority and is contrary to congressional 
intent.
    And, finally, we will be discussing Ms. Blunt Rochester's 
bill to restore consumer outreach and enrollment funding that 
is so important to making healthcare more accessible and 
affordable.
    The Trump administration gutted funding for consumer 
outreach and marketing by 90 percent. The administration's 
refusal to invest in outreach and enrollment is making it 
harder for Americans to get healthcare, and this is leading to 
lower enrollment numbers.
    The administration has overseen 3 consecutive years of 
decline in enrollment, and new enrollment is down by 50 
percent. The administration's sabotage has resulted in the 
highest uninsured rate in 4 years.
    So Ms. Blunt Rochester's bill would fund critical outreach 
and enrollment at $100 million, which was the level before 
Trump's sabotage. Her bill also prevents the administration 
from using these funds to promote junk plans, and her bill is 
an important step in lowering healthcare costs and expanding 
coverage to more Americans.
    Now, all four bills we are considering today are important 
first steps in lowering healthcare costs and protecting 
consumers with preexisting conditions, and I commend all four 
Members for their leadership and look forward to continuing to 
work with my colleagues as we make healthcare more affordable 
for all Americans.
    And, again, I want to thank the chairwoman. I think this is 
a very important hearing and this will lead to legislation 
being passed.
    Thank you, Madam Chair.
    [The prepared statement of Mr. Pallone follows:]

             Prepared statement of Hon. Frank Pallone, Jr.

    Today this committee begins to fulfill the promise we made 
to reverse the repeated sabotage of our Nation's healthcare 
system by the Trump administration, to make healthcare more 
affordable, and to protect the more than 133 million Americans 
with preexisting conditions.
    We will be discussing four bills that will make a real 
difference in people's lives. The first bill, introduced by Ms. 
Castor, would reverse the Trump administration's regulation to 
expand junk insurance plans known as short-term limited 
duration health insurance. The Trump administration expanded 
these junk plans from the current 3-month term and made these 
plans available for up to 3 years.
    These junk plans are exactly that: junk. They discriminate 
against people with preexisting conditions. They set higher 
premiums for people based on age, gender, and health status. 
They deny access to basic benefits like prescription drugs, 
maternity care, and mental health and substance abuse 
treatment. And they set arbitrary dollar limits for healthcare 
services, leading to huge surprise bills for consumers. 
Expanding these junk plans also makes health insurance more 
expensive for people with preexisting conditions, by 
undermining the market for comprehensive coverage.
    The business model of the companies that sell these junk 
plans is to spend as little as possible on the health of their 
enrollees. They accomplish this by denying coverage of 
preexisting conditions, kicking people off their health 
insurance if they get sick or seek medical treatment, and 
pocketing their premium dollars as pure profit. This 
profiteering at the expense of peoples' health is unacceptable. 
It is why we passed the Affordable Care Act in the first place, 
to rein in exactly these types of abuses by health insurance 
companies. And yet the Trump administration would give 
insurance companies the green light to once again discriminate 
against people with preexisting conditions.
    Ms. Castor's bill is an important step in strengthening the 
individual market and reversing the harm caused by the Trump 
administration.
    Ms. Eshoo's bill requires these short-term plans to bear a 
consumer warning. As we will hear from our witnesses today, 
junk plans are often deceptively marketed as comprehensive 
coverage, and consumers are not always aware of the fine print. 
This is about a consumer's right to know. The bill would 
require issuers of these plans to display a clear, prominent 
warning, advising consumers that the plan does not cover 
preexisting conditions, is temporary and may not cover most 
healthcare costs, and that coverage can be terminated when 
someone gets sick or seeks medical treatment.
    I believe this bill works in conjunction with Ms. Castor's 
bill. While consumer disclosure is important, we must also 
prevent all of the problems associated with expanding these 
plans to 3 years.
    We will also be discussing Ms. Kuster's bill to rescind the 
Trump administration's 1332 guidance. Section 1332 of the ACA 
was designed to give States the ability to examine system 
reforms that would improve the well-being of their residents. 
The key word there is improve. States are also required to 
maintain the affordability and the comprehensiveness of 
coverage, and keep the same number of people insured as under 
the ACA. The Trump administration's 1332 guidance turns the 
statute on its head, giving States the green light to undermine 
protections for preexisting conditions. The guidance also gives 
States the green light to provide taxpayer subsidies for junk 
plans, and reinvigorates ideas from the failed Republican 
repeal bill, such as flat tax credits that do not keep up with 
rising premiums and shift costs onto working families. This 
guidance is bad for consumers, bad for individuals with 
preexisting conditions, and bad for taxpayers. It exceeds the 
administration's authority and is contrary to congressional 
intent.
    Finally, we will be discussing Ms. Blunt Rochester's bill 
to restore consumer outreach and enrollment funding that is so 
important to making healthcare more accessible and affordable. 
The Trump administration gutted funding for consumer outreach 
and marketing by 90 percent. The administration's refusal to 
invest in outreach and enrollment is making it harder for 
Americans to get healthcare. This is leading to lower 
enrollment numbers. The administration has overseen 3 
consecutive years of decline in enrollment and new enrollment 
is down by 50 percent. The administration's sabotage efforts 
have resulted in the highest uninsured rate in 4 years. Ms. 
Blunt Rochester's bill would fund critical outreach and 
enrollment at $100 million , which was the level before Trump's 
sabotage. Her bill also prevents the administration from using 
these funds to promote junk plans. Ms. Blunt Rochester's bill 
is an important step in lowering healthcare costs and expanding 
coverage to more Americans.
    All four bills we are considering today are important first 
steps in lowering healthcare costs and protecting consumers 
with preexisting conditions. I commend all four Members for 
their leadership, and look forward to continuing to work with 
my colleagues as we make healthcare more affordable for all 
Americans.
    I yield back.

    Ms. Eshoo. I thank the chairman.
    And now I would like to recognize the distinguished ranking 
member of the full committee, Mr. Walden, my friend.
    Mr. Walden. Good morning, Madam Chair.
    Ms. Eshoo. Good morning.

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

    Mr. Walden. Thank you for having this hearing, and as I 
said in the hearing down below, I know the Dingell family is in 
all of our thoughts and prayers this morning as they cope with 
this terrible loss of our distinguished chairman for whom the 
big hearing room is named, and I know that he taught us all how 
to legislate and despite, as I said downstairs, our best 
attempts to emulate his yes-or-no questioning, nobody else 
pulls it off like John Dingell could pull it off. So he is in 
our thoughts.
    So good morning, and given the title of today's hearing, I 
too am concerned for the second time is as many hearings in 
this subcommittee that we are really not addressing the real 
challenges the consumers are facing, which is the high cost of 
healthcare.
    Madam Chair, I said it last week, I'll say it again. We 
need to work together to help States stabilize health markets 
damaged by the ACA, cut out-of-pocket costs that consumers are 
having to pay with these high deductibles, promote access to 
preventive services, encourage participation in private health 
insurance, and increase the number of options available through 
the market.
    Unfortunately, today's hearing and these bills I don't 
think are adequately addressing any of these goals.
    Why would our Democratic colleagues be opposed to States 
innovating on behalf of their citizens? Why would they be 
opposed to providing patients flexible and affordable insurance 
options that best fit those patients' needs? I just don't think 
it makes sense.
    The administration is allowing 10 million Americans more 
choices and more affordable health insurance options. The 
Democrats' Medicare-for-all proposal would force over 150 
million Americans to lose their employer- or their union-
sponsored health insurance, and I think that is wrong.
    You want to talk about sabotage, that is what we should be 
having a hearing on, is Medicare for all and what is coming. I 
also want to reiterate my call that the Energy and Commerce 
Committee hold hearings on that bill.
    So today, instead of having a constructive, bipartisan 
dialogue about helping States innovate, about providing options 
for patients who are struggling to make ends meet, we are here 
for the second time in as many weeks casting the blame of 
Obamacare's failures on the current President.
    The fact is, we all support protecting people with 
preexisting conditions and we share a desire to stabilize the 
individual health insurance market. Last Congress, I advocated 
for policies that would achieve both of these goals, first 
through the AHCA's Patient and State Stability Fund, and I made 
two more attempts at bipartisan stabilization reforms last 
Congress, working with my colleagues in the Senate.
    Unfortunately, House Democrats repeatedly blocked our 
creative solutions--solutions like improving 1332 waivers to 
better meet States' unique needs and modernize programs to 
stabilize premiums.
    Now, my home State of Oregon, which celebrates its birthday 
tomorrow, we have an active 1332 waiver for a cost-based 
reinsurance program. I supported my home State's application 
and approval. I was the only Republican in our congressional 
delegation.
    Why? Because it represents the very fabric of federalism. 
What works best for Oregon may not work best for California, 
Madam Chair.
    Take Alaska, for example. In studying their individual 
market, they found that a conditions-based reinsurance program 
would better serve their residents. Before they received a 
waiver, 2017 rates were projected to increase 42 percent.
    But after shifting individuals with one of 33 medical 
conditions into a separate pool, premiums for the lowest-cost 
bronze plan fell by an astounding 39 percent. And in Oregon, 
the reinsurance program kept premiums 6 percent below what they 
would have been without it.
    These are real savings for patients in my State. Oregon and 
Alaska--one pretty traditionally blue, the other pretty 
traditionally red--found a way to take advantage of 1332 
waivers to best serve their citizens.
    They are not alone. Today, eight States have active 
waivers: Alaska, Hawaii, Minnesota, Maryland, Maine, New 
Jersey, Oregon, and Wisconsin. Eight diverse and unique States, 
but they have at least one thing in common, Madam Chair, and 
that is each of these eight active waivers were approved under 
the Obama administration's 1332 guidance.
    Yet, today we are here to discuss nullifying the Trump 
administration's 1332 guidance. Why not first observe how 
States react and reform their markets through the new guidance?
    We should understand that better. Perhaps a better use of 
our time would be spent discussing bipartisan solutions to 
reform and improve these waivers. We all want markets that 
work. We do.
    We all want patients to have access to high-quality, 
affordable-priced health coverage. Unfortunately, the 
ironically named Affordable Care Act had made insurance for 
many unaffordable, and I heard it again yesterday from wheat 
growers in my district.
    Together, and with the States as partners, not 
subordinates, we can achieve the shared goals of well-
functioning and stable markets that provide Americans 
affordable healthcare options.
    So one thing is clear: We need to guarantee our healthcare 
system works better for all Americans. That we can agree on, 
and that is why our goal should be to advance solutions to 
protect patients, stabilize healthcare markets, encourage 
greater flexibility for States, and promote policies to help 
Americans get and keep coverage.
    So, Madam Chair, thank you for having the hearing today. We 
look forward to working with you, and I yield back.
    [The prepared statement of Mr. Walden follows:]

                 Prepared statement of Hon. Greg Walden

    Good morning, Madam Chair. Given the title of today's 
hearing, I am concerned that for the second time in as many 
hearings in this subcommittee, we are not addressing the real 
challenges that consumers are facing, which is the high cost of 
healthcare.
    Madam Chair, I said it last week, and I'll say it again: We 
need to work together to help States stabilize health markets 
damaged by the ACA, cut out-of-pocket costs, promote access to 
preventive services, encourage participation in private health 
insurance, and increase the number of options available through 
the market.
    Unfortunately, today's hearing, and these bills are not 
adequately addressing these goals. Why would our Democratic 
colleagues be opposed to States innovating on behalf of their 
citizens? Why would they be opposed to providing patients 
flexible and affordable insurance options that best fit their 
needs? This just doesn't make sense.
    The administration is allowing 10 million Americans more 
choices and more affordable health insurance options. The 
Democrats' Medicare for All proposal would force over 150 
million Americans to lose their employer or union sponsored 
health insurance. You want to talk about sabotage, that is what 
we should be having a hearing on. I want to reiterate my call 
that Energy and Commerce hold hearings on this issue.
    So today, instead of having a constructive, bipartisan 
dialogue about helping States innovate and providing options 
for patients who are struggling to make ends meet, we're here 
for the second time in as many weeks casting the blame of 
Obamacare's failures on our President.
    The fact is we all support protecting people with 
preexisting conditions and we share a desire to stabilize the 
individual health insurance market.
    Last Congress, I advocated for policies that would achieve 
this goal. First, through the ACA's Patient and State Stability 
Fund. And I made two more attempts at bipartisan stabilization 
reforms last Congress, working with our colleagues in the 
Senate. Unfortunately, House Democrats repeatedly blocked our 
creative solutions. Solutions like improving 1332 waivers to 
better meet States' unique needs and modernize programs to 
stabilize premiums.
    In Oregon, we have an active 1332 waiver for a cost-based 
reinsurance program. I supported my home State's application 
and approval as the only Republican in our congressional 
delegation. Why? Because it represents the very fabric of 
federalism. What works best for Oregon may not work best for 
California, Madam Chair.
    Take Alaska, for example. In studying their individual 
market, they found that a conditions-based reinsurance program 
would better serve their residents. Before they received a 
waiver, 2017 rates were projected to increase 42 percent. But 
after shifting individuals with one of 33 medical conditions 
into a separate pool, premiums for the lowest-cost bronze plan 
fell by an astounding 39 percent. And in Oregon, the 
reinsurance program kept premiums six percent below what they 
would have been without it. Those are real savings for patients 
in my State.
    Oregon and Alaska--one State traditionally blue, the other 
traditionally red--found a way to take advantage of 1332 
waivers to best serve their citizens.
    And they're not alone. To date, 8 States have active 
waivers: Alaska, Hawaii, Minnesota, Maryland, Maine, New 
Jersey, Oregon, and Wisconsin. Eight diverse and unique States. 
But they have at least one thing in common, Madam Chair. Each 
of these eight active waivers were approved under the Obama 
administration's 1332 guidance. Yet, today, we're here to 
discuss nullifying the Trump administration's 1332 guidance. 
Why not first observe how States react and reform their markets 
through the new guidance? Perhaps a better use of our time 
would be spent discussing bipartisan solutions to reform and 
improve these waivers.
    We all want a market that works. We all want patients to 
have access to high-quality, affordably priced health coverage. 
Unfortunately, the ironically named Affordable Care Act has 
made insurance unaffordable for many Americans seeking 
individual insurance coverage. Together and with the States as 
partners, not subordinates, we can achieve the shared goals of 
well-functioning and stable market places that provide 
Americans affordable health insurance options.
    One thing is clear: We need to guarantee our healthcare 
system works better for all Americans. That's why our goal 
should be to advance solutions to protect patients, stabilize 
healthcare markets, encourage greater flexibility for States, 
and promote policies to help Americans get--and keep--coverage.

    Ms. Eshoo. And I thank the gentleman.
    I now would like to welcome our witnesses for today's 
hearing. First, Ms. Katie Keith, the associate research 
professor and adjunct professor of law at Georgetown 
University. Thank you for joining us.
    Ms. Jessica Altman, commissioner, Pennsylvania Insurance 
Department. Very important job. Welcome to you.
    And to Ms. Grace-Marie Turner, president of the Galen 
Institute, we thank you for accepting our invitation to join us 
today, and we look forward to your testimony.
    And I am going to recognize each witness for 5 minutes to 
provide your opening statement, and just a little housekeeping. 
Our lighting system--what is in front of you is a series of 
lights. The light will initially be green, and then it will 
turn yellow when you have 1 minute to go, kind of like the 
League of Women Voters debates that we have all been in, right, 
with the lighting system. And we don't have a bell--we have a 
lighting system--and after that you will have 1 minute 
remaining, and at that point the light will turn red when your 
time expires--not when you expire, but when your time expires.
    So let me begin with Ms. Katie Keith. You are recognized 
for 5 minutes, and welcome again and thank you to you.

  STATEMENTS OF KATIE KEITH, ASSOCIATE RESEARCH PROFESSOR AND 
  ADJUNCT PROFESSOR OF LAW, GEORGETOWN UNIVERSITY; JESSICA K. 
ALTMAN, COMMISSIONER, PENNSYLVANIA INSURANCE DEPARTMENT; GRACE-
            MARIE TURNER, PRESIDENT, GALEN INSTITUTE

                    STATEMENT OF KATIE KEITH

    Ms. Keith. Thank you very much, Chairwoman Eshoo, Ranking 
Member Burgess, and members of the committee.
    My name is Katie Keith, and I am a faculty member at 
Georgetown University, where I study private health insurance. 
I am also the author of the following: The ACA Blog Series for 
the Health Policy Journal of Health Affairs, where I am 
responsible for tracking and chronicling implementation of the 
Affordable Care Act, including many of the changes that the 
Trump administration has made in recent years.
    My testimony today will focus on just three of those 
changes, although there have been many more than that, as you 
all know. The actions I will discuss today undermine the ACA 
risk pools, leave consumers who become sick without access to 
healthcare, and drive up premiums for people with preexisting 
conditions.
    I will begin with short-term plans. Last August, three 
departments issues a new regulation allowing short-term plans 
to be sold for up to 12 months and extended for up to 3 years. 
Short-term plans do not have to comply with the Affordable Care 
Act, and they are allowed to discriminate against patients with 
preexisting conditions.
    These plans are medically underwritten and do not have to 
cover entire categories of benefits. A recent study showed that 
43 percent of these plans do not cover mental health services. 
Seventy-one percent do not cover prescription drugs.
    In the midst of an opioid crisis, 62 percent do not cover 
substance use services. And none of these plans covered 
maternity care.
    Some had out-of-pocket maximums as high as $30,000 and 
lifetime limits on care. These plans, which are highly 
profitable for the insurers that sell them, tend to only work 
for those who are healthy.
    The harm to consumers from this new rule is twofold. First, 
these policies pose a significant risk to the individuals who 
enroll in them, only to find that the care that they need is 
not covered when they become sick.
    Many newspapers are filled with stories these days of 
consumers who have enrolled in these plans only to wind up 
facing hundreds of thousands of dollars in unpaid medical 
bills.
    Second, these policies drive up premiums for those with 
preexisting conditions, particularly for middle-income families 
who do not qualify for ACA subsidies.
    Moving on to Section 1332, the Trump administration 
recently issued guidance that encourages States to offer 
skimpier coverage, including short-term plans. The new guidance 
relaxes the previous interpretation of what we refer to as the 
statutory guardrails under Section 1332.
    This could result in State efforts to advance less 
comprehensive coverage and drive up premiums for people with 
preexisting conditions. It is worth noting that there have been 
questions raised about the legality of both the short-term plan 
rule and the Section 1332 guidance.
    The short-term plan rule has already been challenged in 
court and a lawsuit brought by consumer and patient advocates, 
including the Little Lobbyists, who I believe testified before 
this subcommittee last week.
    These patient advocates have sued over the rule because of 
its impact on people living with HIV, people with mental health 
issues, and people with other chronic conditions and 
disabilities.
    The 1332 guidance has not yet been challenged, but approval 
of a waiver under that guidance would likely be challenged 
quickly.
    Finally, the Trump administration has made dramatic cuts to 
funding for ACA marketing and outreach. This includes immediate 
cuts during the final week of the 2017 open enrollment period 
followed by a 90 percent reduction for 2018 from $100 million 
to $10 million.
    Those cuts were maintained by CMS for 2019, and CMS has 
reduced funding for the navigator program by 84 percent. These 
funding decisions were made even though outreach and marketing 
helps bring in younger, healthier consumers, which in turn 
helps keep premiums stable.
    At the same time, awareness of the marketplaces and the 
financial assistance that many people are eligible for remains 
low. We are finding that enrollment of those key features is 
still low even after many years. That is particularly true 
among the uninsured.
    We are also seeing that enrollment of new consumers, who 
tend to be younger and healthier, is down. Enrollment of new 
consumers has dropped by about 50 percent since 2016 alone.
    According to one estimate, there are at least 2.3 million 
fewer new enrollees that would otherwise be in the marketplace 
due solely to cuts to outreach and advertising.
    In closing, most people are healthy most of the time. But 
everyone eventually gets sick and needs access to comprehensive 
health insurance. The actions discussed today do nothing to 
advance high-quality affordable health insurance.
    Instead, these actions divide the risk pool between the 
healthy and sick and increase premiums for people with 
preexisting conditions.
    Thank you again for inviting me. It is an honor and 
privilege to be here, and I look forward to your questions.
    [The prepared statement of Ms. Keith follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you, Professor Keith.
    I now would like to recognize Ms. Jessica Altman, again, 
the commissioner from Pennsylvania Insurance Department. You 
have--you are recognized to present your testimony to us.

                 STATEMENT OF JESSICA K. ALTMAN

    Ms. Altman. Thank you, and good morning, Chairwoman Eshoo, 
Ranking Member Burgess, and members of the Health Subcommittee.
    As mentioned, my name is Jessica Altman, and I am 
privileged to serve as insurance commissioner for the 
Commonwealth of Pennsylvania.
    I want to thank you for convening today's important 
discussion regarding short-term plans and for the opportunity 
to voice concerns about the potential harms for consumers and 
for the health insurance market, more broadly.
    As the name says, short-term plans were created to fill 
brief gaps in coverage. The plans generally have lower premiums 
but significant coverage limitations, as the protections of the 
Affordable Care Act, which I will call ACA, do not apply.
    By recently extending the duration and renewability of 
short-term plans, the Federal administration is seeking to make 
short-term plans look and act like a viable alternative to 
comprehensive major medical insurance without extending the 
protections of the ACA.
    Today, I will highlight my four primary concerns 
illustrated by actual consumer complaints and conclude by 
sharing with you a little bit about my department's approach to 
short-term plans. Please reference my testimony for a more 
thorough perspective.
    The first primary concern with the plans that I raise today 
is one Katie covered well. They have very limited benefits and 
consumer protections. Short-term plans do not have to cover 
essential health benefits, and in Philadelphia the same study 
Katie mentioned found that less than 60 percent covered mental 
health, only one-third in the midst of the opioid crisis that 
is hitting Pennsylvania very hard covered substance use 
disorder treatment or prescription drugs, and none covered 
maternity care.
    Short-term plans can impose lifetime and annual limits on 
coverage, do not include appeal rights, and are not subject to 
a medical loss ratio requirement that sets a floor for the 
percent of premium spent on actual medical care.
    Instead, for the two short-term insurers with 80 percent 
market share, less than 50 cents of every dollar collected in 
premiums was spent on actual medical care.
    Recently, my department worked with a woman who fainted at 
work and hit her head--something that could happen to any of 
us--and it resulted in emergency transport to the hospital.
    The short-term plan paid $200 for the ambulance, leaving 
the patient with $1,250. At the ER, the plan provided $250 
while the bill was over $2,400. Then she was admitted to the 
ICU, where the benefit was, again, $1,250 for a bill that was 
$9,300.
    Finally, the plan paid another $1,250 for an outpatient 
test while the bill was $4,900. After considering cost sharing, 
the plan covered just over $1,300, the consumer $16,000.
    My second concern is the lack of consumer disclosure 
regarding benefits and benefit exclusions. The plans are sold 
without a consumer's access to provider directories, 
formularies, sample coverage documents, summaries of benefits 
and coverage, and a uniform glossary, all of which are required 
to be provided with Affordable Care Act plans.
    The lack of consumer disclosure is so troubling in the 
short-term market that we are creating our own consumer 
awareness campaign to try to cut through the noise of 
robocalls, well-placed online advertising, misleading website 
URLs, and a lot of fine print that are currently bombarding 
consumers across the country to purchase these plans.
    A recent study found that consumers shopping online for 
health insurance, including those using search terms like 
``Obamacare'' or ``Enroll ACA,'' will most often be directed to 
websites and brokers selling short-term plans or other non-ACA-
compliant coverage, and this is, of course, exacerbated by the 
lack of comprehensive ACA information, outreach, and 
enrollment.
    The third issue is claims practices. I am most concerned by 
the use of a practice called postclaims underwriting, which 
often results in recision or denial of coverage.
    As short-term plans often exclude coverage for preexisting 
conditions, policy holders who get sick may be investigated by 
the insurer to determine whether a recently diagnosed condition 
could be considered preexisting and therefore excluded.
    We are currently working with a consumer who purchased a 
short-term plan and was diagnosed with heart failure. After he 
filed a claim for services, he was denied coverage based on the 
preexisting condition. But he had never been diagnosed, never 
sought, and never received care for his heart.
    But instead, the insurer indicated that the claim 
manifested in such a way that an ordinary, prudent individual 
would have sought medical treatment and advice in the year 
prior to purchasing the plan.
    Through the course of working to resolve consumer 
complaints, the claims practices of short-term plans have 
repeatedly demonstrated an inclination to deny coverage rather 
than provide it.
    Lastly--and I see my time ticking down so I will be quick--
encouraging the proliferation of short-term plans has the 
potential to destabilize and drive up costs for the ACA market, 
especially for those with preexisting conditions, by segmenting 
healthier people out of the market.
    The Federal Government does also continue to push for the 
proliferation of short-term plans through regulatory actions 
such as the 1332 guidance, and a waiver like that under the new 
guidance would not be one that Pennsylvania would pursue.
    Thank you. I will shorten my remarks and welcome any of 
your questions.
    [The prepared statement of Ms. Altman follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you very much.
    It is my understanding that Ms. Altman was an intern with 
Mr. Waxman of the Energy and Commerce Committee. So 
congratulations on your climb.
    Ms. Altman. Thank you.
    Ms. Eshoo. And your great foundational learning here at our 
committee and, of course, thank you for your testimony.
    Now I would like to recognize Ms. Grace-Marie Turner. You 
are recognized for 5 minutes, and welcome, and we look forward 
to hearing your testimony.

                STATEMENT OF GRACE-MARIE TURNER

    Ms. Turner. Thank you, Chairwoman Eshoo. Thank you, Ranking 
Minority Member Burgess, and members of the committee for 
inviting me to testify today.
    I am with the Galen Institute, a nonprofit organization 
focusing on ways to ensure access to affordable health coverage 
for all Americans. Enrollment in the individual health 
insurance market is falling. In 2018, 3 million fewer people 
had individual coverage than in 2015. The primary concern is 
the cost of coverage.
    The administration's new 1332 guidance is designed to allow 
States to repurpose some ACA money and improve their markets to 
help those shut out because of high costs. Eight States have so 
far created programs to separately subsidize patients with the 
highest healthcare costs, lowering premiums and leading to 
increased enrollment.
    In addition to Alaska and Oregon, Maryland is seeing huge 
price drops of 43 percent net this year. Putting the sickest 
pool of people in the same pool with others, as the ACA does, 
means premiums are higher, often much higher for those without 
subsidies.
    Virginia State Senator Bryce Reeves told us of an email he 
received from a constituent in Fredericksburg who makes a good 
living and tried to provide for his family but said his 
insurance premiums now cost $4,000 a month. ``That is more than 
my mortgage,'' he told Senator Reeves, asking what he's 
supposed to do.
    Cost relief is essential. The Trump administration last 
year did finalize rules to expand access to temporary bridge 
policies, short-term limited duration plans. These policies 
help people with gaps in employment, early retirees waiting to 
qualify for Medicare, young people and the gig economy, people 
returning to school, and entrepreneurs starting new businesses.
    These short-term plans typically cost less than half of the 
cost of ACA plans. Under the Obama administration's previous 
rule, people would lose their short-term plans after just 3 
months even if they acquired a medical condition within that 
period.
    By extending the contract period to a year, people can be 
protected and have coverage until the next ACA open enrollment 
period. While consumers do need to be informed about these 
plans, for many they may mean the difference between having the 
security of coverage for a major medical event and being 
uninsured.
    The Council of Economic Advisors issued a report just last 
week estimating that these policies produce an economic benefit 
of $80 billion over the next 10 years.
    I would like to turn to preexisting conditions. There is a 
strong bipartisan support for these protections, as Mr. Walden 
and Dr. Burgess both have ensured. The ACA assures that people 
cannot be turned down or have their policies canceled because 
of their health status, and these protections remain in place.
    People with chronic conditions are vulnerable and do need 
protection. But a woman with a serious health problem provided 
us with a testimonial about why more changes are needed.
    Janet reports that in 1999 she was diagnosed with hepatitis 
C. She lives in Colorado and applied for coverage in the 
State's high-risk pool and was accepted. Her premiums in 2010 
were $275 a month. Then her liver failed. She needed a 
transplant. The $600,000 bill was covered 100 percent with 
$2,500 out of pocket.
    Colorado's high-risk pool, however, was closed when the ACA 
took effect. So she moved into the marketplace. Her premiums 
rose to $450, and by 2018 they were $1,100 a month with a 
deductible of $6,300.
    She said those of us who are self-employed but make more 
than the threshold of tax credits wind up footing the whole 
bill ourselves.
    Finally, regarding navigators--legislation proposed by 
Representative Blunt Rochester would provide $100 million a 
year for the navigator program. But CMS found that, in 2016, 78 
percent of navigators failed to achieve their enrollment goals, 
and navigators enrolled fewer than 1 percent of enrollees while 
spending $62 million that year.
    CMS now funds navigators based upon their ability to meet 
their enrollment goals during the previous year and relies more 
on brokers and insurance agents, who enrolled 42 percent of 
enrollees.
    California spent heavily on marketing last fall to increase 
enrollment in its State exchange, yet it experienced a 24 
percent drop in new enrollees. Marketing doesn't work when the 
main reason that people don't sign up for coverage is because 
of cost.
    I would welcome the opportunity to work with you in 
developing new ways to help lower the cost of health coverage 
while maintaining quality and consumer protections, including 
preexisting condition protections.
    Thank you, Madam Chairman.
    [The prepared statement of Ms. Turner follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you, Ms. Turner, for your testimony, and 
we have now concluded the opening statements. We are going to 
move to Members' questions, and I will start by recognizing 
myself for 5 minutes.
    I have a lot of things in front of me that have been 
suggested that I ask. But after listening to your verbal 
testimony, I want to mix this up a little bit.
    We heard the first two witnesses, Ms. Keith and Ms. Altman, 
talk about the shortcoming of these short-term plans and the 
plan of the administration to stretch them out over 3 years.
    Now, Ms. Turner, you said we have a commitment to 
preexisting conditions in the coverage. Why is it not included 
in these short-term plans?
    I would also like to give 30 seconds to Ms. Keith and Ms. 
Altman to ask any questions that they would like of Ms. Turner 
because there is a difference between your testimony and Ms. 
Turner's.
    But first, can you talk about what--I think the word 
commitment is conflated in its use. There is a difference 
between a commitment to and actually practicing what you say 
you have a commitment to.
    So I don't see these very important insurance reforms that 
we brought about with the ACA and you say that you have a 
commitment to preexisting conditions and the other insurance 
reforms.
    So can you just in a minute or less explain why there is a 
difference between your commitment and what is in these plans?
    Ms. Turner. Short-term plans are really gap coverage. 
People buy them because they can't afford coverage that has all 
of the ACA protections.
    Ms. Eshoo. Let me ask you this: Are you opposed to an 
advisory in plain English on the cover of these policies to 
inform the potential consumer what is not included so that it 
is very clear about what they are buying?
    Ms. Turner. Oh, absolutely. Absolutely. I think consumers 
very, very much need to be informed about their policy.
    Ms. Eshoo. OK. Good. Good.
    All right. Now, Ms. Keith, do you want to ask a question or 
have a comment?
    Ms. Keith. Yes. I don't have a question. Thank you, 
Chairwoman. What I would say is something that did not get 
brought up in my oral statement yet, is that the limitations of 
these plans, there is no magic about why these short-term plans 
are cheaper than ACA plans.
    They are, on average, about 54 percent less expensive. 
There is no secret to that. The reason is because they can 
exclude people with preexisting conditions. That fact alone 
allows them to be 38 percent cheaper than ACA plans.
    When you add in some of the benefit gaps and out-of-pocket 
costs, that is what makes them half the cost of ACA plans. And 
so the idea of giving people coverage, you know, is the product 
worth buying if it doesn't cover anything when you need to use 
it, I think might be the question.
    Ms. Eshoo. Ms. Altman?
    Ms. Altman. I was going to bring up the same study, and to 
put it another way, 70 percent of the price difference between 
short-term plans and traditional ACA plans is due to 
preexisting condition exclusions. The story you told----
    Ms. Eshoo. Can you say that again?
    Ms. Altman. Seventy percent of the difference in price 
between short-term plans and Affordable Care Act coverage is 
due to excluding preexisting conditions.
    You know, the story you told from Colorado was incredibly 
compelling and, to me, it really reinforces why people need 
comprehensive coverage so that you can get coverage for that 
expensive transplant and you can get coverage for your liver 
failure and your hepatitis C.
    You know, my only question is today you talked about how 
the purpose of short-term plans is to fill gaps in coverage and 
that is the intended purpose, and I suppose my question is, If 
it is meant to fill a gap, why would it need to be 3 years?
    Ms. Eshoo. Can you answer that, Ms. Turner?
    Ms. Turner. I think that that is really up to consumers. 
Many of the people who are uninsured now--many of the 3 million 
are uninsured because they simply can't afford coverage.
    State Senator Reeves' constituent desperately wants to 
provide for his family until another option is better. So he 
can't know how long he is going to need to have this 
protection.
    One of the reasons that the new rule extended that coverage 
is because 3 months just is too short a time to give anybody 
the security that they need coverage, and in Colorado Janet is 
actually now in an ACA plan. Her meds are not covered under the 
plan that she is in under the ACA, so she has $19,000 out of 
pocket now.
    Ms. Eshoo. Well, I think--if I might say this, I think it 
is important for consumers to have choice. I am not opposed to 
that.
    What I am worried about is, I found this out in healthcare 
the two basic things. Everyone knows what they pay in a 
premium. Most people don't know what they are buying--what they 
are getting--and this can be a really slippery slope for a lot 
of people and--or maybe for a few that is going to make them, 
especially if they are healthy and they are young, they are 
betting on their immortality and that nothing is ever going to 
happen to them. But it is--there are a lot of questions, so 
thank you.
    My time has certainly expired. I now would like to 
recognize Mr. Griffith for his 5 minutes of questioning.
    Mr. Griffith. Thank you, ma'am. Right here beside you.
    Ms. Eshoo. Yes. Right. Sitting right next to me.
    Mr. Griffith. I am glad to hear, Madam Chair, that you are 
for consumers having choices. I think that is very important. I 
also look forward to working with you on your bill--1147, I 
believe--that deals with making sure that consumers have the 
information that they need.
    I would say, as we work forward on that piece of 
legislation, it looks to me right now that it includes such a 
huge volume that many consumers probably wouldn't read it.
    So what we have to do is try to figure out where the sweet 
spot is, and I look forward to working with you on that because 
I do think it is important that consumers know, if they are 
buying an alternative product, that, A, it is an alternative 
product and, B, that it doesn't cover everything but here is 
what it does cover, because, as you pointed out, Ms. Turner, 
many folks are looking for something because they cannot afford 
the plans that fall under the ACA with all the mandates that 
are there.
    Could you repeat the quote from Senator Bryce Reeves? Since 
I am from Virginia, he is--while his district is about 4 hours 
away, I do think it is instructive to hear from him again. 
Could you repeat that for us?
    Ms. Turner. Yes. Senator Reeves was at an event--speaking 
at an event. He had just gotten an email from a constituent 
saying that he had just received his healthcare bill to provide 
for his family, and the premium was $4,000 a month, which he 
said, ``That is more than my mortgage. What am I supposed to 
do?''
    Mr. Griffith. Yes. We hear stories similar to that 4 hours 
away on the other side of Virginia. I represent the southwest 
portion of the State.
    We hear of a lot of people who can't afford the out-of-
pockets and the deductibles--that that is forcing them to look 
at bankruptcy options--the same complaints we heard before that 
the Affordable Care Act was supposed to fix. Hasn't worked for 
my constituents.
    It, clearly, hasn't worked on the other side of the 
Commonwealth of Virginia. I can't speak to the country as a 
whole. But from anecdotal evidence, it seems that the same is 
out there.
    And as you pointed out in your testimony, this is one of 
the reasons why people are looking at some of these 
alternatives. I think they ought to know what they are getting 
because some people will just buy something because it is 
cheaper. But some people buy something that doesn't cover 
everything because they are desperate. Is that true?
    Ms. Turner. That is true and, unfortunately, in many parts 
of the country and especially Virginia, if you live in one 
county you may not have a choice. This constituent had no other 
choice in Fredericksburg, and so people are looking exactly for 
that--to find other ways they can have health insurance they 
can afford and protect their families but not have it--not be 
able to pay their mortgage.
    Mr. Griffith. It is interesting that you raise that point 
about the choice because, under the ACA--I represent 29 
different geopolitical subdivisions, and for those that aren't 
from Virginia, we have separate cities.
    So some of those are small cities as well as counties. But 
I have 29. A fair number of those have but one provider. They 
just--the market is just not there to support it.
    I am surprised that that is the case in the Fredericksburg 
area, because that is a much bigger area populationwise than 
some of my jurisdiction. But you are saying they have that 
problem too--there was just one provider of insurance?
    Ms. Turner. Yes, and I would hope that Virginia would look 
at the Section 1332 waivers to figure out how they can attract 
more competitors back into the markets.
    Mr. Griffith. And I would hope that that would be the case, 
too. Let us talk about the woman you spoke of, Janet with 
hepatitis C. Could you go over the numbers again of how much 
she was paying under the plan that resembled the--what the 
House was trying to do last year, or 2 years ago now, to do our 
repeal and replace--with the high-risk pool? She was only 
paying $275, I think you said, a month for her insurance?
    Ms. Turner. When she was first diagnosed with hepatitis C 
in 1999, her premiums in the State's high-risk pool were $275 a 
month, and then they rose. When she had to first enroll, that 
high-risk pool was closed so she had----
    Mr. Griffith. So hang on. But before that high-risk pool 
was closed, you indicated, she had to have a liver transplant?
    Ms. Turner. She had to have--her liver failed and she had 
to have a $600,000 liver transplant.
    Mr. Griffith. And that was covered?
    Ms. Turner. Totally covered by the high-risk pool. She had 
$2,500 out of pocket. But then when the ACA took effect, her 
premiums rose to $450, and by 2018 they were $1,100 a month, 
and one of the things I didn't mention in my testimony is that 
none of her antirejection drugs are covered under the new plan. 
So she has to pay out of pocket $19,000 a year.
    Mr. Griffith. Wow. Plus, there was a $6,300 deductible, I 
think you mentioned.
    Ms. Turner. Correct.
    Mr. Griffith. And so what you are saying is that this high-
risk pool, which was an alternative before the ACA, was an 
alternative to the ACA which would work for some people and we 
should probably have more choice. Wouldn't you agree, yes or 
no?
    Ms. Turner. She said--yes--and she said, ``I want the high-
risk pool back.''
    Mr. Griffith. All right. I thank you very much, and I yield 
back.
    Ms. Turner. Thank you, Mr. Griffith.
    Ms. Eshoo. I thank the gentleman.
    I will now recognize the chairman of the full committee, 
Mr. Pallone, for 5 minutes.
    Mr. Pallone. Thank you, Madam Chair, and I just, you know, 
want to reiterate that, of course, in my opinion the problems 
that we face with, you know, more people becoming uninsured and 
increased costs are directly related to the sabotage that the 
Trump administration has implemented, and that is why we are 
having this hearing and trying to deal with these--with the 
sabotage and coming up with legislation that would turn that 
around.
    But I wanted to talk about the 1332--Section 1332 of the 
ACA. Ms. Turner--my questions are of Ms. Keith--but Ms. 
Turner's testimony appears to conflate the October 2018 Trump 
guidance with the Section 1332 reinsurance waivers that were 
approved both under Obama initially and then now under Trump.
    So, Ms. Keith, can you walk us through the Section 1332 
reinsurance waivers? Those are the ones that, you know, were 
initially under Obama, now under Trump. What are they, and how 
long have they been in existence, and have those reinsurance 
been successful in reducing premiums in the States that have--
where they have been enacted? Including my own, I guess.
    Ms. Keith. Thank you, Chairman.
    Yes. So a number of States--seven of the eight States with 
an approved Section 1332 waiver now have done that for a State-
based reinsurance program. I think this is evidence that 
Section 1332 as is, is working--you know, Congressman Griffith 
mentioned this, Ms. Turner has mentioned this--using those 
Section 1332 waivers that we already have. The Federal 
Government has passed through about--almost $1 billion in 
Federal funds to help States come up with these solutions that 
have brought down premiums, ranging from 7 percent on the low 
end to more than 30 percent at the high end, and more States, I 
would expect, are considering that this year to bring those 
programs to their States as well. There has certainly been 
bipartisan support, as you can tell, from States ranging from 
Wisconsin to Maryland to Oregon to Alaska.
    Mr. Pallone. And I agree with you, and certainly my State 
is an example of what you said. But now I want to turn to the 
Trump administration's recent 1332 guidance, which it issued in 
October of 2018, and these are entirely unrelated to the 
reinsurance waivers you just discussed.
    The Trump administration's recent 1332 guidance creates new 
standards that are wholly inconsistent, in my opinion, with 
congressional intent, and the Trump guidance would allow States 
to increase consumer costs, reduce coverage, and undermine 
protections for people living with preexisting conditions--in 
other words, more Trump sabotage.
    So, Ms. Keith, do you believe that the new Trump changes to 
the guidance are consistent with the law and the clear 
statutory directive that States must provide coverage that is 
as comprehensive and affordable as under the ACA?
    Ms. Keith. Thank you for that question.
    In my opinion, I think the guidance is quite inconsistent 
with Section 1332 itself. Section 1332 absolutely gives States 
the flexibility to be innovative, but it directs them to do so 
in a way that builds upon the ACA and is consistent with the 
goals of the law, which is to improve access to affordable 
quality coverage, not to undermine it. The guidance itself, by 
allowing or at least encouraging States to consider options 
like subsidizing short-term plans, plans that do not cover 
preexisting conditions, as we have discussed, to me flies in 
the face of Section 1332 and what it was designed to allow 
States to do.
    Mr. Pallone. All right, and I just want to have you repeat 
what you said with regard to junk plans specifically. I 
understand that the Trump guidance would allow States to 
redefine what counts as coverage to include junk plans. Is that 
correct?
    Ms. Keith. It would allow--it encourages States to bring 
forth proposals that would allow that, yes.
    Mr. Pallone. And then do you believe--obviously, you have 
said you don't believe that this new definition of coverage is 
consistent with the law, correct?
    Ms. Keith. That is right.
    Mr. Pallone. And then I also understand that the guidance 
allows States to direct the ACA's affordability subsidies 
towards junk plans, so subsidizing junk plans. Do you think 
that is consistent with the law?
    Ms. Keith. I do not. Section 1332 cannot be used to waive 
any and all provisions of the Affordable Care Act. In 
particular, it cannot be used to allow States to waive 
community rating, guaranteed issue, protections for preexisting 
conditions.
    If a State were to try to subsidize plans that did do that, 
I think it would be an end run around Section 1332 itself and 
what the law requires.
    Mr. Pallone. I thank you, and I agree with you. I think 
that the Trump administration's guidance is blatantly unlawful, 
contrary to the plain reading of the statute and wholly 
inconsistent with congressional intent. It is part of the Trump 
administration's ideologically motivated efforts to sabotage 
Americans' healthcare coverage, and I want to commend Ms. 
Kuster for her work on this important legislation to rescind 
this guidance and hope that our Republican colleagues will join 
us in these efforts.
    And I just wanted to say, Madam Chair, you know, most--a 
lot of the sabotage--most of the sabotage that the Trump 
administration is doing, in my opinion, is totally illegal. So 
you might say, well, then why are we trying to move and have 
hearings on legislation if you don't think it is legal to begin 
with?
    Well, I guess that is a good question. But the bottom line 
is that we are going to do it because we've got to make the 
point that, you know, that their interpretation--the Trump 
administration interpretation of the law is to allow all this 
stuff that sabotage the ACA, so we are going to come back and 
say, you know, that is not allowed under the law, but we are 
still going to clarify it by moving forward legislation that 
would make that clear and improve it.
    Thank you.
    Ms. Eshoo. I thank the chairman of the full committee.
    And now I would like to recognize the gentleman from 
Kentucky, Mr. Guthrie, for 5 minutes.
    Mr. Guthrie. Thank you, Madam Chair. I really appreciate it 
and appreciate all of you being here, and I want to start by 
what I heard from Dr. Burgess and echo some of his opening 
remarks on the cost of plans and talk about how it affects 
people--people outside of being subsidized that--just looking 
for alternatives to have some--have coverage because they can't 
afford--you may have all the mandates and all the guaranteed 
issues, but if they can't afford it, they can't afford it.
    And, particularly, I have a constituent named Dustin 
Jones--he is a resident of Glasgow, Kentucky--who has called 
and said he had the coverage that he liked before the 
Affordable Care Act. Now he is going to have to go uninsured 
because he says he is just at the point he can't afford 
insurance anymore.
    And so I will be honest, I have had people stop me and say, 
because of Medicaid expansion in Kentucky, they have had 
coverage they haven't had before. So there are people--
everybody can point to cases such as that.
    But I think all of us have people like Mr. Jones that are 
in that middle-income area that health insurance has just 
become unaffordable because so many of the mandates that are 
there.
    And we want to cover people with preexisting conditions, 
and we need to do it in a way that is affordable. I think Ms. 
Altman said that plans are 70 percent cheaper because they 
don't do preexisting conditions, so I guess there is that 
inverse, it would be 70 percent more expensive because--and 
that is what we wanted to do in the Affordable Care Act, 
replace that we looked at.
    We got highly criticized, but it was examples--I think 
Wisconsin had a highly functioning high-risk pool and people 
said they were better off before where you socialize the cost 
of preexisting conditions across the State instead of just 
people in the individual market, because it puts people like 
Mr. Jones out of being able to afford health insurance.
    And so the--and the bottom line was that everybody was 
covered with preexisting conditions. It was just a way to do it 
that didn't put the burden on just people in the individual 
market. It socialized those costs across the State.
    But, Ms. Turner, in your testimony you mentioned the 
additional consumer protection that the Trump administration 
added for short-term limited duration plans. Just give you an 
open to explain that further, the additional consumer 
protections that the Trump administration added.
    Ms. Turner. You mean in terms of allowing people to keep 
these policies for a longer period of time--that they 
previously, under the Obama administration, were limited to 
just 3 months.
    And for many people who may be retiring at age 63 or 64 and 
they need gap coverage until they qualify for Medicare, people 
who are starting a new company, people between jobs, that just 
wasn't long enough and being able to give them the opportunity 
to purchase these short-term bridge policies was very helpful.
    And I agree that people need to be informed consumers. But 
I think they do understand this is not permanent coverage. This 
is to fill a need in a particular time for an estimated 2 
million people.
    Mr. Guthrie. So it is not only the Trump administration 
giving the patients more healthcare products to choose from, 
they are doing so in a way that has additional consumer 
protections.
    So I just want to--also, Ms. Turner, you mentioned how 
States are working within the 1332 waiver to innovate as 
laboratories of democracy. We have already seen eight States 
get approved under the strict Obama administration guidance.
    Do you anticipate even more innovation as States review and 
reform their markets in compliance with the Trump 
administration policies?
    Ms. Turner. Yes, absolutely, and the States are doing 
everything they can under the ACA to try to provide access for 
people who are shut out of the market.
    These are people in the individual market who generally 
don't qualify for the subsidies under the ACA trying to afford 
health insurance for their family like Senator Reeves' 
constituent in Fredericksburg to try to provide a policy that 
they can afford.
    And there are other provisions that the administration is 
providing as well: the association health plans so small 
companies can aggregate to get some of the benefits and the 
lower costs of larger companies; the new health reimbursement 
arrangement rule that would allow companies to provide a 
stipend to employees that may have the opportunity to get 
coverage outside the market, maybe a spouse's coverage, and be 
able to buy into that policy to get a family plan.
    So they are really looking for ways to give people more 
options and to give States more options to use the existing ACA 
money in a way that works better for their citizens.
    Mr. Guthrie. OK. Thank you very much.
    Just one more example--a person who does transmission work 
on cars--hopefully, you never have to do that, but if you do 
that I--that I use and been to. It is a single-person shop, and 
he runs his own shop and he told me--it was about 6 months 
ago--that he closes from--he doesn't open until, like, 9:00 and 
then he closes from 3:00 to 5:00 and then comes back and does 
an evening, and what he's doing, he is driving a school bus to 
pay for his health insurance.
    And he said by the fact that he went to work for the county 
system driving a school bus, by the time he does all of his 
premiums he really doesn't make any money doing it but he said, 
``But I am making $1,600 a month, because that is what I am 
saving in my health insurance.''
    So there are people really struggling with this, and we 
need to be mindful of the Affordable Care Act didn't solve 
everybody's problem.
    So thank you very much, and I yield back my time.
    Ms. Turner. Thank you, Congressman.
    Ms. Eshoo. I thank the gentleman from Kentucky.
    Now I am pleased to recognize the gentlewoman from 
California, Ms. Matsui.
    Ms. Matsui. Thank you very much, Madam Chair, and I want to 
thank the witnesses for being here today. It has been very 
enlightening and interesting here.
    The topic of this hearing is incredibly important to me and 
my constituents and actually all Americans whose lives have 
been changed by the Affordable Care Act.
    Just last week, this committee heard testimony from 
families whose lives have been fundamentally changed by the 
protections of the ACA, and that brings us to today's 
discussion, and, very sadly, the sabotage of the Trump 
administration disguised in a disingenuous attempt to expand 
coverage is shameful.
    This administration has done nothing to expand coverage. 
Rather, they have undermined the progress made by the ACA, 
leading to further market destabilization and harming patients 
along the way.
    Now, these junk insurance plans sound good. However, they 
discriminate against people with preexisting conditions and set 
higher premiums based on age, gender, and health status.
    Promoting the use of junk insurance plans is particularly 
frustrating when this administration has also slashed outreach 
funding for open enrollment into healthcare marketplaces.
    Expanding junk insurance will undermine the market, taking 
young, healthy individuals out of the risk pool and making 
health insurance less affordable for consumers with preexisting 
conditions.
    The Trump administration has even acknowledged that the new 
rule would raise premiums for ACA-compliant plans and could 
result in adverse selection against individual market risk 
pool.
    Ms. Altman, according to the Kaiser Family Foundation, if 
an individual loses coverage under a short-term policy, then 
they may not be eligible for a special enrollment period under 
the ACA.
    In other words, the individual would experience a lapse in 
coverage. Given this information, I am concerned that these 
junk insurance plans could put many more individuals at risk.
    Could you reiterate to the committee how--before the 
implementation of the ACA--how a lapse in insurance coverage 
impacted your financial situation and physical health?
    Ms. Altman. Certainly. I think before the ACA, lack of 
insurance coverage or lack of comprehensive insurance coverage 
impacted people in the same way that it could today: Their 
inability to seek the care that they need, their inability to 
afford the care that they need, and potentially financial 
devastating debt.
    I think one of the perhaps less talked about benefits of 
the Affordable Care Act has been reductions in Americans going 
into debt due to medical bills and the reductions in 
uncompensated care and the burden that is on the economy and on 
our healthcare system as well.
    Ms. Matsui. Right. Could I just say this too? And I hear 
from my constituents, both patients and physicians, who are 
frustrated they are receiving high unexpected medical bills, 
and part of this is because they are enrolled in a junk 
insurance plan like we are discussing today that have an 
incredibly high deductible.
    A $10,000 deductible doesn't count as real insurance if you 
have to spend $10,000 out of your pocket before your insurance 
kicks in. What does that really buy you, and shouldn't 
consumers fully understand what they are signing up for?
    Now, Ms. Altman, your testimony talking about this--what 
steps does your department take to alert consumers to the fine 
print of these plans?
    Ms. Altman. Thank you for that question.
    One of the greatest challenges with these plans is trying 
to counter all of the noise in the marketplace. A lot of the 
marketing is very aggressive. Some of it is outright untrue, 
and some of it is in a gray area and misleading, at best.
    We have undergone a number of efforts to try and get 
accurate education out in the marketplace, accurate information 
about short-term plans, about the Affordable Care Act, about 
the difference about when to enroll--all of those questions.
    But it is definitely an uphill battle as consumers are 
being bombarded with the marketing that is out there. We are 
now working on our own campaign that will highlight the 
questions consumers should be asking themselves and try to be 
proactive in getting that level of information out in the 
marketplace.
    Ms. Matsui. And shouldn't CMS be a part of this, in 
essence, to educate the public about all the plans, in essence, 
of junk plans included, about what they include or do not 
include?
    And I have just got a short question here. I think it was 
brought up--the extension of a plan to 3 years, it was said, 
actually helps consumers. How could it help consumers if they 
can be kicked off the plan at any time?
    Ms. Keith?
    Ms. Keith. Sure. Thank you for that question. I do think 
that is the right question--how is being in a plan for a longer 
period of time that offers what can sometimes be illusory 
coverage. So the idea that these plans are offering coverage 
but can at any time exclude coverage because of a preexisting 
condition or engage in postclaims underwriting--the idea of 
extending those plans when the coverage may not be there when 
the person really needs it, I wouldn't call that a consumer 
protection.
    Ms. Matsui. OK. Thank you. I have run out of time.
    I yield back.
    Ms. Eshoo. I thank the gentlewoman.
    Now I would like to recognize the gentleman from Illinois, 
Mr. Shimkus, for 5 minutes.
    Mr. Shimkus. Thank you, Madam Chairman.
    When my colleague from California was talking about that 
plan, I thought she was talking about an Obamacare plan.
    In March 26th, 2018, I got this email from Ms. Penny from 
Centralia, who said, ``We are a small company that employs five 
people. We just received our new health insurance premiums for 
2018 with a rate increase of $650 per month''--that was an 
increase of $650 per month--``and a higher deductible ranging 
from $3,200 to $4,000.
    ``Nothing has been done to resolve the health''--and then 
she goes--just complains about being forced to buy an insurance 
product that she can't use.
    And in rural America we heard this quite a bit. Small 
businesses forced to buy insurance they can't use because they 
can't use--it costs so much and then the deductible is so high 
that they're not covered.
    So that is why this is a really important discussion. I am 
also glad finally my colleagues--I was up at a telecom, or down 
at a telecom hearing so I missed some of this debate. But it 
sounds like we are talking about, quote, unquote, ``junk 
plans.'' So let us--what are--what are these junk plans?
    Well, we will see. The Trump administration has permitted 
workers in small businesses to pull together to buy insurance 
known as association health plans. I have always been a 
supporter of that. Farm bureau, manufacturing association, 
chamber of commerce--bigger pools negotiating.
    Obviously, my colleagues call all these junk plans, even 
though most of these so-called junk plans comply with ACA 
mandates. They aren't charging people different premiums based 
upon health conditions, and they are not banning people with 
preexisting conditions from enrolling.
    So, Ms. Turner, do you think labeling association health 
plans as junk is a fair description for coverage that many 
hardworking Americans seek out and choose to buy for their 
family?
    Ms. Turner. I am very supportive of giving small companies 
in particular more options for health insurance, which is what 
association health plans do, and individuals also need other 
options, which is what the short-term limited duration plans 
provide.
    There was a study recently--I think just last week--about 
association health plans, and they were in fact providing 
coverage as comprehensive as larger companies, and they were 
not excluding people with preexisting conditions.
    Mr. Shimkus. I think one of the things that fired us up so 
much about this debate was the debate who is to determine what 
policies we have. When we thought this was going to go to the 
Supreme Court, we thought it would stand on the inability of 
the National Government to tell you what you had to buy.
    In fact, when this was debated here in the halls of 
Congress, that was the arguing point. We said this is not 
constitutional.
    Then the administration fought for constitutionality based 
upon not the right of the individual to make a choice what they 
want to buy, but on the right to tax.
    So that is why it was upheld, not on the individual being 
forced to buy something, especially my constituents were being 
forced to buy something that they can't use, as Ms. Penny has 
highlighted here, and she is trying to provide for her 
employees and she can't do it.
    So the employees across the country are already taking 
advantage of this option to provide more affordable insurance 
to their workers. In fact, 28 AHPs have formed already with 
some showing up to 30 percent savings on premiums.
    The Las Vegas Chamber of Commerce is in the process of 
signing up 500 employees for an AHP, which could save some 
employees more than $2,000 per year.
    Ms. Turner, do you--again, if these plans are junk, why are 
they so attractive to business owners and their employees?
    Ms. Turner. People are just desperate for choices. They 
feel shut out of the market not only because of the premiums 
under the comprehensive coverage under the ACA but also because 
of the deductibles, which can be $10,000 a year in the ACA 
plans.
    And so people are looking for other options--short-term 
limited duration plans or bridge coverage and other ways to get 
economies of scale through association health plans and letting 
States have more power through their 1332 options.
    Mr. Shimkus. Yes, and I will end this. I appreciate it.
    We Republicans believe in markets and competition, not 
centralized control dictates from the National Government 
authority, and that is why we are--I am glad we are having this 
hearing today, and I look forward to more discussions.
    And with that, Madam Chairman, I yield back my time.
    Ms. Eshoo. I thank the gentleman. Just for the record, this 
hearing is not about association health plans. We are talking 
about the short-term, what they cover, what they don't. And so 
I think it would be wise to stay away from conflating things 
and putting words in other people's mouths that they haven't 
uttered.
    Mr. Shimkus. Will the gentlelady--will the gentlelady 
yield----
    Ms. Eshoo. No, I want to move on.
    Mr. Shimkus [continuing]. For discussion?
    Ms. Eshoo. No, because this hearing is on these short-term 
plans, not on association health plans. So I think it is 
important to----
    Mr. Shimkus. So you appreciate association health plans? Is 
that----
    Ms. Eshoo. I Do----
    Mr. Shimkus. OK. Very good.
    Ms. Eshoo [continuing]. Except for what the administration 
is doing to some of them. We can have a hearing on that. But 
today's hearing is not about association health plans.
    I now would like to recognize the gentlewoman from Florida, 
a valuable member of our committee always, Ms. Castor, for 5 
minutes of questioning.
    Ms. Castor. Well, thank you, Madam Chair. Thank you for 
holding this very important hearing on our legislation to 
address the Trump administration's sabotage on affordable 
healthcare for our families back home, including my bill, H.R. 
1010, that will stop the expansion of these junk health 
insurance plans.
    See, working families across America, they remember well 
the attempt by the Trump administration and Republicans in 
Congress to repeal the ACA in its entirety, including the 
protection on preexisting conditions.
    What the Congress--the Republican Congress was not able to 
accomplish, here they are now trying to accomplish through 
administrative rule, and that is where they have now adopted an 
administrative rule that would expand the use of these junk 
insurance plans that do allow discrimination for--if you have a 
preexisting condition like a cancer diagnosis or diabetes or 
asthma or something like that.
    These junk plans also deny basic health benefits. So that 
is why I filed H.R. 1010 along with my colleagues, 
Congresswoman Barragan and other Members, to address these 
plans that really don't protect our neighbors as they should.
    It really is difficult to understand why the administration 
is promoting plans that do not provide adequate coverage. It 
really appears to be a cynical ploy to lure families into these 
plans that were too prevalent before the Affordable Care Act, 
where benefits were excluded and families faced massive 
healthcare bills.
    I am very concerned that the public is being snookered 
here, and Commissioner Altman, I would like to ask you a few 
questions about this--about these junk plans. I understand that 
these plans often impose lifetime and annual limits on care. Is 
that right?
    Ms. Altman. That is correct.
    Ms. Castor. So can you describe what these plans typically 
look like, how they are marketed, what kind of coverage they 
provide?
    Ms. Altman. Sure. I think to the average consumer the plans 
can look like they cover a lot of things. They have coverage 
for hospitalization, coverage for ambulance transport, coverage 
for doctor's visits--some of those things.
    But when you begin to look beneath that, first of all, 
there are many exclusions, both in terms of certain benefit 
categories like mental health and prescription drugs and 
maternity, but also for any care related to a preexisting 
condition, whether determined before the plan was issued or 
after, exclusions for any injury that results from sports 
activities or other risky activities--things like that.
    Then you have cost sharing, high deductibles, copayments, 
coinsurance. Then you have annual limits on coverage--
potentially lifetime limits on coverage--although as a short-
term plan, it is unlikely someone would be able to retain this 
plan for a lifetime.
    And then you get into what they actually cover within those 
categories of benefits. I think the story I shared in my 
testimony is very indicative of the fact that the coverage 
levels are not reflective of the cost of services.
    So a consumer may see it covers $100 or $200 for an 
ambulance ride, and that may sound reasonable to them and, 
like, coverage. But, of course, we know an ambulance ride 
generally costs well over $1,000.
    Ms. Castor. So then they are stuck paying that?
    Ms. Altman. Correct.
    Ms. Castor. Unlike an Affordable Care Act policy. So we 
have heard a lot of discussion about choice here today, and 
choice is important--that under the Affordable Care Act 
individual market policies in your State, I read in the 
testimony you actually have more--had another insurer come into 
the marketplace. Is there adequate choice among those policies 
that are being offered in Pennsylvania right now?
    Ms. Altman. That is correct. We have put in a lot of work 
to get our individual market in a very good place. I approved 
statewide average decreases this year. We have----
    Ms. Castor. Wait. Wait. You have increased competition and 
choice, and Pennsylvania is now lowering costs?
    Ms. Altman. Correct. We have a new entrant. Thirty of 
Pennsylvania's 67 counties had more insurers offering coverage 
this past year compared to the year before, and we reduced our 
single-care counties from 20 to 10 simply by working to make 
the market a place for----
    Ms. Castor. But if we had more junk health plans, it would 
seem that that would be a false choice for folks because they 
would be on the hook for substantial costs. Is that right? Do 
you agree with that?
    Ms. Altman. If they chose that route and, of course, for 
over one in four Pennsylvanians who have preexisting 
conditions, those plans are no choice at all.
    Ms. Castor. And I would like to offer the groups that are 
now endorsing H.R. 1010. If folks are confused by some of the 
debate here today, here are some trusted organizations that now 
support the expansion of junk health plans: American Heart 
Association, American Lung Association, AARP, Cystic Fibrosis 
Foundation, March of Dimes, to name a few.
    Thank you, and I yield back.
    Ms. Eshoo. I thank the gentlewoman. I thank her for the 
legislation that she is offering.
    It is now my pleasure to recognize the ranking member of 
the full committee, Mr. Walden, of Oregon.
    Mr. Walden. Good morning again.
    Ms. Eshoo. Yes.
    Mr. Walden. You must be torn as I am with the other hearing 
going on downstairs. I know your passion for telecommunications 
issues as well.
    Ms. Eshoo. In fact, I am going to ask Ms. Castor to come to 
this chair, take the gavel, and have you proceed.
    Mr. Walden. Perfect. Thank you.
    Thank you, Madam Chair, and I want to thank our witnesses. 
This is a really important issue for all of us to contemplate, 
and I know--I met with some wheat growers from my district 
yesterday, as fate would have it, and guess what issue came up? 
It was high cost of healthcare and health insurance--both the 
cost of individual items in the healthcare continuum, but also 
the health insurance.
    And I am trying to remember--I should have made a note on 
it--but I think one of the growers talked to me about how his 
rates per month had gone from, like, $300 to $600 to $900. Now, 
it is, like, $1,000 a month for him and his wife, and the 
deductible, I am going to say, was somewhere between $6,000 and 
$8,000.
    So to my friend's comment about the consumer picking up the 
difference in charge, there are a lot of consumers now as a 
result of these enormously high deductibles you have to do to 
get a premium you might be able to afford, you are paying it 
out of pocket through your deductible.
    And so I think what I am trying to get at, and Republicans 
are, is how do we have choices out there that fit families that 
they can afford that will actually give them first dollar--not 
first, but an affordable family dollar health insurance and not 
something that amounts to something that is catastrophic.
    I do hope we do hearings on association health plans. I do 
think we have the right to talk about them in the context of 
this hearing, by the way, and I do hope we will eventually hear 
from the majority--Democrats--about a hearing on Medicare for 
all, because we know by the estimates that would cost $3.2 
trillion and do away with the health insurance that 150-plus 
million Americans have through their unions or their employers. 
And with the strength of the economy, more and more people are 
showing up on those plans and probably fewer on the others.
    And maybe, Ms. Turner, you could address this. My 
understanding is, under the Obama administration, there was a 
3-month period for short-term limited duration plans. The Trump 
administration simply said to States, you can go up to 12. But 
States have the right to step in here and regulate as they see 
fit, right? Is that correct?
    Ms. Turner. Yes, absolutely.
    Mr. Walden. And so there are some 33 States that have left 
the door open for this innovation to occur, correct?
    Ms. Turner. Yes.
    Mr. Walden. And so, when you're looking at options people 
can afford that work for them, do these plans that are out 
there, do you think they give them options that work, or not?
    Ms. Turner. Consumers will determine that, and I absolutely 
agree that having State flexibility allows the States to--I 
mean, they are much better, frankly, at regulating local health 
insurance markets in their State than Washington can be and 
really figuring out what other consumers need--more information 
about these plans----
    Mr. Walden. Right.
    Ms. Turner [continuing]. To make sure they are buying 
insurance that works for them and that they are smart, informed 
buyers.
    Mr. Walden. Uh-huh.
    Ms. Altman, I am intrigued that the rates went down in 
Pennsylvania, correct? Is that right? So that is this year? Was 
that for all the plans?
    Ms. Altman. In the individual market.
    Mr. Walden. In the individual market. How much over the 
last five----
    Ms. Altman. But that is the statewide average. Not all of 
the plans were done on their own, but on average, yes.
    Mr. Walden. Yes. Understood. Yes.
    Over the last, say, 5 years, what has happened in terms of 
rates in Pennsylvania in the individual market, on average?
    Ms. Altman. Sure. There is no question that rates have gone 
up in this market. I think there are----
    Mr. Walden. How much?
    Ms. Altman. I don't know off the top of my head the 
increase.
    Mr. Walden. How much did they go up the year before?
    Ms. Altman. So the year before, they went up around 25 to 
30 percent.
    Mr. Walden. And how much did they----
    Ms. Altman. But that is an important year, because they 
should have gone up 6 percent, and in that year the reason they 
did not was because of the decision to cease paying cost-
sharing reductions and uncertainty created by the----
    Mr. Walden. How much did they go up the year before that?
    Ms. Altman. Around I want to say--you are testing my 
memory--about 15 percent and about 8 the year before that.
    Mr. Walden. So 8, 15, 20, what?
    Ms. Altman. And then at 20----
    Mr. Walden. Twenty.
    Ms. Altman [continuing]. And then minus two.
    Mr. Walden. And minus two. So they went down, but they went 
down 2 percent after they had gone up. I am trying to remember 
that first year with the cost-sharing deal. Twenty-five percent 
they went up?
    Ms. Altman. Sure. It should have been 15.
    Mr. Walden. Fifteen and 8. I am a journalism major, so I 
will let somebody else do the math. But the long and the short 
of it is, consumers didn't get a $2,500-per-year reduction in 
their premiums along the way, right?
    Ms. Altman. Well, of course, 80 percent of consumers in 
that market received financial assistance that largely shields 
them from those----
    Mr. Walden. Correct. And so my wheat grower friends that 
aren't eligible for that are small entrepreneurs. They have 
gotten socked with rate increases. They don't get the 
subsidies. They are the kind of working middle-class folks that 
are just off the subsidy side because they are just at that 
realm.
    I had a town hall 1, 2 years ago in Arlington, Oregon, and 
actually we had this debate there, and this farmer got up and 
talked about what his family had faced, and this person who was 
very much in support of the ACA--Obamacare--went up to him 
afterwards and said, ``I didn't know people like you existed.'' 
He was very serious about it.
    So we have this gap out there that some of us are trying to 
figure out a way to fill, and that is what Republicans are 
talking about--how do we fill that gap for those people that 
don't get the subsidies you get on the exchange if you are the 
right income but you are still left out with a high deductible 
and premiums off the charts?
    My time has expired, Madam Chair? Thank you for your 
indulgence.
    Ms. Castor [presiding]. Thank you.
    Mr. Schrader is recognized for 5 minutes.
    Mr. Schrader. Thank you, Madam Chair, and I appreciate the 
previous gentleman's discussion--the ranking member of the 
committee--and there has been a lot of discussion about the 
cost of the premiums, the deductibles, in the individual 
marketplace.
    I think it is important for America and a lot of people 
here to understand that that is only one facet of the 
Affordable Care Act, and the rest of the Affordable Care Act, 
ostensibly, is working very well.
    We heard last Congress of the repeal-and-replace debate 
that, frankly, a lot of red State people were very pleased that 
the Medicaid situation changed dramatically for them.
    Many millions of Americans had healthcare for the first 
time. So I guess I would like to look to my colleagues and say, 
``Hey, let us work on the individual marketplace.'' I am fine 
with that, and I think there is an opportunity for us to work 
together and maybe adjust the cost-sharing stuff, the 
reinsurance issues or risk pools or--and maybe expand the 1332 
waivers, but under constraints.
    You know, the people forget--I come from Oregon--people 
forget that the goal of healthcare is to provide better health. 
It is not to get insurance. And, ostensibly, getting better 
health means you don't have to read the fine print all the 
time.
    There is some commonality in these plans that are out 
there, and you have the opportunity to buy a product that 
covers what people would call essential health benefits--that 
overall that someone had a mother, someone has got a daughter 
out there. I mean, you know, being a woman and having maternity 
care should be an option.
    I mean, everyone benefits from that over the long haul, and 
the goal of insurance--to provide healthcare--is to prevent 
people from getting too sick to begin with, and that has gotten 
lost, I think, in a lot of the debate.
    So I am hoping that we actually get to that.
    Ms. Turner, real quickly, with these short-term plans and 
the expansion of the short-term plans, how do you actually 
justify that when the rules of the road clearly state that the 
waivers that are granted under 1332 are only supposed to be for 
those plans that provide coverage that is at least as 
comprehensive as the coverage under the exchanges and that the 
coverage and cost-sharing protections are as affordable?
    In other words, they go together--again, getting at the 
fact the undermining of these essential benefits I think is 
disingenuous to a lot of American consumers. What is the 
justification for doing that in these newer short-term plans 
the administration has put forward?
    Ms. Turner. The administration has spent I think about a 
year with a lot of career Federal officials looking at this and 
how can you write the rule in a way that is compliant with the 
text of the ACA to make sure they are comprehensive, they don't 
increase the deficit, they are at least as affordable to make 
sure that that would be allowed. So the rules would have to 
allow to make sure if people did buy short-term plan that it 
fit these criteria.
    So all the short-term plans are not junk plans. In fact, I 
think very few of them are. Buyer beware. People need to be 
aware, they need to be informed, and there are protections if 
they are going to use a subsidy for these plans to make sure 
that they are compliant with the ACA.
    Mr. Schrader. Well, and I think you write the rules in the 
way you would like to write the rules, and I think that is 
challengeable and we are going to see, I think, that reverse 
either in the courts or in this particular Congress.
    Ms. Altman, a lot of discussion about 1332 waivers and the 
ability for them to give States the opportunity to innovate. I 
totally agree with that. Oregon has been doing that for years.
    The Affordable Care Act really, I think, points that out as 
a great opportunity for States. I don't think there is any 
disagreement with that, and it is being done and has been done 
prior to this current administration very successfully. But it 
has been with these essential health benefits in play, and it 
hasn't been, I think, a curse or restrictive.
    Please talk a little bit about the role those essential 
health benefits play in the waiver programs.
    Ms. Altman. Sure. So essential health benefits are sort of 
10 categories of core benefits that the Affordable Care Act was 
supposed to guarantee access to so that people with healthcare 
needs could have the benefits that they need to get the 
treatment they need regardless of the type of condition that 
they have.
    Those are what ensure that whether you have a mental health 
issue, a physical health issue, an emergency or cancer, those 
benefits will be available, and they were intended through the 
guardrails in the ACA to be extended to any coverage offered 
through the 1332 waivers.
    Mr. Schrader. Thank you.
    And Ms. Keith, I mean, given the fact that ostensibly the 
Health and Human Services Department of the United States of 
America's goal is to help Americans get quality, affordable 
healthcare, how do you think the current administration 
justifies curtailing the enrollment outreach programs? That 
makes no sense to me.
    Ms. Keith. I won't try to speak for them or on their 
behalf. My understanding is they think this is a more cost-
efficient way, and that they believe that outreach in 
enrollment funding is not cost effective.
    I would counter there have been other examples from other 
States--Covered California is an example--that attributes a 
decline in 6 to 8 percent of premiums just from the outreach 
and marketing work that they did to bring in healthy consumers. 
So it does, certainly--has been shown to help stabilize 
premiums.
    Mr. Schrader. Thank you very much, and I yield back.
    Ms. Castor. Thank you.
    Mr. Long is recognized for 5 minutes.
    Mr. Long. Thank you, Madam Chairwoman.
    Ms. Turner, I would like to talk about the roles that 
navigators and independent agents and brokers played. You note 
in the plan in your--you note that for the plan year 2017 
navigators received more than $62 million in Federal grants 
while enrolling less than 1 percent of all enrollees. Seventeen 
of these navigators enrolled fewer than 100 each at an average 
cost of $5,000 per enrollee.
    The top 10 most costly navigators spent over $2.5 million 
to enroll 314 people. One grantee received $200,000 and 
enrolled one person, and over three-quarters of navigators 
failed to achieve their enrollment goals while spending more 
than $50 million.
    Ms. Turner, under the Trump administration CMS has changed 
how navigators receive funding based on performance measures. 
Do you think that these changes help ensure accountability 
within the navigator program?
    Ms. Turner. CMS has said in its report that it really is 
trying to respect that taxpayer dollars be spent wisely and, 
basically, they are making the following year's grant 
contingent on a navigator meeting their previous year 
enrollment goals.
    And as you say, even with this generous funding, the 
navigators enrolled fewer than 1 percent of all enrollees in 
healthcare.gov. And so I think that does need to--we need to 
look at how can we get the best benefit, and they looked at 
private brokers and agents who live and breathe in this space, 
and they were much more successful, enrolling 42 percent of 
enrollees.
    Mr. Long. The subject of this hearing is about reversing 
ACA's sabotage. Do you consider these efforts by CMS as 
sabotaging the ACA?
    Ms. Turner. No, and the navigators were particularly--when 
the ACA was new, people didn't even know what a deductible was. 
So people needed to be educated about the fundamental 
principles of insurance.
    But now that we see in California, for example, there has 
been a 24 percent drop in new enrollees, despite their spending 
$100 million on marketing navigators last fall. But they are 
finding many more people are having their coverage renewed and 
sometimes automatically renewed.
    So we are in a different space now with the ACA.
    Mr. Long. According to the Missouri Department of 
Insurance, since 2011 the annual cost of coverage per 
individual has increased by an estimated 235 percent in the 
individual market, and now there is only one option on the 
marketplace for my entire district--7th District of Missouri.
    Do you see the efforts of the Trump administration to give 
States more flexibility to lower premiums and provide more 
insurance options for individuals as positive steps that can 
benefit consumers?
    Ms. Turner. Absolutely, and I think that is what they are 
trying to do both with the bridge plans as well as the 
association health plans, and as well as the Section 1332 
flexibility.
    Being able to tailor the insurance funding to the needs of 
their citizens is something that States can do much more 
effectively than the Federal Government.
    Mr. Long. So I am assuming you don't consider these efforts 
as sabotaging the ACA?
    Ms. Turner. I think they are really trying to give 
consumers new options, particularly those who are shut out of 
the market because of costs, and even many of the people with 
ACA coverage say, ``I might as well not have coverage because I 
can't afford the $6,000 to $10,000 deductible.''
    Mr. Long. Thank you.
    And before I yield back, as a point of personal privilege, 
I was born in 1955. John Dingell was sworn into Congress in 
1955. I had the great honor to serve with him for two terms.
    Of course, the room downstairs is named after him. 
Yesterday morning, after an hour delay because of weather, we 
loaded up two planeloads of congressmen, headed to his funeral 
in Dearborn, and got up there and circled for an hour waiting 
for the temperature to raise 1 degree.
    If it would have raised one degree we would have made it, 
and we didn't. We were low on fuel, and so a legend in his own 
time, John Lewis--Representative John Lewis--and Speaker 
Pelosi, who weren't on the flight, along with Chairman Upton, 
Chairman Walden was there, Anna Eshoo.
    I am not going to name all the names because I will leave 
people out. But we held an impromptu service for John at 30,000 
feet, and I just want to send out my best to Debbie. I know 
that John followed his father in Congress and Debbie has 
followed him and she has done an outstanding job on this 
committee, and I just wanted to send my best and thoughts and 
prayers out to Debbie and the entire Dingell family because we 
are sure going to miss him.
    I yield back.
    Ms. Castor. Thank you, Mr. Long, for your comments about 
the Dean of the House, John Dingell.
    Mr. Ruiz is recognized for 5 minutes.
    Mr. Ruiz. Thank you, Ms. Chairwoman.
    I, and everybody in this room, agrees that we need to do 
something about costs. The premiums are skyrocketing in the 
exchange. That is not the issue that we are debating here.
    When we look back at why the costs have gone up so much, 
all we have to do is listen to the insurance companies 
themselves, which have said and have warned that if we don't 
pay the cost-sharing reduction subsidies, they are going to 
increase costs.
    The other thing is they talked about the changes that were 
made by Senate Republicans to the risk corridors. They 
increased costs because of those. The other is because of the 
expired reinsurance programs, et cetera, and all of these have 
been a part of the repeal efforts of the ACA.
    So when we look at the junk plans, this is not a solution 
to the problem of high costs. In fact, these junk plans will 
make costs higher in the exchange because this will siphon low, 
healthy, high-corporate-profit-type patients into this lower-
risk pool--junk plans--leaving behind the higher-risk, more 
expensive type of patients for everybody else.
    So healthcare costs for everybody else will go up, and if 
there is something that I have learned as an emergency 
physician, is that not every healthy person stays healthy 
forever.
    So I have seen a 48-year-old man in a motor vehicle 
collision who was previously completely healthy who will now 
have traumatic brain injury, symptomotologies for the rest of 
their lives, and be paralyzed and require very expensive care 
and lots of medications.
    I have seen a 52-year-old man who comes in with yellow eyes 
and yellow skin who has been newly diagnosed with severe liver 
problems due to hepatitis, which is going to require expensive 
medications.
    And I have seen young and healthy 30-year-old women who 
come in with anxiety or depression with new diagnoses of 
clinical depression and also with a mass in their breast with a 
working diagnosis of breast cancer that has metastasized, which 
would require expensive chemotherapy.
    So, even if those younger and healthy individuals buy this 
junk plan, healthcare costs will be more expensive for them 
because under these junk plans they can choose not to cover 
their medication. They can choose not to cover their mental 
health coverage. They can start implementing a cap in lifetime 
coverage for these individuals that will need more care for 
longer periods of time.
    We are not invincible. The whole purpose of health 
insurance is, what if you get sick, what if you get injured 
during an accident? And I have seen them and I have counseled 
family members and patients about their terrible diagnoses or 
their terrible prognoses, and it is not a fun thing to do.
    So I have some questions in regards to costs. Ms. Keith, 
would junk plans increase costs for everybody else and can you 
explain it further, please?
    Ms. Keith. Yes, that is correct. Every analysis, including 
the Trump administration's own analysis, has found that 
expansion of these short-term plans through this new rule are 
increasing premiums in the ACA marketplaces.
    A study by the Kaiser Family Foundation that looked at what 
insurance companies actually said about their premiums for 2019 
showed that short-term plans, the individual mandate, repeal 
and the association health plan have increased premiums on 
average by 6 percent in 2019.
    Mr. Ruiz. And so, you know, in one way I am hearing this 
opposing kind of arguments--yes, we are for preexisting, but we 
need a reduced cost--but it seems like by this junk plan they 
are going to eliminate protections for preexisting illnesses in 
order to keep costs down because corporate insurance companies 
would love not to cover the sick. They would like to cover the 
wealthy and healthy.
    So can you have it both ways in this junk plan? I mean, do 
they discriminate with people with preexisting illnesses?
    Ms. Keith. They absolutely do. I believe that is their 
business model, yes.
    Mr. Ruiz. So if you support junk plans you are supporting 
the idea that--to take us back to a time where health 
insurances were allowed to deny or charge higher premiums or 
charge for higher--or not cover certain procedures for those 
conditions. Is that correct?
    Ms. Keith. Yes, it is.
    Mr. Ruiz. Can you describe the medical underwriting process 
that Americans are subject to under these plans?
    Ms. Keith. Sure. So it varies by insurance company but, 
essentially, if you are applying to enroll in a short-term 
plan, you would fill out a very detailed health questionnaire 
about your own health, about the health of your family members 
and maybe a medical history.
    You would also grant that insurance company access to all 
of your medical records. They would look at what prescription 
drugs you have taken. They would look at what medical exams you 
have taken.
    They would take that information and they would give you a 
price, or they would decline to cover you at all, or they would 
use that to dictate what benefits they will and will not cover.
    Mr. Ruiz. Thank you.
    Ms. Castor. Thank you.
    Dr. Bucshon, you are recognized for 5 minutes.
    Mr. Bucshon. Thank you, and just in light of my friend Dr. 
Ruiz's comments, it is about choice. If you have a preexisting 
condition, don't choose a short-term health plan that is cheap. 
They don't discriminate at all, because it is a consumer 
choice. So to say that a plan specifically discriminates 
against people, that is just factually not true. They don't 
discriminate, because it is about consumer choice.
    We are here today discussing legislative proposals that 
really do nothing, in my opinion, to address the high cost of 
healthcare and the lack of affordable insurance options for 
patients.
    One thing--again, Congress is here discussing the cost of 
health insurance plans but, again, we are not really addressing 
the true problem, in my view, which is the cost of the product 
is too expensive.
    And so if we all continue to chase a product that is too 
expensive and try to cover it, we are never going to catch up, 
in my view.
    The other thing is, is insurance is about risk. That is 
what insurance is about. So your description, Ms. Keith, of all 
of these things--about being assessed for what your risk is--
that is what insurance is about. And so we need to figure out a 
way to cover people who have a lot of risk, and that is what 
Republicans did in our healthcare bill.
    We did it with high-risk pools. What is it, 4 percent of 
the people or 5 percent of the people in the country are 40 to 
50 percent of the healthcare costs?
    So we want to cover people with preexisting conditions, but 
we just want to do it in a different way. If you put everybody 
in the same pool, there is no way, based on the history of 
insurance and how it works, that actuaries will tell you that 
you can get the costs down for everybody and keep the costs 
low. It just doesn't work.
    So we want to cover people with preexisting conditions. I 
was a physician before. I had people that I took care of that 
didn't have coverage. That is wrong. We just want to do it in a 
different way.
    So, Ms. Turner, do you think that any of the legislative 
proposals today would address the high cost of healthcare 
plans?
    Ms. Turner. I actually think they would. They would remove 
options for many consumers. Three million people had dropped 
out of the individual market before the first short-term 
limited duration plan under the Trump administration rules was 
available.
    People are dropping out of coverage because they couldn't 
afford it. They want some options, and bridge coverage through 
the short-term plans provides many people an option. They 
should definitely be informed about these policies.
    But if they buy a policy and they--say they buy a year 
policy and they are diagnosed with cancer when they have that 
coverage, they are covered, and if they didn't have that 
option, they would be completely exposed to those costs.
    Mr. Bucshon. Yes. I think everyone here agrees on both 
sides of the aisle we need more probably disclosure to 
consumers and make sure consumers--like someone mentioned, have 
it in big print right on the front page--you know, what your 
choice is here--you know, what the cost is, number one, but 
number two, what actually is included in these plans, right.
    And it may--you are right, if you have--if you are 
underwritten and you are high risk, you are probably not going 
to be able to get insurance through one of these plans. That is 
not the point. That is not what we were trying to cover.
    But under the Affordable Care Act, I hear from constituents 
all the time that the plans are just not affordable in the 
Affordable Care Act, and so we need to work together to try to 
find a way to improve that and, you know, one of the things I 
think that we can do is work on the cost to the product, and I 
keep saying that because Congress always works on trying to 
provide coverage but not trying to get the cost of healthcare 
down.
    So, Ms. Turner, how do you think repealing the Trump 
administration's guidance on Section 1332 innovation waivers 
would impact the affordability for patients in States with 
waivers?
    Ms. Turner. The States that have received waivers so far 
have been able to reduce premiums anywhere from 43 percent to 7 
percent in the States so far that we have numbers for, and so 
those citizens would definitely be adversely impacted by being 
thrown back into the same pools that don't provide States with 
the same flexibility and the same options that they would have 
under this new guidance to be able to provide more affordable 
options for their residents.
    And about the essential benefits, the essential benefits in 
the ACA may not be everything that somebody needs. Janet, that 
I talked about in my example----
    Mr. Bucshon. Right.
    Ms. Turner [continuing]. Needed to have her antirejection 
medicines covered, and they were not covered under her ACA-
compliant plan. So States need to be able to make sure the 
plans work for their citizens.
    Mr. Bucshon. I want to briefly talk about cost-sharing 
reduction payments, which everyone is saying is sabotage of the 
ACA. That was a bailout, in my opinion, put into the law so 
that if the pools didn't work--insurance companies were losing 
money--they had a Federal backstop with taxpayers footing the 
bill.
    I yield back.
    Ms. Castor. Thank you.
    Ms. Kuster is recognized for 5 minutes.
    Ms. Kuster. Thank you, and thank you for your testimony. I 
appreciate it.
    I want to join my colleagues in honoring John Dingell and 
our mile-high memorial yesterday for him, and we will all be 
together with Debbie Dingell, our colleague, and her family 
tomorrow.
    I just want to move on to the Section 1332 and direct my 
questions, if I could, to Professor Keith. There is clear 
statutory directive in Section 1332 that States must provide 
comprehensible and affordable coverage to a comparable number 
of residents under the ACA.
    But, unfortunately, last fall the Trump administration 
issued new guidance, and I am afraid that that is going to hurt 
people with preexisting conditions like my dear friend Bodie, 
who is a young man with spinal muscular atrophy in my district, 
necessitating a wheelchair to get around.
    Thanks to the ACA, there is no longer broad-based 
exclusions to wheelchairs or to all the other affordable 
healthcare that helps Bodie lead a fulfilling life.
    But for Americans like Bodie, this concerns me in this 
Trump guidance because it runs counter to the statutory 
directives. So last week, I introduced H.R. 986, the Protecting 
Americans with Preexisting Conditions Act, to nullify the new 
guidance.
    I have heard from my Republican colleagues this morning 
that they want to protect Americans with preexisting 
conditions, and I would encourage them to sign on to my bill.
    If I could, Professor Keith, I would like to suggest a 
quick lightning round about my concerns of these short-term 
limited duration insurance products so that Americans will 
understand our concerns.
    If you could just respond--under these plans are insurers 
allowed to refuse to offer a policy to an individual with a 
preexisting condition?
    Ms. Keith. Yes, they are.
    Ms. Kuster. And are insurers allowed to exclude coverage 
for preexisting conditions?
    Ms. Keith. Yes.
    Ms. Kuster. And are insurers allowed to charge higher 
monthly premiums based on health status and factors such as age 
and gender?
    Ms. Keith. That is correct.
    Ms. Kuster. And are insurers allowed to impose annual or 
lifetime dollar limits on care?
    Ms. Keith. Yes.
    Ms. Kuster. And are insurers allowed to opt not to cover 
entire categories of benefits? Here, I am thinking of mental 
health services, prescription drugs, or maternity care.
    Ms. Keith. That is correct.
    Ms. Kuster. And are insurers--even in States like 
Pennsylvania, New Hampshire, West Virginia, that had been so 
hard hit by this opioid epidemic--allowed to offer policies 
that do not include coverage for substance abuse treatment?
    Ms. Keith. That is correct.
    Ms. Kuster. And are insurers allowed to retroactively 
cancel coverage once care is needed?
    Ms. Keith. Yes. That has been one of the biggest abuses and 
something that the Affordable Care Act prohibited.
    Ms. Kuster. And are insurers allowed to impose much higher 
out-of-pocket costs than under the Affordable Care Act?
    Ms. Keith. That is correct.
    Ms. Kuster. And so I would simply ask you or Commissioner 
Altman, if you could, we have heard from Ms. Turner about her 
opinion that these plans protect consumers and bring down 
costs. Are there alternatives--waivers such as reinsurance 
products that could bring down costs for consumers?
    Ms. Altman. Absolutely. There are other mechanisms out 
there--and reinsurance is a great example--that can lower costs 
for those to help afford premiums without putting people in the 
position of having to choose between no coverage or substandard 
coverage like the short-term plans provide.
    Ms. Kuster. So it is your professional opinion that rather 
than this list that we have gone through this morning of ways 
that insurance companies are choosing to make higher profits--
and I believe you have testified the profits are as high as 50 
percent of every premium dollar?
    Ms. Altman. Actually, there are some even higher than that. 
The two largest carriers, with 80 percent of the market, do 
spend less than 50 cents of every premium dollar on care. The 
rest is some administrative cost, and the rest profit.
    Ms. Kuster. Which is shocking to the American people. 
Rather than all that premium dollar going into profit while 
families are put at risk, you believe there is alternative that 
this committee could consider to focus on reinsurance or risk 
pools?
    Ms. Altman. I do, so that no one has to choose between 
their health and their financial well-being.
    Ms. Kuster. Thank you. My time is up, but I very much 
appreciate that.
    Ms. Altman. You are welcome.
    Ms. Kuster. I yield back.
    Ms. Castor. Thank you.
    Mr. Gianforte is recognized for 5 minutes.
    Mr. Gianforte. Thank you, Madam Chair, and I thank the 
panelists for being here and your testimony.
    Hardworking Montanans regularly tell me how their 
healthcare costs continue to rise and benefits shrink. I just 
had a town hall this week, and individuals in Missoula and 
Livingstone, Montana, both raised this very issue. It is a real 
burden on families in Montana.
    Obamacare has not provided an affordable option for many 
Montanans. In the first year of Obamacare, more than 20,000 
Montanans lost their coverage because of the law, and in the 
first 3 years under Obamacare, Montanans' premiums have shot up 
66 percent, and we had testimony you have had similar 
experience in Pennsylvania.
    Unfortunately, premiums continue to skyrocket for Montanans 
and Americans across the country under the current scheme. 
Thankfully, the Trump administration is empowering States to 
address these rising healthcare costs by allowing States 
greater flexibility with the strict Federal mandates of 
Obamacare.
    The Department of Health and Human Services is effectively 
allowing more Americans to get coverage that best suits their 
needs. The administration has implemented rule changes that 
expand State Innovation Waivers to improve access to short-term 
limited duration insurance plans, eliminate the costly 
individual mandate penalty, expand association healthcare 
plans. These measures entrust consumers to pick the best 
healthcare for their family.
    Let us be frank. Obamacare has robbed consumers of choice. 
Obamacare asserted that a Washington bureaucrat knows an 
individual's healthcare needs better than she does. The Trump 
administration changes are empowering consumers so they can 
make healthcare decisions that work best for themselves and 
their families, providing waivers, empower States to promote 
innovation that benefits patients and consumers.
    The State Innovation Waivers, originally born in the Obama 
administration and expanded under President Trump, allow States 
to be creative with healthcare solutions while saving money and 
lowering premiums, which is the issue I hear over and over 
again as I travel our State.
    Alaska has taken advantage of the waivers. We have talked 
about this. They saw premiums drop in some plans by over 40 
percent. We heard testimony today--similar experience in 
Maryland and other States.
    Unfortunately, for a second week in a row, members of the 
majority here have put on a political theater. They want the 
American people to believe that there are lawmakers who oppose 
protections for Americans with preexisting conditions.
    I don't know of any Democrats or Republicans on this 
committee that are in favor of this, who want to strip 
protections for Americans with preexisting conditions. We all 
agree on that. There is broad bipartisan support here.
    I think we should work together to find permanent 
legislative solutions that protect people with preexisting 
conditions.
    I also think we should work together to continue empowering 
States to innovate and address healthcare affordability--I know 
that is the issue back in Montana--and we should encourage 
innovation and affordability, not terminate efforts to improve 
healthcare and make it more affordable.
    Ms. Turner, these State Innovation Waivers that allow for 
flexibility and creativity for the States who want to find 
cost-saving solutions, do you think that we would continue to 
see this sort of cost savings and innovation if we move to a 
single-payer, Government-run, Medicare-for-all program?
    Ms. Turner. No, and I think what we would find is that the 
American people would see--they would not have any choice. It 
would be the single-payer Government program, whatever form 
that takes.
    And what we are seeing is the States are so much better 
able to be able to fine tune funding to the needs of their 
citizens. The American Health Care Act that this Congress 
passed in 2017 provided specific money to the States, $123 
billion, to be able to help with those high-cost patients. So 
they had better protection than being thrown into the same pool 
and often having benefits denied.
    Mr. Gianforte. Yes. So what would the effect be of stopping 
the State Relief and Empowerment Waivers on individuals in the 
States where that ability to innovate was taken away?
    Ms. Turner. The States would basically become functionaries 
for the Federal Government. It would really undermine our 
system of government, I think, in giving the Federal Government 
so much control.
    One of the things that we have learned through these 
waivers and through the 70-changes-plus that have been made to 
the ACA so far is that we need to have more flexibility and 
more State control.
    Mr. Gianforte. OK. Thank you, and I yield back.
    Ms. Castor. Thank you.
    Mr. Sarbanes, you are recognized for 5 minutes.
    Mr. Sarbanes. Thank you, Madam Chair. I thank the panel for 
your testimony.
    Ms. Altman and Ms. Keith, maybe you could tell me--the 
short-term plans that we have been talking about, the people 
offering those plans can and do deny people or reject people 
based on a preexisting condition, do they not, in some 
instances?
    Ms. Keith. They do. That is correct.
    Mr. Sarbanes. Yes. So it is incompatible, it seems to me, 
to claim, as we are hearing from a lot of the Members on the 
other side, that they absolutely want to protect people against 
discrimination based on preexisting conditions, on the one 
hand, but to defend these short-term limited duration plans on 
the other hand, because those plans actually put people in that 
position of being able to be denied, based on that situation. 
Would you agree there is some incompatibility there?
    Ms. Keith. I think that is correct, and these short-term 
plans exacerbate, I think, many of the out-of-pocket costs that 
everyone in this hearing has said they are concerned about. So 
folks who maybe are healthy enough to enroll in a short-term 
plan but then become sick can face catastrophic costs that 
should concern all of us.
    Mr. Sarbanes. It is this distinction that we were able to 
focus on when we put the ACA together originally, where people 
are seduced into thinking that they have got their health 
situation covered and are doing that relatively inexpensively, 
only to then find if they do get sick that they are out of luck 
because the deductibles are incredibly high or the benefits 
that they thought they would be entitled to are not available 
to them. There were the caps that the insurance industry would 
place on how much it would cover.
    So, in a sense, you are buying the healthcare equivalent of 
a pig in a poke when you are buying these short-term limited 
duration plans.
    Why, by expanding the duration of them up to a year, we 
wouldn't view that as going back to the bad old days, which 
produced all these stories of heartache that motivated us to 
try to make these changes, I can't--I can't understand for a 
moment why anyone would support that kind of a policy shift.
    But I wanted to ask you a specific question, which is that 
these short-term junk plans, as we are calling them over here 
on this side, where they can reject a beneficiary based on HIV 
status, based on weight, pregnancy, other kinds of things, 
could somebody apply for one of those plans, check a box saying 
they don't have a preexisting condition because they are not 
aware?
    And that was the other things we discovered when we were 
doing this. How many things qualify as preexisting conditions 
that no one would ever imagine would disqualify them from 
coverage?
    So somebody could get into a plan and then, when they go to 
get the benefits of it, they would discover then that they are 
not qualified for those based on this preexisting condition 
disqualification.
    Could that happen? And so then you are trying to access it 
and, boom, you can't access it and you are--and not only that, 
you are thrown off the plan at that point because they say 
``Oh, you know, you weren't qualified in the first place'' 
after you have paid premiums for I don't know how many months, 
and I don't know whether you would get those back. But is that 
a fair dilemma that people can find themselves in?
    Ms. Keith. That is absolutely correct. What you are 
describing is something called postclaims underwriting that an 
insurance company would use to go back and see if there is 
something that the consumer did not disclose or something, in 
their view, they omitted.
    What the insurance company would typically do is 
retroactively cancel the policy altogether.
    Mr. Sarbanes. Yes. So basically these--did you want to 
comment?
    Ms. Altman. I am just going to add I think it is important 
to note that we are not talking about cases where patients 
intentionally did not disclose----
    Mr. Sarbanes. Right. Right.
    Ms. Altman [continuing]. Because fraud--true fraud has 
always been a reason. Cases where something was noted on a 
medical record that they may not have remembered, potentially 
didn't even know about because their doctor----
    Mr. Sarbanes. Right.
    Ms. Altman [continuing]. Wrote it in the notes without 
explaining to them, or in the case that I listed in my 
testimony, they were never diagnosed or sought care but 
experienced symptoms for which the insurer deems they should 
have sought care.
    Mr. Sarbanes. I mean, this is--I have to yield back my 
time, but just to say we are inviting people back into a world 
with mirrors and trapdoors that was exactly the place we wanted 
to get away from when we passed the ACA. So we got to really 
push back against these junk plans.
    And with that, I yield back my time.
    Ms. Eshoo [presiding]. Thank you, Mr. Sarbanes.
    I now would like to recognize the gentleman from Georgia, 
Mr. Carter.
    Mr. Carter. Thank you, Madam Chair, and thank all of you 
for being here. Certainly an important area that is affordable 
healthcare costs.
    You know, before I became a Member of Congress I practiced 
pharmacy for over 30 years. I started when I was 2. But, 
nevertheless, you know, one of the things that I heard so often 
was the cost of healthcare and particularly the cost of 
insurance, and that is something that I was committed to work 
on and I am committed to work on and continue to work on as a 
Member of Congress.
    Ms. Turner, I read an article in Axios the other day that 
said that 42 percent of people participating in the individual 
marketplace weren't able to use their insurance because out-of-
pocket costs were so high or their deductible was so high.
    And it is my understanding that that is why we have the 
1332 waivers, is so that States can actually address this 
issue. I believe in your testimony you gave examples of some 
States where it has actually worked--maybe Alaska, Oregon.
    Can you repeat that for me, please?
    Ms. Turner. Yes, Congressman.
    The 1332 waivers really are designed to give States 
flexibility to separately subsidize the people with predictably 
high healthcare costs that are driving up the premiums for 
everyone else.
    They are the ones who are causing premiums to go up as the 
healthy people drop out. And a number of States have applied 
for waivers to in different ways subsidize them.
    Alaska said, we will look at these 33 categories and if 
people qualify for those, then they will be able to get 
separate subsidies. Others have reinsurance, high-risk pools, 
invisible high-risk pools.
    States are working to figure out how to do this, with 
dramatic results. We see, for example, in Alaska that premiums 
went down by almost 20 percent. Enrollment went up by 7 
percent. In Minnesota, premiums went down again by almost 20 
percent. Enrollment went up by 13, 14 percent, and on and on 
where you see----
    Mr. Carter. And that is the point I am trying to make. I 
mean, obviously, this has helped. It has helped tremendously, 
and expanding it has helped. Yet, the impetus for the hearing 
today is a set of bills that are actually going to constrict 
this, so we are not going to have the ability to expand on this 
like--and enjoy the benefits of it working like it has worked.
    I am really confused by that because this is our second 
hearing in the committee that has the broadest jurisdiction 
over healthcare costs of any other committee in Congress, and I 
am just trying to figure out where we are going.
    The first week we had a hearing on a lawsuit that is still 
in litigation. It has not been settled yet and may not impact 
anyone.
    Here we are having a hearing this week on what is going on 
and how we can actually constrict the affordability and make 
healthcare costs even more expensive for people. And yet, when 
I go--when I am in my district people are talking about, what 
about prescription drug pricing.
    We haven't even discussed prescription drug pricing yet. 
Yet, there are other committees in this House--the Ways and 
Means Committee yesterday had a hearing on prescription drug 
pricing, the Oversight and Government Reform Committee has 
already had a hearing on drug pricing--and yet here we are in 
the most broadest jurisdiction of healthcare, and we haven't 
had a prescription drug pricing hearing yet.
    Madam Chair, I certainly hope that we will get to that at 
some point here, because it is extremely important. The point 
here is that people being able to buy health insurance doesn't 
help anyone if they can't use it.
    You know, when I first went into business I read something 
and it said, When is a deal not a deal? It is not a deal when 
you buy something you don't need or you can't use, and that is 
what people were being forced to do: buy insurance that they 
can't afford to use. That is not helping them, and that is what 
we need to be addressing here and what I hope that we can 
address.
    Let me ask you, Ms. Turner--when folks have a gap in 
coverage and employment or people who retire and are not yet 
eligible for Medicare, what are the options for them?
    Ms. Turner. Previously under the Obama administration they 
had the option to buy a short-term plan. These have been around 
for decades. But it had to--it could only last for 3 months, 
and people generally, if they are in gaps in coverage, they 
need coverage for longer than that. So this is what the Trump 
administration did. They said that you can have the policy for 
up to a year and it can be renewable for another 2 years.
    Mr. Carter. And in these plans there are options. So they 
give these people who are in this gap, if you will, the ability 
to actually fill in that gap and the ability to have coverage, 
which we all want.
    Ms. Turner, I really appreciate all of you being here and 
appreciate this opportunity, and Madam Chair, again, I look 
forward to the hearings that we are going to have on 
prescription drug pricing, and I yield back.
    Ms. Eshoo. I thank the gentleman. I look forward to them as 
well.
    I now would like to recognize the gentlewoman from 
Illinois, Ms. Kelly.
    Ms. Kelly. Thank you, Madam Chair, and thank you to all the 
witnesses, and I too want to salute Congressman John Dingell 
for all of his work, and he will be sorely missed.
    The Trump administration has recklessly expanded junk 
health plans that do not offer comprehensive coverage. These 
junk plans could unwittingly leave, as we have heard, families 
on the hook for thousands of dollars of healthcare costs.
    According to an article in the New York Times, Kevin 
Conroy, a patient from California, had a heart attack and 
underwent triple bypass surgery 2 months after enrolling in a 
short-term junk plan. His insurance company refused to pay for 
any of his treatment, leaving him with a $900,000 bill.
    In another case, United Health refused to cover a patient's 
breast cancer treatment, leaving her with a $400,000 bill. The 
insurance company claimed that breast cancer was a preexisting 
condition even though the patient was not diagnosed with cancer 
until after she bought the junk plan.
    Ms. Altman, according to your testimony, I understand that 
in your State several consumers have been stuck with large 
unpaid medical bills because a short-term policy denied 
coverage even for medical conditions arising after an 
individual enrolled in a policy.
    These conditions should, theoretically, be covered since 
they arose after individuals enrolled in the plan, but often 
the insurance company, as we have discussed, that sell these 
junk plans refuse to pay out.
    You have explained about postclaims underwriting, and also 
we talked about how consumers need to be more educated. But I 
want to know where does all the money go if these insurance 
companies are not using premium dollars to pay for healthcare?
    Ms. Altman. Sure. So, as we have talked a little bit about, 
Affordable Care Act plans are subject to a medical loss ratio 
that ensures that they spend at least 80 cents of every premium 
dollar on care with the remainder going to administrative costs 
and profit, and if they don't meet that standard they are 
required to refund dollars to their policy holders.
    The short-term market, on the other hand, averages, based 
on a study, 64 cents on every dollar, the largest carriers 
average less than 50 cents a dollar spent on care, with one of 
those carrier spending only 34 cents on the dollar.
    So the remaining funds would go some to administrative 
costs and the remainder to profit. I think all evidence points 
to these being very profitable lines of business for the 
insurers that sell them.
    Ms. Kelly. Thank you.
    And also I agree with my colleagues. I would--I want us to 
work together too and get something done for the American 
people. But, as I recall, in the last years all I have been 
given the opportunity to do is vote to repeal the Affordable 
Care Act or tear up some part of it.
    And, Ms. Turner, I know you have been more negative about 
the navigators but also besides the marketing the time period 
was cut so short so people--it was harder for people to 
register.
    And we talk about the economy is better, so I would like to 
think we went down some because people got jobs and so they did 
have health insurance. So I just want to know from you, do you 
think the ACA has been helpful to anybody?
    Ms. Turner. Oh, absolutely, and actually California 
extended its enrollment period to I think the middle of 
January, and they still were down 24 percent in new enrollment.
    So I think that the real issue is how do we make these 
plans more attractive to people so that they can afford both 
the premiums, especially if they are not in the subsidized 
market, as well as the deductibles are low enough that they 
feel they could actually access the insurance, and that is what 
I am hopeful that States will take advantage of the 1332 
flexibility in the law to allow that.
    Ms. Kelly. OK. Thank you for your answer.
    I just want us to also recognize that there were many, many 
millions of people that had no insurance, and just like people 
can talk about the stories they are hearing there are many 
stories that, even in my own family, how people that weren't 
insured have insurance and they are very happy.
    Ms. Turner. And they are grateful, yes.
    Ms. Kelly. I yield back.
    Ms. Eshoo. I thank the gentlewoman from Illinois.
    And I now am pleased to recognize the gentleman from North 
Carolina, Mr. Hudson.
    Mr. Hudson. Thank you, Chairman Eshoo, and this is my first 
chance to publicly congratulate you on taking the gavel. I look 
forward to finding common ground and working with you 
throughout this Congress.
    When I noticed today's hearing title, ``Strengthen Our 
Healthcare System: Legislation to Reverse ACA Sabotage and 
Ensure Preexisting Conditions Protections,'' one word really 
stood out to me--the word ``sabotage.''
    I know my colleagues and I on this panel agree that we 
should strengthen our healthcare system. I talk to constituents 
of mine every time I am home who need better access to more 
affordable care, and I know my colleagues and I want to ensure 
protections for preexisting conditions. That was universally 
accepted at our hearing last week.
    But the word ``sabotage'' really stuck out at me. 
Unfortunately, this conversation around healthcare has become 
increasingly partisan. We saw this with the Affordable Care 
Act, and we saw it again with the American Health Care Act last 
Congress.
    But this conversation should be bipartisan because 
healthcare is an issue that affects every single American. From 
the time we are born until the time we die, there will never be 
a time when the healthcare industry doesn't touch our lives.
    I was talking to a constituent last week who--he and his 
wife are in their 50s--he told me his wife couldn't afford to 
buy health insurance on the exchanges. But, because of the 
short-term insurance plans now being offered, she was finally 
able to purchase insurance that they could afford.
    He noted that on a previous insurance, if they paid all 
their premiums and met their deductible, they would have spent 
$18,000 out of pocket before they accessed the first bit of 
healthcare.
    So that brings me to today and this word ``sabotage.'' I 
don't think these short-term plans are a long-term solution for 
people buying health insurance, and the administration agrees 
with that, which is why they are only available for up to 3 
years.
    But they do help provide option for folks back home who 
feel like they have no place else to go. I definitely don't see 
them as sabotaging the ACA--more so as enhancing the intent, 
however misguided the execution of the ACA, of providing more 
people with health insurance.
    Ms. Turner, in your testimony you noted these plans were 
helpful for early retirees like my constituent who needed to 
bridge the gap after losing employer-sponsored healthcare. I 
think that is definitely true with the folks I have talked to.
    But one criticism of the short-term plans I have heard 
today has been that consumers may not be sufficiently educated 
on the restrictions and limitations that come with these 
policies. They may not understand the tradeoffs for lower 
premiums.
    In my conversation with my constituent, he recognized his 
wife did not have coverage for everything but that the plan 
covered everything they needed.
    Ms. Turner, yes or no: The final rule provides a disclosure 
notice that must be prominently featured on the insurance 
materials. Is that correct?
    Ms. Turner. Yes, sir.
    Mr. Hudson. It appears from my anecdotal experience that 
those disclosure notices are working. Would you agree with 
that?
    Ms. Turner. Yes, sir.
    Mr. Hudson. I appreciate that. One other issue that has 
been raised--and if I could stick with the John Dingell yes-or-
no answers--Ms. Keith, I believe New Jersey and California have 
limited or banned the sale of short-term limited duration 
insurance plans. Is that correct? Yes or no.
    Ms. Keith. That is correct, yes.
    Mr. Hudson. And Commissioner Altman, do other States have 
the authority under the Trump administration's action to limit 
or ban short-term limited duration plans if they choose?
    Ms. Altman. Yes.
    Mr. Hudson. So if that is true, then, that if any State 
doesn't like the new arrangements, they are free to pass their 
own laws limiting or banning short-term limited duration 
insurance plans.
    I think that is just important to note for the record that, 
you know, States have the option here and States are looking 
for solutions for their constituents, a lot of them in the 
cases like the one I described of my constituents who are just 
trying to bridge a gap, who are trying to find a way to afford 
insurance for their families.
    So I think it is important to note that we are not forcing 
anyone into this. We are giving flexibility to the States, and 
I would love to see us do an extended hearing, Madam Chair, 
where we bring in some folks from the States to talk about are 
these plans really working.
    We hear a lot of discussion from the other side about this 
could do that, it could be that. But let us look at what the 
facts are and what is really happening on the States. I think 
that would be really important.
    So with that, I will yield back.
    Ms. Eshoo. I thank the gentleman.
    I now would like to recognize the gentlewoman from 
Delaware, Ms. Blunt Rochester, a new member of the committee. 
We are thrilled that you are here. You are recognized for 5 big 
minutes.
    Ms. Blunt Rochester. Thank you, Madam Chairwoman, and also 
thank you to the witnesses today. I also would like to send my 
condolences to the Dingell family on the passing of such a 
legend as John Dingell.
    In 2017 in January, the Trump administration halted all ACA 
marketplace outreach for the final week of the 2017 open 
enrollment and then slashed ACA enrollment funding for 
advertising and outreach by a staggering 90 percent--90 
percent.
    Delaware's marketplace, forced to do more with hundreds of 
thousands of dollars less in funding, saw a decrease in 
enrollment every year since then, down 20 percent since the 
State's peak enrollment in 2016.
    The administration's repeal efforts and damage to the 
Affordable Care Act have resulted in new enrollments going down 
and costs going up for the over 22,000 Delawareans and 8.5 
million Americans receiving their health insurance through the 
individual marketplace.
    These Delawareans are now paying more than $100 in premium 
costs over what they paid before over the national average, and 
I really--I heard my colleague Mr. Hudson's point about the 
word ``sabotage,'' and as I was sitting here thinking of what I 
would even say, you know, the saying ``If it walks like a duck 
and quacks like a duck, it must be a duck'' came into my head.
    And it came into my head because, when you shorten the 
amount of time that people have to apply and then you couple 
that with slashing information and outreach to people, it 
appears and it feels like sabotage, and I am really proud to 
have been able to introduce the MORE Health Education Act to 
restore funding for educational outreach.
    All of the bills that we are discussing here today will 
help Americans enroll in quality comprehensive plans in the 
marketplace, and they will ultimately lower costs. But, more 
importantly, the goal is to make Americans healthier.
    And so my first question is, number one, I just want to 
clarify, Ms. Turner, that this particular bill was for 
marketing and outreach and not the navigators. But you will 
probably see more coming forward.
    But I wanted to ask Ms. Keith to clarify something that was 
stated, that marketing doesn't work. Can you just talk about, 
does marketing work? People say, ``We already know about the 
ACA, why do we need to have marketing?''
    Can you share a little bit about that?
    Ms. Keith. Thank you for that question. It is very 
important.
    Multiple studies, including studies conducted by CMS 
itself, have shown the value of advertising and marketing 
outreach under the ACA in particular. One of the changes by 
making such dramatic cuts to the advertising budget is that, 
beginning in 2018, CMS ran no TV advertisements, even though 
that was one of the most cost-efficient ways of reaching people 
and had a measurable impact on people enrolling.
    I think Ms. Turner has cited California having lower new 
enrollees this year. I think it is worth noting that California 
has had the same enrollment overall, and I think part of that 
is that new enrollees--California had strong enrollment of new 
enrollees in previous years, and I think the State would point 
to things like loss of the individual mandate as reasons why 
perhaps new enrollment is lower. But I did want to clarify 
that, that enrollment in California is stable.
    Ms. Blunt Rochester. Got you. Great. And also, I wanted to 
follow up with that. Why do you think we still need outreach 
and marketing?
    Ms. Keith. Awareness remains low. Documented studies have 
shown this. Even as of November of last year there were about 
69 percent of uninsured consumers and consumers who had 
purchased individual coverage who did not know the deadline was 
December 15th or had the date wrong. Sixty-nine percent of 
folks who we are trying to reach for this type of coverage who 
would be eligible are not aware of their options, and outreach 
and marketing plays a key role in that.
    I would just emphasize that we are seeing very aggressive 
marketing of the short-term plans as well, and so, as we have 
seen cuts to ACA outreach and marketing, it is being filled, 
this void is being filled by these short-term plans, and it is 
very confusing for many consumers.
    Ms. Blunt Rochester. And Commissioner Altman, can you talk 
about the State of Pennsylvania and what impact these kinds of 
cuts have had?
    Ms. Altman. Sure. So Pennsylvania, under a prior 
administration, chose to use the Federal exchange. So we rely 
on CMS and the Federal Government to operate our exchange, and 
marketing and outreach are supposed to be a core element of 
that.
    And so, in my perspective, when the Federal Government 
ceased doing that and ceased trying to reach out to 
Pennsylvanians, they weren't meeting those obligations. But 
they still needed to be met because people are not aware--the 
number of consumers I talk to who don't know basic information.
    We have tried to fill that gap with our own campaign, but 
our resources are certainly limited.
    Ms. Blunt Rochester. Great. Thank you so much for your 
questions.
    I would yield back my time in a minute just to say that, 
even as a Member of Congress, we were limited in what we could 
say. So I applaud the work of the committee, and I yield back 
the balance of my time.
    Ms. Eshoo. I thank the gentlewoman, and we are thrilled 
that you are part of the committee.
    It is a real pleasure to recognize the gentlewoman from 
Indiana, a wonderful colleague and a good friend, value added 
no matter where she is in the Congress--Mrs. Brooks.
    Mrs. Brooks. Thank you, Madam Chairwoman, and I just want 
to also have the opportunity--this is my first opportunity to 
publicly congratulate you on leading this important committee, 
and I look forward to continuing our work that we have done in 
the past, particularly on Pandemic All-Hazard Preparedness Act 
and many other areas, and look forward to your work and working 
with you on this most important subcommittee.
    I want to focus a little bit on the marketing, because my 
colleague talked about marketing and, Ms. Turner, marketing and 
outreach is an incredibly important aspect of any product. I 
assume you would agree with that.
    However, the more products and the more choices there are, 
marketing--there have to have products that people want to 
consume and/or want to--and/or understand what it is they are 
consuming.
    And, like so many others, I have many Hoosiers who have 
shared with me that the high cost of the premiums and the high 
deductibles are what so many--you know, their barriers have 
been to purchasing a lot of the products.
    So can you help us understand why having more choices--
however, it needs to be informed choices, and I agree that 
there is a concern whether it is with different types of 
products--people have to understand what they are buying, and 
that is, I think, what the biggest problem is with these short-
term products, is they don't quite understand what is covered 
and what is not covered.
    Can you please talk with us about why having more choices 
is better for healthcare overall for consumers regardless of 
their health status?
    Ms. Turner. It does give them options. It gives them 
options of networks, doctors, the hospitals that are available 
to them and, unfortunately, and I think about half of counties, 
people in ACA coverage have a choice of one plan. It is take it 
or leave it, so there is really no choice there at all.
    And people who can't afford that coverage are now being 
given other options through short-term plans and other 
administrative ideas.
    Mrs. Brooks. Can you share with us a little bit about how 
the Federal Government might be able to increase enrollment? 
Are there other ideas that any of you might have as to how the 
Federal Government might be able to increase enrollment in 
health insurance aside from spending money on marketing and 
navigators?
    Ms. Turner. If the policies were more affordable, if there 
were more competition in the market so that the one provider 
doesn't have the opportunity to buy up all the doctors and 
hospitals and charge higher premiums, giving people more 
competition in these markets--so looking at the anticompetitive 
monopolies that some of these hospitals and systems have is 
important, but also providing more options through Section 1332 
for States to tailor their risk models so that the highest-risk 
people are not in the same pool with everybody else and driving 
up premiums, driving the healthy people out. I think this has 
got to be a State-based solution and the 1332 that was a part 
of the original ACA was envisioned to give States that 
flexibility.
    Mrs. Brooks. Talking a bit more about that, how have 
Section 1332 waivers--have they increased access to care in the 
States that have approved waivers, and can you give any 
examples----
    Ms. Turner. Absolutely.
    Mrs. Brooks [continuing]. Of access to care?
    Ms. Turner. Access to care--and which is, of course, in 
many people's case it is access to coverage to help finance 
that care. But in Arkansas, Minnesota, Oregon, Maryland, Maine, 
New Jersey, Wisconsin, those are many of the States that 
already have requested waivers to spend some part of the ACA 
money themselves in a way that does a better job of risk 
mitigation--high-risk pools, reinsurance, invisible high-risk 
pools--to give--to separately subsidize the people who have the 
highest costs so that you can then lower premiums for others in 
the individual market and attract more people, which then 
further lowers premiums.
    Everybody wants more healthy people in these insurance 
pools. The ACA is working against that. Section 1332 gives 
States tools to be able to get more healthy people into their 
markets.
    Mrs. Brooks. Thank you. I yield back the balance of my 
time.
    Ms. Eshoo. I thank the gentlewoman.
    And it is a pleasure to recognize from California another 
new member of our subcommittee, and she is so welcome, the 
gentlewoman Ms. Barragan.
    Ms. Barragan. Thank you, Madam Chairwoman.
    I want to thank you all for joining us here today. We have 
heard a lot about these junk plans in my first term as a 
first--as a new Member of Congress. It feels like we just had 
all kinds of conversations about healthcare and it was centered 
around repealing the Affordable Care Act, which would limit 
access to healthcare to people.
    So it is nice to be able to have this conversation and 
actually have a debate on what some of what has been happening 
over the last 2 years is doing to pricing and as a result of 
some of the policies that have been implemented for the last 2 
years.
    I myself am a cosponsor of what we are talking about 
today--to eliminate these junk plans--and I want to talk a 
little bit about that. One of my colleagues on the other side 
said, let us talk about the facts--let us talk about what is 
happening.
    You know, we received the story of Sam Bloechl from 
Chicago, and I want to share his story because I think it is 
important to highlight what is happening and what people are 
going through.
    Now, Sam's story was brought to us by the Leukemia and 
Lymphoma Foundation. Sam unknowingly enrolled in a junk plan 
after he was deceptively steered into it by a broker.
    Now, Sam had been experiencing back pain and he was 
completely transparent about this when he talked to the broker 
about his condition. Sam writes in a letter to the committee 
that he thought it would be smart to talk to a broker about 
upgrading his coverage so he could have better healthcare 
access for any future medical care.
    Now, the broker assured Sam that the junk plan was the 
right insurance plan for him, given his back pain. After 
enrolling in the junk plan, Sam was diagnosed with an 
aggressive form of blood cancer--non-Hodgkin's lymphoma.
    After undergoing 6 months of chemotherapy and radiation, 
his insurance company informed him that they were not going to 
pay for the treatment, leaving him with $800,000 in medical 
bills.
    The insurance company also refused to pay for a bone marrow 
transplant, treatment necessary to allow Sam to achieve lasting 
remission. Now, Sam writes in his letter that the insurance 
company claimed that cancer was a preexisting condition because 
he had previously visited a chiropractor for his back pain.
    Sam was left with almost a million dollars in medical bills 
and no insurance--and no health insurance for the treatment 
that he needed in order to stay alive.
    Now, while fighting cancer, Sam is also trying to figure 
out how to avoid bankruptcy. Sam is only 32 years old and a 
business owner. He writes that instead of planning for his 
future with his fiance and building his business, he is left up 
at night wondering how to stay afloat.
    So I want to start by entering Sam's letter to the 
committee into the record now. And I also--Madam Chairwoman, 
can I enter that into--thank you very much.
    [The information appears at the conclusion of the hearing.]
    Ms. Keith, can you discuss how insurance companies are able 
to essentially defraud patients like Sam?
    Ms. Keith. Certainly. So it sounds like Sam was a victim of 
something called postclaims underwriting, which is something we 
have been discussing where his back pain, which he disclosed, 
was used as a reason to deny coverage for his cancer treatment 
and care, leaving him on the hook for all these bills.
    I think other ways that short-term plans have exposed 
consumers to high out-of-pocket costs like this is through 
their refusal to cover preexisting conditions, the benefit 
gaps.
    But even when you think you fully understand the product 
and you disclose your back pain and you think you know what you 
are getting, to be surprised that your cancer treatment 
wouldn't be covered I think is something that is very troubling 
for patients and consumers--the stories that we are hearing all 
across the country.
    Ms. Barragan. Right.
    Commissioner Altman, could you describe the impact of the 
Trump administration's decision to expand the junk plans on 
patients who may be in a similar situation to Sam?
    Ms. Altman. Yes, and thank you for sharing that story. I 
think that story is so indicative of many of the pieces we have 
talked about today, from limited benefits to deceptive 
marketing practices which are, for the record, illegal, to 
postclaims underwriting and, frankly, also to the fact that 
something like this can happen to anyone, and that is why every 
person needs comprehensive health insurance to cover things 
like unexpected cancer diagnoses, and the story is also one 
that demonstrates the short-term plans are not that.
    Ms. Barragan. Well, thank you. I know. Sam writes that 
somebody shouldn't have to worry about filing for bankruptcy or 
getting stuck with $800,000 in medical bills. I agree. I think 
that is why we are having the hearing today. I also think that 
is why having legislation to protect individuals like Sam and 
reverse the administration's attacks on Americans with 
preexisting conditions is important.
    And with that, I yield back.
    Ms. Eshoo. I thank the gentlewoman.
    I am now pleased to recognize the ranking member of the 
subcommittee, Dr. Burgess, for 5 minutes.
    Mr. Burgess. Thank you for the recognition. Thanks to our 
witnesses for being here. I know it has been a long morning and 
now afternoon, but I appreciate your input into this important 
subject.
    Ms. Turner, let me ask you--probably 2 years ago, I guess 
in March of 2017, the Health Affairs published the article on 
the invisible high-risk pools that the State of Maine had used 
to rescue its insurance industry after their attempt at 
community rating guaranteed issue got them into so much 
difficulty in the individual market. The invisible risk pool 
was a way to sort of reconstitute that market. Would you 
qualify those as junk plans?
    Ms. Turner. I think that the risk pools actually provide 
the social safety net so that, if somebody does wind up in a 
situation like Janet that I describe in Colorado who had 
insurance but when she was diagnosed with hepatitis C, the 
high-risk pool in the State was there to provide her care and, 
ultimately, pay for her $600,000 liver transplant. So there are 
other options available than the ACA, and we have seen those in 
the past, and Maine is another example.
    Mr. Burgess. Great. Thank you.
    Madam Chairwoman, just before we finish up, I am going to 
have another--a couple of unanimous consent requests so that I 
don't get gaveled out. I just would like to make that 
information available to you.
    Now, Ms. Turner, staying with you, one of the issues I 
brought up in my opening statement was the issue of global 
budgeting. Can you speak to how a global budget system would 
impact patients and the healthcare system at large?
    Ms. Turner. Whoever controls the money is going to control 
the choices, and whoever is controlling that global budget, 
whether it is a regional health administrator, whether it is a 
Federal bureaucracy, whether it is a hospital system, is going 
to control the choices for that patient and they are going to 
allocate the money in a way that I am sure they will believe is 
going to be the fairest way possible, but it always winds up 
they wind up with shortages, they wind up with waiting lines.
    We have seen in California--I am sorry, in Canada--that 
hospitals have to close in December because they have run out 
of money. So I think that it significantly diminishes 
individual patient choice, and it often leads to rationing of 
care.
    Mr. Burgess. While we are on the subject of Canada, it is 
my understanding that Canada is opposed to the system in the 
United States where, if a bill is submitted by CMS it is paid. 
In Canada, there is a fixed budget and, once that budget is 
exhausted, the bills are held until the next year. So a 
fundamental difference in the approach.
    One of the things that has concerned me for some is that 
you do see that there is an effort to create a single-payer, 
Government-run system, and you see this not just in the United 
States.
    I mean, this has been something that has been ubiquitous 
across the world. Why is that? Why does a country want to 
control something that inherently should be an individual 
issue?
    Ms. Turner. Now, I have thought about this for many years, 
and I do believe that there is a sense of fairness--that if 
everybody is in the same system that everybody will be treated 
the same.
    But that is not the way that it works in any country that 
has some form of a Government-centralized healthcare system. 
The affluent people always find a way to buy out of it, and 
people who have fewer means always wind up with their care 
rationed and limited.
    Mr. Burgess. So does it concern you, some of the statements 
we have heard about pushing to that type of system, 
particularly those that say we are going to void any private 
insurance? The large group market would disappear of necessity 
under a single-payer system in this country.
    Ms. Turner. With 173 million people in the employer health 
insurance market that value their coverage, I think that would 
be very problematic. When you have 60 million people on 
Medicaid that value that coverage and that would see it 
compromised if we had another 200 and what would be 70 million 
people on that program.
    So I think that there--the system as it is has evolved over 
decades, and I think it is important to build on that system 
and figure out how do we help these 15 million people who are 
in the individual market who are the most exposed to the high 
premiums and the high cost, the high deductibles, and the 
possibility of losing their coverage.
    Mr. Burgess. I do know when I ran my medical practice, 
obviously, I was in the small group market when I bought 
insurance for my employees. I would have welcomed the ability 
to go into an association health plan.
    If county medical societies across the country had put 
together a group health insurance model, that would have been 
welcome news for me and those patients would have been 
protected from preexisting conditions, unlike others in the 
individual market.
    So thank you so much for your time today, and I will yield 
back.
    Ms. Eshoo. Thank you, Dr. Burgess.
    Let us see. It is now my pleasure to recognize the 
gentleman from California, Mr. Cardenas.
    Mr. Cardenas. Thank you very much, Madam Chair and Ranking 
Member, for putting this very important hearing together in 
full view of the public, and I want to thank the witnesses for 
being here as well--the ones I agree with and the ones I 
disagree with. Thank you so much for providing your 
perspective.
    Since the passage of the Affordable Care Act in 2010, more 
than 20 million Americans have gained meaningful access to 
insurance coverage. Before Donald Trump became President, the 
uninsured in this country fell from 18 percent to 11 percent, 
the biggest jump in any period of time in the country's 
history.
    Yet, basically, since day one the Trump administration has 
actively undermined the law and attacked Americans' healthcare. 
The administration cut the advertising and enrollment budget 
from $100 million to $10 million. This has had a very real 
consequence, and I have heard stories from my own district 
where constituents mistakenly believed that the healthcare 
exchanges ended with the Presidency of President Obama.
    The administration's sabotage efforts have resulted in the 
highest uninsured rate in 4 years. According to a Kaiser Family 
Foundation study, over 80 percent of uninsured adults were not 
aware of the deadline to enroll in coverage in 2017. Again, it 
was this Trump administration that reduced the enrollment 
administration's advertising budget from $100 million to $10 
million.
    Another survey by the Commonwealth Fund said that 41 
percent of uninsured adults are still unaware of the ACA 
marketplaces or that subsidies are available to help them pay 
for coverage.
    The Trump administration is strangling healthcare for 
millions of people and undermining the law of the land.
    Ms. Keith, I understand that uninsured Americans are less 
likely to be aware of the deadlines or availability of 
affordable coverage. Is that a correct statement of today?
    Ms. Keith. That is correct, yes.
    Mr. Cardenas. OK.
    Also, Ms. Keith, can you briefly describe how gutting 
funding for outreach and enrollment impacts new enrollments?
    Ms. Keith. Certainly. New enrollees tend to be younger and 
healthier. As you can imagine, patients who are older and have 
health conditions are very motivated to enroll in coverage.
    It is really younger and healthier consumers who aren't 
aware and need to better understand the marketplace options 
available to them. What we have seen is since 2016 new 
enrollment through healthcare.gov is down by about 50 percent.
    We need younger and healthier consumers to help keep the 
risk pools stable and help keep premiums down. I believe I 
mentioned earlier Covered California attributes its marketing 
in 2015 and 2016 to a reduction in 6 to 8 percent in premiums. 
So advertising can pay off in terms of sort of bringing in 
younger and healthier people who need coverage for themselves 
but also help the risk pool.
    Mr. Cardenas. Now, Ms. Keith, can you describe how what you 
just described--younger, healthier patients not enrolling--how 
that affects other Americans' ability to get comprehensive 
healthcare?
    Ms. Keith. Sure. By not having younger and healthier folks 
in or having fewer and fewer new enrollees, there is a 
possibility that premiums will increase.
    Mr. Cardenas. OK.
    Ms. Altman, what is the level of awareness among consumers 
in Pennsylvania, for example, about the ACA and their 
healthcare options in the ACA marketplaces?
    Ms. Altman. I would say that my experience in speaking to 
Pennsylvanians is very reflective of the study that Ms. Keith 
mentioned. In particular, there seems to be a significant lack 
of awareness about the financial support available under the 
Affordable Care Act.
    Many consumers come to enrollment events and think there is 
no way they will be able to afford the coverage, only to find 
out that it is all more affordable than they ever thought it 
could be.
    Mr. Cardenas. Thank you. And also, Ms. Turner, you 
mentioned something that, as a former business owner, on the 
face of it I would probably agree with but I don't agree with 
in this case about how we are trying to provide comprehensive 
healtcare to as many Americans as possible, and I quote, 
``individual patient choice.''
    When I was a little boy, my parents had an individual 
patient choice, and they chose to go without insurance coverage 
because it was too far out of reach for my family's single-
income, first-grade-education immigrant father who was a 
gardener.
    He couldn't be a CEO--didn't aspire to be, or what have 
you. But he provided food on the table for 13 people every 
single day, and I am so proud of him and my mother for doing 
what they could with what little they had.
    Also, my parents' individual choice was to not participate 
in preventative medicine practices like going to see a doctor 
because even that was too expensive for us to do as a low-
income family.
    My parents' individual patient choice was to look at us and 
pray for us when we got a bad fever or something and then, now 
and again, once in a while, say it is time to go--time to take 
us to the emergency room.
    Not to our regular care doctor, not to a place where we 
could actually be preventative in these measures, but the 
dangerous choice of waiting to the last minute to decide, ``I 
think my child is in very serious danger. Now it is time to go 
to see a doctor.'' That is individual choice that the 
Affordable Care Act, as flawed as it is, has been trying to 
overcome, and it was able to overcome that for tens of millions 
of people that before were like my family when I was growing 
up.
    Thank you very much, Madam Chair. I yield back.
    Ms. Eshoo. I thank the gentleman. You just saw and heard 
passion on display.
    Now, we have two Members that have been waiting very, very 
patiently. They are members of the full committee. Ms. 
Schakowsky is also a chair of a subcommittee, and the rules of 
the committee allow for Members that are not part of this 
subcommittee to come and to participate, but they have to come 
last.
    So thank you to the gentlewoman from Illinois and for her 
great service on this subcommittee in previous Congresses. I 
recognize her for 5 minutes of questioning.
    Ms. Schakowsky. I thank you, Chairman Eshoo, for allowing 
me to waive onto the subcommittee, a subcommittee I served on 
for 16 years, and I am happy to be here today.
    I just wanted to point out that the State of Illinois 
passed legislation preventing these short-term--we call them 
junk plans, because there was a robust debate about those.
    And while we saw 7 percent lower enrollment, I think it 
could have been even higher had--that we could have done better 
had the--I call it--I do call it sabotage of limiting the 
navigators.
    Ms. Turner said that only 1 percent of the navigators had 
anything to do with it. Has the public program that was 
essentially defunded been helpful, and would we have had more 
enrollment had we had the dollars to advertise the programs?
    Both of you, actually.
    Ms. Keith. Absolutely, and I think when we talk about 
navigators, who we are really talking about is community-based 
organizations, United Ways, legal aid societies, American 
Cancer Society, organizations like that who are sort of bedrock 
institutions in the community.
    Although some of that data I think has been disputed on 
navigators, I will say under the statute navigator enrollment 
is only one of the five things that navigators are supposed to 
work on. Their real goal is to help folks with limited English 
proficiency, lower-income folks.
    They have a lot of other things they are doing that aren't 
just enrollment. So I think having those navigators there is 
really helping families with complex conditions, families who 
need a little bit of extra help to get enrolled.
    And then to your question, I tend to agree--if we had 
outreach and marketing funding you would--the marketplaces sort 
of remain stable even with these cuts, but at least one study 
has showed that we should have 2.3 million more new enrollees 
at a minimum. So the marketplace should be much bigger than it 
is.
    Ms. Altman. Just speaking for Pennsylvania, I can say that 
the navigator organizations in Pennsylvania are incredibly 
committed and incredibly effective in reaching people and 
helping the most challenged individuals through their 
healthcare questions and issues and enrolling people both in 
the marketplace and in Medicaid as well, particularly with the 
expansion, and especially in reaching groups of people who are 
not going to be reached otherwise--those who have specific 
healthcare needs.
    One of our navigator organizations focuses on individuals 
with mental health conditions, focusing on groups for whom 
English is not their primary language. We have other navigator 
organizations focused on certain communities in that category. 
And so they do fill a very unique void.
    Ms. Schakowsky. Let me interrupt. I have little time left. 
I wanted to refer to a bill, H.R. 1143, that Representative 
Eshoo sponsors. But I wonder if either of you are knowledgeable 
about the Georgetown University Health Policy Institute 
findings about really what has happened when brokers are 
telling people about these plans and how they concluded that 
insurance brokers selling these plans engaged in deceptive 
marketing practices.
    Ms. Keith. Thank you for that question. This was a study 
done by my colleagues on the really aggressive marketing and 
outreach we've seen in short-term plans. By and large, there 
are a lot of ads funded going towards marketing of these short-
term plans.
    Brokers--we found instances where brokers were very 
aggressive by phone--you have a lot of robocalls--brokers who 
would refuse--really wanted someone to purchase while they were 
on the phone and refused to provide written information at all. 
You are seeing plan--or website, web brokers saying that they 
sell ACA plans and short-term plans but then only allowing 
enrollment in short-term plans. I worry----
    Ms. Schakowsky. And did some of those people think they 
were getting a comprehensive ACA plan?
    Ms. Keith. I am sure that is true. It is very confusing.
    The other thing I was going to add is that we have seen 
steering. So even when patients might be eligible for subsidies 
or consumers might be eligible for subsidies through the 
marketplace, being directed to a short-term plan when they 
might qualify for a much cheaper, more comprehensive policy.
    Ms. Altman. I will just add very quickly that my department 
has had to revoke the insurance licenses of a number of agents 
and brokers who have done exactly what you said and lied to 
consumers and told them these plans are things that they are 
not, and it is falling to States to do what we can to be 
vigilant in a very active marketplace with a lot of marketing 
that is very questionable.
    Ms. Schakowsky. Let me just say choice is a good thing. It 
needs to be informed choice. People really need to know what is 
going on, and these plans--I am happy that they were outlawed 
in the State of Illinois.
    I yield back. Thank you very much for letting me be here.
    Ms. Eshoo. Thank you for your patience and your attendance.
    I now would like to recognize another member of the full 
committee--not of the subcommittee but always welcome here and 
a new member to the full committee, the gentleman from Florida, 
Mr. Soto. You are recognized for 5 minutes.
    We are going to vote pretty soon, too.
    Mr. Soto. Thank you. Yes, I will be efficient. Thank you, 
Chairwoman Eshoo.
    So sabotage of the ACA--allow me to count the ways. Let me 
just go through the top five as I see it: first, eliminating 
cost-sharing subsidies, that raised rates; second, cutting 
enrollment period in half; third, cutting marketing dollars in 
half or more; fourth, eliminating high-risk corridors, hurting 
competition; and fifth, eliminating individual mandates.
    One that we still need to talk about is, there was an 
attempt to eliminate preexisting conditions in the Trumpcare 
bill that did not pass, thank God, but if we didn't stop them, 
we would have seen even that sabotaged.
    I think all parties can agree this was a big issue in the 
last election and that Americans want us to get to work on 
bipartisan solutions on it. I come from the State of Florida, 
home to the largest Federal exchange in the Nation--1.7 million 
Floridians are on the ACA exchanges, up 50,000 from last year.
    So, first, I would like to get a potential consensus here 
from the witnesses. Yes or no: Did eliminating the cost-sharing 
by the Trump administration and the last Congress raise rates 
altogether?
    Yes or no, and we'll start with Ms. Keith.
    Ms. Keith. Yes, it did.
    Mr. Soto. Ms. Altman?
    Ms. Altman. Absolutely.
    Mr. Soto. Ms. Turner?
    Ms. Turner. It was not--funding was not included in the 
original law, and this Congress was trying to provide the 
funding in context of larger reforms.
    Mr. Soto. So I will take that as a no. OK.
    And then, for my second and final question: Why would a 
State like Florida still have an increase in ACA enrollment 
even with these five clear sabotages of the ACA opinions?
    We will start with Ms. Keith.
    Ms. Keith. One response is that there is still continued 
demand for the type of coverage that the ACA provides for 
comprehensive, affordable, quality coverage. At the same time, 
you still have subsidies available for most folks who enroll 
through the marketplace, and that has been, I think, the 
enduring stability of these programs.
    Mr. Soto. Ms. Altman?
    Ms. Altman. Just reiterating, I think that demonstrates the 
value proposition that the comprehensive coverage along with 
the financial assistance available on the marketplace provides 
to millions of Americans.
    Mr. Soto. And Ms. Turner?
    Ms. Turner. Maybe sort of ending on a bipartisan note, 
there is such broad agreement that we need to help people to 
purchase coverage who are shut out of the market for whatever 
reason and make it more affordable. I hope to work with you in 
doing that.
    Mr. Soto. Just to conclude, you know, Florida is a giant 
State, third largest in the union, and a lot of our 
constituents don't have access to the foundational plans of 
this Nation--employer-based plans--that so many Americans are 
on, particularly because they may work in the service industry 
or the agriculture industry, which is why the ACA continues, 
despite all the sabotages, to be a smashing success in my 
State, because this is really the only option people have.
    So from Florida's perspective, we cannot let this fail, and 
despite attempts to make it fail it has still thrived for us to 
still be the largest Federal exchange in the Nation.
    So I look forward to hearing from all of you on that in the 
future and work with the committee, and thank Chair Eshoo for 
the opportunity.
    And with that, I yield back.
    Ms. Eshoo. You are always welcome here. I would--I think 
that this is--we have concluded the questioning of both the 
guests of the subcommittee and all the Members.
    I want to thank the witnesses again. I think that each one 
of you did an outstanding job. I don't necessarily agree with 
you, Ms. Turner, but you worked hard to answer the questions, 
and I certainly appreciate that.
    Ms. Turner. Thank you, Chairman.
    Ms. Eshoo. I also want to thank the authors of the 
legislation. They are not here now, but I think to say this for 
the record that they have worked hard on these bills, and I 
want to thank Congresswomen Castor, Kuster, and Blunt 
Rochester.
    And I also would like to ask for unanimous consent to place 
into the record the following: the letter of endorsement from 
the AARP for all of the bills that were discussed today, a 
letter of endorsement from the American Academy of Physicians, 
the testimony for the record from Sam Bloechl, a letter of 
endorsement from the Federation of American Hospitals--that is 
an endorsement of the legislation that was discussed today--the 
same from the American Medical Association on the four bills, 
the letter from the American Lung Association in support of 
H.R. 987, letter from the American Lung Association in support 
of H.R. 1010, statement from the American Lung Association in 
support of legislation repealing 1332, statement from the 
American Heart Association in support of H.R. 1010, statement 
from the American Heart Association in support of H.R. 986, 
statement for the record from the Association for Community 
Affiliated Plans, a statement for the record from America's 
Health Insurance Plans, a letter from 23 health partners and 
patient advocacy groups to the Trump administration expressing 
strong concerns with the Section 1332 waiver guidance, a letter 
from 23--I am almost done--23 health partners and patient 
advocacy groups to the Trump administration expressing strong 
concerns with the short-term limited duration insurance final 
rule, a letter from the American Hospital Association, and a 
statement of support from Families USA.
    Not hearing any opposition, these items will be placed in 
the record.
    [The information appears at the conclusion of the hearing.]
    And I would like to recognize Dr. Burgess for his request 
for items to be placed in the record.
    Mr. Burgess. So, Madam Chair, I have a unanimous consent 
request to place into the record a statement for the record 
submitted by the Coalition to Protect and Promote Association 
Health Plans.
    I also would like to submit for the record an article from 
the Washington Post, ``The Health 202: Association health plans 
expanded under President Trump look promising so far,'' and I 
appreciate your offer to have a hearing on association health 
plans.
    We have heard some discussion about lifetime limits, and I 
would point out that even under Medicare there are sometimes 
what are called therapy caps. Therapy caps were repealed for 
physical therapy and occupational therapy last year in the 
bipartisan Budget Act of 2018.
    But I would just like to submit for the record the members 
of the committee who voted against that and therefore voted 
against repeal of therapy caps in the bipartisan Budget Act, 
and I thank you for the consideration.
    [The information appears at the conclusion of the hearing.]
    I will yield back.
    Ms. Eshoo. I thank the gentleman.
    We don't often enough say ``thank you'' to the staff to the 
committee, and so on behalf of all of the members of the 
subcommittee I want to thank both the majority staff and the 
minority staff for the work that they do to help prepare us, to 
bring the witnesses forward, to draw up some of the talking 
points and the answers to questions that may be asked, and it 
is sincere thanks from all of the members of the subcommittee.
    So with that, I think we will make it over to the floor and 
maybe even be there, Dr. Burgess, before the bells ring.
    Thank you again to the witnesses, the time that you have 
given to us, and, you know, your commitment to these issues by 
dedicating your lives to them. It is in no small measure, I 
think, a gift to the country.
    Mr. Burgess. So do we have five legislative days to submit 
questions for the record?
    Ms. Eshoo. We do, and we have 10 business days to submit 
additional questions for the record to be answered by the 
witnesses who have appeared and, of course, we trust and I ask 
that the witnesses respond promptly to any questions that you 
may receive, and we have already placed what we wish to place 
into the record.
    So at this time, the subcommittee is adjourned.
    [Whereupon, at 1:28 p.m., the committee was adjourned.]
    [Material submitted for inclusion in the record follows:]
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