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


  STRENGTHENING OUR HEALTHCARE SYSTEM: LEGISLATION TO LOWER CONSUMER 
                        COSTS AND EXPAND ACCESS

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 6, 2019

                               __________

                           Serial No. 116-12
                           
                           
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                           


      Printed for the use of the Committee on Energy and Commerce

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                        energycommerce.house.gov
                        
                               __________
                        
                        
                   U.S. GOVERNMENT PUBLISHING OFFICE                    
36-535 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
                                     MICHAEL C. BURGESS, Texas
ELIOT L. ENGEL, New York               Ranking Member
G. K. BUTTERFIELD, North Carolina,   FRED UPTON, Michigan
    Vice Chair                       JOHN SHIMKUS, Illinois
DORIS O. MATSUI, California          BRETT GUTHRIE, Kentucky
KATHY CASTOR, Florida                H. MORGAN GRIFFITH, Virginia
JOHN P. SARBANES, Maryland           GUS M. BILIRAKIS, Florida
BEN RAY LUJAN, New Mexico            BILLY LONG, Missouri
KURT SCHRADER, Oregon                LARRY BUCSHON, Indiana
JOSEPH P. KENNEDY III,               SUSAN W. BROOKS, Indiana
    Massachusetts                    MARKWAYNE MULLIN, Oklahoma
TONY CARDENAS, California            RICHARD HUDSON, North Carolina
PETER WELCH, Vermont                 EARL L. ``BUDDY'' CARTER, Georgia
RAUL RUIZ, California                GREG GIANFORTE, Montana
DEBBIE DINGELL, Michigan             GREG WALDEN, Oregon (ex officio)
ANN M. KUSTER, New Hampshire
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...........................................     2
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     4
    Prepared statement...........................................     5
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     6
    Prepared statement...........................................     7

                               Witnesses

Peter V. Lee, Executive Director, Covered California.............     9
    Prepared statement...........................................    12
J. P. Wieske, Vice President, State Affairs, Council for 
  Affordable Health Coverage.....................................    24
    Prepared statement...........................................    26
    Answers to submitted questions...............................   195
Audrey Morse Gasteier, Chief of Policy and Strategy, 
  Massachusetts Health Connector.................................    36
    Prepared statement...........................................    38

                           Submitted Material

H.R. 1385, the State Allowance for a Variety of Exchanges (SAVE) 
  Act............................................................    86
H.R. 1386, the Expand Navigators' Resources for Outreach, 
  Learning, and Longevity (ENROLL) Act of 2019...................    90
H.R. 1425, the State Health Care Premium Reduction Act...........    95
Letter of March 5, 2019, from Hon. Angie Craig, Cochair, Health 
  Care Task Force, New Democrat Coalition, et al., to Hon. 
  Richard Neal, Chairman, House Ways and Means Committee, et al., 
  submitted by Mr.Schrader.......................................   105
Letter of April 12, 2013, from Mr. Upton, et al., to Kathleen 
  Sebelius, Secretary, Department of Health and Human Services, 
  submitted by Mr. Griffith......................................   110
Letter of June 28, 2013, from Tim Murphy, Chairman, Subcommittee 
  on Oversight and Investigations, House Committee on Energy and 
  Commerce, et al., to Kathleen Sebelius, Secretary, Department 
  of Health and Human Services, submitted by Mr. Griffith........   113
Letter of August 29, 2013, from Mr. Upton, et al., to navigator 
  grant recipient, submitted by Mr. Griffith.....................   116
List, undated, navigator grant recipients, submitted by Mr. 
  Griffith.......................................................   120
Letter of September 30, 2013, from Mr. Upton to Gary Cohen, 
  Deputy Administrator and Director, Center for Consumer 
  Information and Insurance Oversight, Centers for Medicare and 
  Medicaid Services, Department of Health and Human Services, 
  submitted by Mr. Griffith......................................   123
Letter of March 5, 2019, from Deborah P. Brown, Chief Mission 
  Officer, American Lung Association, to Hon. Angie Craig, a 
  Representative in Congress from the State of Minnesota, 
  submitted by Ms. Eshoo.........................................   129
Letter of March 5, 2019, from Deborah P. Brown, Chief Mission 
  Officer, American Lung Association, to Ms. Castor, submitted by 
  Ms. Eshoo......................................................   131
Letter of March 5, 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..........................................................   132
Statement of the American Cancer Society Cancer Action Network, 
  March 6, 2019, submitted by Ms. Eshoo..........................   134
Letter of March 4, 2019, from Justine Handelman, Senior Vice 
  President, Office of Policy & Representation, Blue Cross Blue 
  Shield Association, to Ms. Eshoo and Mr. Burgess, submitted by 
  Ms. Eshoo......................................................   137
Statement of the Asian & Pacific Islander American Health Forum, 
  March 6, 2019, submitted by Ms. Eshoo..........................   139
Letter, undated, from the Young Invincibles to Mr. Pallone, et 
  al., submitted by Ms. Eshoo....................................   142
Report, ``Exploring the Impact of State and Federal Actions on 
  Enrollment in the Individual Market: A Comparison of the 
  Federal Marketplace and California, Massachusetts, and 
  Washington,'' by Washington Health Plan Finder, et al. 
  submitted by Ms. Eshoo.........................................   144
Statement of America's Health Insurance Plans, March 6, 2019, 
  submitted by Ms. Eshoo.........................................   158
Letter of March 6, 2019 from Mary R. Grealy, President, 
  Healthcare Leadership Council, to Mr. Pallone and Mr. Walden, 
  submitted by Ms. Eshoo.........................................   180
Brief of March 4, 2019, ``How Affordable are 2019 ACA Premiums 
  for Middle-Income People?,'' Kaiser Family Foundation, 
  submitted by Mr. Burgess.......................................   182
Article of March 5, 2019, ``ACA premiums rising beyond reach of 
  older, middle-class consumers,'' by Amy Goldstein, Washington 
  Post, submitted by Mr. Burgess.................................   187
H.R. 1510, the Premium Relief Act of 2019, submitted by Mr. 
  Burgess........................................................   189
Letter of March 6, 2019, from Justine Handelman, Senior Vice 
  President, Office of Policy & Representation, Blue Cross Blue 
  Shield Association, to Mr. Burgess, submitted by Mr. Burgess...   193

 
  STRENGTHENING OUR HEALTHCARE SYSTEM: LEGISLATION TO LOWER CONSUMER 
                        COSTS AND EXPAND ACCESS

                              ----------                              


                        WEDNESDAY, MARCH 6, 2019

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:00 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, Lujan, Schrader, Kennedy, Cardenas, Ruiz, 
Dingell, Kuster, Kelly, Barragan, Blunt Rochester, Rush, 
Pallone (ex officio), Burgess (subcommittee ranking member), 
Upton, Shimkus, Guthrie, Griffith, Bilirakis, Long, Bucshon, 
Brooks, Carter, Gianforte, and Walden (ex officio).
    Also present: Representatives Peters and Soto.
    Staff present: Jacquelyn Bolen, Health Counsel; Jeff 
Carroll, Staff Director; Tiffany Guarascio, Deputy Staff 
Director; Zach Kahan, Outreach and Member Service Coordinator; 
Saha Khaterzai, Professional Staff Member; Una Lee, Chief 
Health Counsel; Samantha Satchell, Professional Staff Member; 
Andrew Souvall, Director of Communications, Outreach, and 
Member Services; Sydney Terry, Policy Coordinator; C. J. Young, 
Press Secretary; Mike Bloomquist, Minority Staff Director; Adam 
Buckalew, Minority Director of Coalitions and Deputy Chief 
Counsel, Health; Margaret Tucker Fogarty, Minority Staff 
Assistant; and J. P. Paluskiewicz, Minority Chief Counsel, 
Health.
    Ms. Eshoo. Good morning, everyone. Welcome to the 
witnesses. 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

    Today is the second legislative hearing of the Health 
Subcommittee in the 116th Congress. We are going to examine 
legislation today to drive down costs and increase options in 
the private insurance markets created by the Affordable Care 
Act.
    Democrats made a promise to the American people to lower 
their healthcare costs and undo the Trump administration 
sabotage of the ACA. Today we are continuing to deliver on that 
promise by examining legislation that creates a reinsurance 
program for all States, funds States that did not initially set 
up State-based insurance marketplaces to set up these State-run 
private exchanges, and restore funding for patient navigators.
    If an individual is not enrolled in Medicare or Medicaid, 
does not get their insurance through their employer, or is a 
small business owner or self-employed, the legislation we are 
considering today will help bring down the cost of health 
insurance. The bill gives States the funding and flexibility to 
improve the private marketplaces created by the ACA and 
increase choices for Americans who purchase their health 
insurance from these exchanges.
    Representatives Angie Craig and Scott Peters have written a 
bill which provides funding for State-based reinsurance 
programs and establish a Federal reinsurance program similar to 
the one established in the Affordable Care Act that expired in 
2016, so all Americans can benefit from lower premiums in the 
individual marketplace. Reinsurance programs add money to the 
health insurance market created by the ACA to cover the costs 
of patients with high medical costs such as those with 
preexisting conditions.
    This will drive down costs for middle-class Americans who 
don't receive the ACA tax credit. By providing payments that 
enroll high cost patients, many of whom have preexisting 
conditions, reinsurance protects against premium increases and 
will bring down the cost of health insurance coverage for those 
who buy their insurance from ACA exchanges. For anyone who 
cannot afford health insurance on the private market today, 
this bill will bring premiums down next year and help 
individuals afford high quality, comprehensive coverage.
    We will also examine the bipartisan SAVE Act introduced by 
Representatives Andy Kim and Brian Fitzpatrick which provides 
funding to States to set up State-based insurance marketplaces 
like the original ACA did. I am very proud of Covered 
California that is California's State-based insurance market. I 
think it is the gold standard for these programs and currently 
has enrolled 1\1/2\ million Californians. That is a lot of 
human beings that have coverage today that never had coverage 
before. If a State originally chose not to establish their own 
State-based marketplace when the ACA became law, this bill 
gives those States the funding they need to establish a 
marketplace that meets their needs while maintaining the 
minimum benefits established by the ACA.
    Lastly, we will consider Representative Castor's ENROLL 
Act. It provides funding for navigators who assist small 
businesses or self-employed individuals with guidance and 
information to determine the best health insurance option for 
their needs.
    [The prepared statement of Ms. Eshoo follows:]

                Prepared statement of Hon. Anna G. Eshoo

    Good morning everyone, welcome to the witnesses. The Chair 
now recognizes herself for 5 minutes for an opening statement. 
Today is the second legislative hearing of the health 
subcommittee in the 116th Congress. We're going to examine 
legislation today to drive down costs and increase options in 
the private insurance markets created by the Affordable Care 
Act.
    Democrats made a promise to the American people to lower 
their healthcare costs and undo the Trump administration's 
sabotage of the ACA.
    Today we're planning to deliver on that promise by 
examining legislation that creates a reinsurance program for 
all States, funds States that did not initially set up State-
based insurance marketplaces to set up these State-run private 
exchanges, and restores funding for patient navigators.
    If an individual is not enrolled in Medicare or Medicade, 
does not get their insurance through their employer, or is a 
small business owner or self-employed, the legislation we're 
considering today will help bring down the cost of health 
insurance. The bill gives States the funding and ability to 
improve the private marketplaces created by the ACA and 
increase choices for Americans who purchase their health 
insurance from these exchanges.
    Representatives Angie Craig and Scott Peters have written a 
bill which provides funding for State-based reinsurance 
programs and establishes a Federal insurance program similar to 
the one established in the Affordable Care Act that expired in 
2016 so all Americans can benefit from the lower premiums in 
the individual marketplace.
    Reinsurance programs add money to the health insurance 
market created by the ACA to cover the cost of patients with 
high medical costs such has those with preexisting conditions. 
This will drive down costs for middle-class Americans who don't 
receive the ACA tax credit.
    By providing payments that enroll high cost patients, many 
of whom have preexisting conditions, reinsurance protects 
against premium increases and will bring down the cost of 
health insurance coverage for those who buy their insurance 
from ACA exchanges.
    For anyone who cannot afford health insurance on the 
private market today, this bill will bring premiums down next 
year and help individuals afford high quality comprehensive 
coverage.
    We will also examine the bipartisan SAVE Act introduced by 
Representatives Andy Kim and Brian Fitzpatrick, which provides 
funding to States to set up State-based insurance marketplaces 
like the original ACA did.
    I'm very proud of Covered California, that is California's 
State-based insurance market. I think it's the gold standard 
for these programs and currently has enrolled one and a half 
million Californians. That is a lot of human beings that have 
coverage today that never had coverage before.
    If a State originally chose not to establish their own 
State-based marketplace when the ACA became law, this bill 
gives those States the funding they need to establish a 
marketplace that meets their needs while maintaining the 
minimum benefits. established by the ACA.
    Lastly, we will consider Representative Castor's ENROLL 
Act. It provides funding for navigators who assist small 
businesses or self-employed individuals with guidance and 
information to determine the best health insurance option for 
their needs.
    I promised that I would yield a minute of my time to 
Congressman Ben Ray Lujan. I'm happy to yield to the gentlemen 
from New Mexico for the remaining time.

    Ms. Eshoo. I promised that I would yield a minute of my 
time to Congressman Ben Ray Lujan. Is Ben Ray here? Yes, he is. 
So I am happy to yield to the gentleman from New Mexico for the 
remaining time.
    Mr. Lujan. Thank you, Madam Chair. Democrats made a 
commitment to the American people that we would lower their 
healthcare costs, and with their support we are now in the 
majority. It is the expectation of the American people that we 
move forward in a bipartisan way to address this major issue. 
Ms. Craig's and Mr. Peters' bill is strong. In fact, the bill 
is modeled after the reinsurance program that made its debut in 
the Republican repeal effort.
    Now what I am concerned about is what we will hear today is 
that congressional Republicans are more focused on interjecting 
an abortion fight into an unrelated debate, that they are 
making sure families can't see their doctors. I do not 
understand that, but what I do know is the Democrats are going 
to forge ahead in our goal to lower healthcare costs for the 
American people.
    I am ready and willing to work with my colleagues across 
the aisle when they want to join forward in this progress. I 
thank the Chair and I yield back.
    Ms. Eshoo. I thank the gentleman.
    The Chair now recognizes 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. Well, thank you for the recognition and thanks 
to our witnesses. Today we are convened to discuss, according 
to the title of this hearing, legislation to lower consumer 
costs and expand access to healthcare. Legislation that my 
friends on the other side of the dais have put forth today is 
once again disappointing. I do believe there are some areas 
where we could have worked together, particularly on the area 
of reinsurance, but there was no effort to work in a bipartisan 
way on that issue.
    Republicans have supported reinsurance when coupled with 
additional structural reforms to improve healthcare markets and 
have led efforts to establish a patient and State stability 
fund to provide States with the funding and the flexibility 
that they need to successfully set up and implement cost 
reduction programs.
    While I see that much of this language may be similar to 
that which we have supported before, there are some critical 
provisions that are missing from the text. The benefits of a 
smart and thorough reinsurance policy would allow States to 
repair markets damaged by the Affordable Care Act while 
honoring federalism. Unfortunately, the bill before us today is 
particularly restrictive and does not provide States with 
adequate flexibility to use those funds. It also fails to 
include critical and longstanding Hyde protections.
    I have introduced H.R. 1510. It includes a responsible 
reinsurance policy that enables States to use funds for a wide 
variety of initiatives from helping high-risk individuals to 
enrolling in coverage to promoting access to preventive 
services, providing maternity coverage and newborn care. It is 
important to mention that this bill would also provide Hyde 
protections.
    Next, I would like to turn to the issue of navigators. As a 
physician, as a Member of Congress, and just your average 
simple country doctor, I like to base my decisions on evidence-
based research. I found it interesting as I read the Democrats' 
memo that they are trying to sell us this legislation to 
increase funding for navigators without outlining the impact 
that navigators have had in enrolling individuals.
    Navigators are not a new phenomenon. We have sufficient 
data to show that they have been only minimally effective, 
spending 36 million in 2018, prior to that 63 million, all to 
enroll less than 1 percent of the fee-for-service market. 
However, CMS data shows that agents and brokers have helped 42 
percent of fee-for-service enrollment plan for 2018, 
substantially more cost effective than navigators. The agents 
and brokers cost $2.40 per enrollee.
    The final bill before us today would provide $200 million 
to create State exchanges, which is another effort that has 
proven to be astonishingly efficient in wasting taxpayer 
dollars. Seventeen States have spent a total of four and a half 
billion dollars to establish exchanges, many of which have 
failed. The Subcommittee on Oversight under Chairman Upton 
found that the CMS was not confident that the remaining State-
based exchanges would be sustainable in the long term. 
Additionally, it found that only one State had complied with 
the Affordable Care Act's requirement that all State-based 
exchanges publicly publish costs related to its operations.
    Again it is disappointing that not only none of these bills 
adequately address the affordability of health insurance, I am 
disappointed that there was only a minimal attempt to work on 
the reinsurance and no attempt to even discuss the other two 
bills. Bipartisanship means asking for my input, not just my 
vote.
    If you had asked for my input, I would have suggested that 
we look at language like I have introduced in H.R. 1510, a bill 
that includes reinsurance coupled with structural reforms to 
the Affordable Care Act, gives States more choice on how to 
repair their markets that have been damaged by Obamacare, and 
the legislation is, in fact, fully offset by stopping bad 
actors from gaming the system, and includes language that 
affirms the longstanding consensus that taxpayers should not 
foot the bill for abortions.
    I thank the gentlelady for the time and I yield back.
    [The prepared statement of Mr. Burgess follows:]

             Prepared statement of Hon. Michael C. Burgess

    Thank you, Chairwoman Eshoo. Today, we are convened to 
discuss, according to the title of this hearing, ``legislation 
to lower consumer costs and expand access'' to healthcare. 
Alas, the legislation that my friends on the other side of the 
dais have put before us today is once again disappointing. I do 
believe that there are some areas here where we could have 
worked together, particularly on the issue of reinsurance, but 
there was little effort to work in a bipartisan way on this 
issue.
    Republicans have strongly supported reinsurance when 
coupled with additional structural reforms to improve 
healthcare markets and have led efforts to establish a patient 
and State stability fund to provide States with the funding and 
flexibility they need to successfully set up and implement 
cost-reduction programs. While I see that much of this language 
may be similar to that which we have supported before, there 
are some critical provisions that are missing from the text.
    The benefits of a smart and thorough reinsurance policy 
would allow States to repair markets damaged by the Affordable 
Care Act, while honoring federalism. Unfortunately, the bill 
before us today is particularly restrictive and does not 
provide States with adequate flexibility to use the funds. The 
bill also fails to include critical and long-standing life 
protections that exist in current law.
    I have introduced a bill that includes a responsible 
reinsurance policy that enables States to use funds for a wide 
range of initiatives, from helping high-risk individuals enroll 
in coverage, to promoting access to preventive services, to 
providing maternity coverage and newborn care. It is important 
to mention that my bill also includes Hyde protections.
    Next, I would like to turn to the issue of navigators. As a 
physician, a Member of Congress, and as your average Joe 
consumer, I like to base my decisions on evidence-based 
research. I found it interesting as I read the Democrats' memo, 
that they are trying to sell us this legislation to increase 
funding for navigators, without outlining the impact that 
navigators have had in enrolling individuals. Navigators are 
not a new phenomenon, and we have sufficient data to show that 
they have been minimally effective.
    The Centers for Medicare and Medicaid found that during the 
plan year 2018 open enrollment period, navigators received $36 
million, but enrolled less than 1 percent of the fee-for-ervice 
enrollment population. In 2017, when navigators received a 
larger sum of grant funding, $63 million, they still only 
enrolled less than 1 percent. CMS data show that agents and 
brokers helped with 42 percent of the fee-for-service 
enrollment for plan year 2018. This was substantially more cost 
effective than navigators, as agents and brokers only cost 
$2.40 per enrollee. Why buy a faulty product when there's a 
better one on the market? Especially when, under this bill, an 
individual would be essentially forced into an ACA plan as 
navigators not required to be knowledgeable on alternative 
forms of coverage, such as short-term limited duration and 
association health plans.
    The final bill before us today would provide $200 million 
to create State exchanges, which is another effort that has 
previously been proven to be a remarkable waste of taxpayer 
dollars. Seventeen States spent a total of $4.5 billion to 
establish exchanges, many of which failed. The Subcommittee on 
Oversight and Investigations released a detailed report in 2016 
that found that CMS was not confident that the remaining State-
based exchanges will be sustainable in the long term. 
Additionally, it found that only one State had complied with 
the Affordable Care Act's requirement that all State-based 
exchanges publicly publish costs related to its operations.
    Again, I find it disappointing that not only do any of 
these bills adequately address the affordability of health 
insurance. I am also disappointed that our friends on the other 
side of the aisle made only one attempt to work on reinsurance 
and no attempts to even discuss the other two bills. 
Bipartisanship means asking for my input, not my vote. I yield 
back.

    Ms. Eshoo. I thank the ranking member.
    Now it is my pleasure to recognize the chairman of the full 
committee, Mr. Pallone, for 5 minutes.

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

    Mr. Pallone. Thank you, Madam Chair. The bills we are 
considering today reflect Democrats' continued commitment to 
deliver on our promise to make healthcare more affordable and 
accessible to all Americans and to reverse the Trump 
administration's sabotage of the Affordable Care Act. This 
legislative hearing comes several weeks after we held another 
legislative hearing on bills that were important first steps in 
lowering healthcare costs and protecting consumers with 
preexisting conditions.
    Today we will be discussing three more bills that will 
reduce consumers' costs and improve access to care. And one way 
to ensure that people have access to healthcare is to provide 
them the support and information they need to make the right 
decision. So we will be discussing a bill introduced by Ms. 
Castor that would reverse the Trump administration's harmful 
cuts to the navigator program.
    The Trump administration has gutted funding for the 
navigator program by over 80 percent, leaving huge swathes of 
the country without access to fair and unbiased enrollment 
help. We should restore this critical funding and ensure that 
navigators can provide fair and impartial information on 
people's enrollment and financial assistance options.
    We also have to look at providing States another round of 
funding to establish State-based marketplaces. The SAVE Act was 
introduced by Representatives Andy Kim and Brian Fitzpatrick. 
As you may recall, some State legislatures who wanted to 
establish State-based marketplaces were unable to do so due to 
the opposition of the Republican Governors. In my State of New 
Jersey, former Governor Chris Christie, in 2012, vetoed a bill 
to establish a State-based marketplace for the residents of New 
Jersey.
    While all States have been negatively affected by the Trump 
administration's sabotage of the ACA, State-based marketplaces 
have been better able to weather these storms. In 2018, 
premiums in these marketplaces were 17 percent lower than in 
the Federally Facilitated Marketplace, and enrollment in these 
States has outpaced enrollment in the Federally Facilitated 
Marketplace States. The State-based exchanges framework also 
gives States the opportunity to tailor the program to meet the 
needs of their State residents, and the bill provides us 
another opportunity to make healthcare more affordable.
    And, finally, we will consider a bill introduced by Ms. 
Craig and Mr. Peters to provide 10 billion in reinsurance 
funding for States that set up their own reinsurance programs. 
States may also use this funding to provide financial 
assistance to help lower premiums and out-of-pocket costs for 
consumers and beyond the ACA's subsidies. Reinsurance pays for 
the costs of people with serious medical conditions whose 
healthcare costs are significantly higher than the average 
person. This support helps reduce premiums through the 
individual market, making healthcare more affordable.
    Seven States have successfully implemented State-based 
reinsurance programs through the 1332 waiver program, including 
my State of New Jersey. These programs have significantly 
lowered premiums and have had widespread bipartisan support. 
Now the bill that we are considering today would build upon the 
success of these programs, but the funding would come from the 
Federal Government.
    I believe that that is the right approach. A sustained 
Federal commitment is needed in order to lower costs for all 50 
States and the District of Columbia. Like with the Part D 
program, reinsurance should be a permanent part of the 
individual market and it should be a federally financed 
responsibility.
    Now the bills that Ms. Craig and Mr. Peters have introduced 
are modeled after the reinsurance program that all the 
Republicans on this committee supported in the repeal bill of 
last year. We all agree that Congress must take action to 
reduce costs for middle-class consumers and we all agree that 
reinsurance is a good thing. And that is why I was disappointed 
that we were unable to get to bipartisan agreement on 
reinsurance.
    My colleagues on the other side of the aisle have made it 
clear that they will not support any reinsurance bill without 
Hyde language. There is no reason, in my opinion, to drag 
Republicans' anti-choice politics into this discussion. There 
is bipartisan consensus that reinsurance is effective in 
bringing down costs for middle-class consumers. A number of 
States under Republican leadership such as Maine, Maryland, and 
Wisconsin, happily took Federal money for reinsurance without 
raising the issue of Hyde and we should take this opportunity 
to allow States to make healthcare more affordable for their 
residents.
    [The prepared statement of Mr. Pallone follows:]

             Prepared statement of Hon. Frank Pallone, Jr.

    The bills we are considering today reflect Democrats' 
continued commitment to delivering on our promise to make 
healthcare more affordable and accessible for all Americans, 
and to reverse the Trump administration's sabotage of our 
healthcare system. This legislative hearing comes several weeks 
after we held another legislative hearing on bills that were 
important first steps in lowering healthcare costs and 
protecting consumers with preexisting conditions. Today, we 
will be discussing three more bills that will reduce consumers' 
costs and improve access to care.
    One way to ensure that people have access to healthcare is 
to provide them the support and information they need to make 
the right decision. We will be discussing a bill introduced by 
Ms. Castor that would reverse the Trump administration's 
harmful cuts to the navigator program. The Trump administration 
has gutted funding for the navigator program by over 80 
percent, leaving huge swathes of the country without access to 
fair and unbiased enrollment help. We should restore this 
critical funding and ensure that navigators can provide fair 
and impartial information on people's enrollment and financial 
assistance options.
    We should also look at providing States another round of 
funding to establish State-based marketplaces. The SAVE Act was 
introduced by Representatives Andy Kim and Brian Fitzpatrick. 
As you may recall, some State legislatures who wanted to 
establish State-based marketplaces were unable to, due to the 
opposition of their Republican Governors. In my State of New 
Jersey, former Governor Chris Christie in 2012 vetoed a bill to 
establish a State-based marketplace for the residents of New 
Jersey.
    While all States have been negatively affected by the Trump 
administration's sabotage, State-based marketplaces have been 
better able to weather these storms. In 2018, premiums in these 
marketplaces were 17 percent lower than in the Federally 
Facilitated Marketplace, and enrollment in these States has 
outpaced enrollment in the Federally Facilitated Marketplace 
States.
    The State-based exchange framework also gives States the 
opportunity to tailor the program to meet the needs of their 
State residents. This bill provides us another opportunity to 
make healthcare more affordable.
    Finally, we will consider a bill introduced by Ms. Craig 
and Mr. Peters to provide $10 billion in reinsurance funding 
for States to set up their own reinsurance programs. States may 
also use this funding to provide financial assistance to help 
lower premiums and out-of-pocket costs for consumers, above and 
beyond the ACA's subsidies.
    Reinsurance pays for the costs of people with serious 
medical conditions whose healthcare costs are significantly 
higher than the average person. This support helps reduce 
premiums throughout the individual market, making healthcare 
more affordable. Seven States have successfully implemented 
State-based reinsurance programs through the 1332 waiver 
program, including the State of New Jersey. These programs have 
significantly lowered premiums and have had widespread 
bipartisan support.
    The bill that we are considering today would build upon the 
success of these programs, but the funding would come from the 
Federal Government. I believe that this is the right approach. 
A sustained Federal commitment is needed in order to lower 
costs for residents of all 50 States and the District of 
Columbia. Like with the Medicare Part D program, reinsurance 
should be a permanent part of the individual market, and it 
should be a Federal financial responsibility.
    The bill that Ms. Craig and Mr. Peters have introduced is 
modeled after the reinsurance program that all the Republicans 
on this committee supported in the repeal bill of last year. We 
all agree that Congress must take action to reduce costs for 
middle-class consumers and we all agree that reinsurance is a 
good thing.
    That's why I am disappointed that we were unable to get to 
bipartisan agreement on reinsurance. My colleagues on the other 
side of the aisle have made clear that they will not support 
any reinsurance bill without Hyde language.
    There is no reason to drag Republican's anti-choice 
politics into this discussion. There is bipartisan consensus 
that reinsurance is effective in bringing down costs for 
middle-class consumers. A number of States under Republican 
leadership, such as Maine, Maryland, and Wisconsin happily took 
Federal money for reinsurance without raising the issue of 
Hyde. We should take this opportunity to allow States to make 
healthcare more affordable for their residents.
    I look forward to the discussion today and I yield back.

    Mr. Pallone. So I want to yield now, the minute or so left, 
to Mr. Peters, if I could, Madam Chair.
    Mr. Peters. Thank you, Mr. Chairman or Chairman Pallone for 
yielding me time and thanks to Chairwoman Eshoo and Ranking 
Member Burgess for holding this hearing today.
    I am grateful to the committee for their consideration of 
H.R. 1425, the State Health Care Premium Reduction Act, a bill 
that I recently introduced with Representative Angie Craig. I 
would also like to thank Reps Schrader, Underwood and Kuster 
for their early support of the bill.
    Let's be honest. Stabilizing the individual marketplace may 
not be a bipartisan priority, but lowering healthcare insurance 
premiums and reducing out-of-pocket costs for working Americans 
certainly is. And it is widely acknowledged by both Republicans 
and Democrats that one of the best ways to lower premiums is to 
provide adequate Federal funding to create State reinsurance 
programs.
    H.R. 1425 creates a dedicated stability fund that States 
can use to lower premiums and out-of-pocket costs for all 
individuals by defraying the costs of high-cost enrollees. Our 
bill is expected to lower premiums for individuals by 
approximately 10 percent. So Representative Craig and I look 
forward to working with both our Republican and Democratic 
colleagues to provide millions of Americans with swift relief 
from the rising costs of healthcare, and I thank you for the 
time.
    Ms. Eshoo. I think I would now like to introduce the 
witnesses that are here today and welcome them and thank them 
for being willing to share their expertise with us.
    First, Mr. Peter Lee. I am going to move off of script and 
say to everyone that Mr. Lee comes from one of the most 
distinguished families in California and our country. I am 
going to go way back many, many years. I think it was your--was 
it your grandfather that founded--he was Dr. Lee--founded the 
Palo Alto Medical Clinic? He had five sons, all M.D.s, at 
least--and a daughter--well, you are ahead of me--a daughter 
that was also a doctor.
    And out of those five sons, one served in two 
administrations in the healthcare arena. So Mr. Lee comes to us 
not only with great genes, but with having implemented the ACA 
in California. We are really honored to have you here today and 
thank you for your commitment, unswerving commitment that has 
traveled through more than one generation of your family. You 
are a gift to the country.
    Mr. Wieske, welcome to you. He is the Vice President for 
State Affairs at the Council for Affordable Health Coverage.
    Ms. Audrey Morse Gasteier, who is the Chief of Policy and 
Strategy for the Massachusetts Health Connector, again, thank 
you.
    I am going to recognize each witness for 5 minutes for 
their opening statement. There is a lighting system. The light 
will be green when it first comes on, then it will be followed 
by yellow, then you will have 1 minute remaining, so we ask you 
to stay within the 5 minutes.
    So I am going to begin with the distinguished Mr. Lee.

    STATEMENTS OF PETER V. LEE, EXECUTIVE DIRECTOR, COVERED 
   CALIFORNIA; J. P. WIESKE, VICE PRESIDENT, STATE AFFAIRS, 
   COUNCIL FOR AFFORDABLE HEALTH COVERAGE; AND AUDREY MORSE 
 GASTEIER, CHIEF OF POLICY AND STRATEGY, MASSACHUSETTS HEALTH 
                           CONNECTOR

                   STATEMENT OF PETER V. LEE

    Mr. Lee. Good morning, Chairwoman Eshoo, Ranking Member 
Burgess, and distinguished members of the subcommittee. I do 
want to note that as you see I am Mr. Lee, not Doctor, so 
clearly the gene pool dilutes over time, but I want to very 
much appreciate your remarks about my family. I serve as the 
executive director of Covered California and am honored to 
participate in this hearing to help inform your deliberations.
    Remarkable progress has been made throughout the country 
with the Affordable Care Act, but recent Federal policy actions 
are having significant negative effects on millions of 
Americans. I welcome the fact that today's hearing is about 
building out and improving the Affordable Care Act which is 
what we need to focus on.
    Well, Covered California, for 6 years, has effectively used 
all the tools of the Affordable Care Act to improve 
affordability for coverage, promote competition, give choice to 
consumers, and drive improvements in the delivery system. We 
have made investments in marketing, in outreach, in navigators, 
and the results show that we have a 20 percent healthier 
enrolled population which means our premiums are 20 percent 
healthier than in the Federal marketplace would have if they 
had our risk mix.
    We made remarkable progress in California and across the 
Nation, but recent Federal policy actions are posing challenges 
such as the Federal elimination of the individual mandate 
penalty, promotion of limited benefit plans, and significant 
reductions in marketing and outreach that don't affect 
California, but affect 39 States relying on the Federal 
marketplace. These policies are having the direct effect of 
raising premiums and pricing millions of Americans out of 
coverage.
    Today, California, Massachusetts, and Washington exchanges 
released an analysis showing a very different story of what 
happens in States like ours that lean in to support consumers, 
compared, sadly, to what has happened in consumers served by 
the Federal marketplace. The findings in that report are stark.
    Since 2014, Federal marketplace States have had a 
cumulative premium increase of over 85 percent. In our three 
States the increase has been less than half of that. This means 
that if the Federal Government had spent roughly--because of 
that the Federal Government spent roughly $35 billion--$35 
billion more in premium tax credits than it would have if their 
premium increases had matched ours. But the biggest impact has 
been felt by millions of middle-class Americans who get no 
financial help who have been priced out of coverage.
    This analysis shows the importance of the mandate penalty 
also. California and Washington have leaned in to promote 
insurance. We have good risk mixes. But this last year we saw 
significant drops in new enrollment. The State of 
Massachusetts, who you will hear from more today, saw a 31 
percent increase in their new enrollment. That is because they 
had a mandate that predated the Affordable Care Act that is in 
place today. Their consumers know about it. So while recent 
Federal actions are taking us backwards, I am encouraged that 
today's hearing focuses on ways to move forward and build on 
the Affordable Care Act.
    The first proposal relates to reinsurance to help stabilize 
markets. Reinsurance can have a profound effect on coverage 
affordability particularly for middle-class Americans who don't 
qualify for premium subsidies. It would directly benefit them 
by lowering premiums and creating greater carrier participation 
that provides market stability to encourage health plans to 
play. We have 11 carriers in California. Many parts of America 
have one or two. Reinsurance helps bring plans to the market.
    Now I would note, State-based reinsurance programs may work 
for some, but it is not a viable strategy for the vast majority 
of States. Most States will not come up with State funds to 
invest in the risk of uncertain Federal pass-throughs. H.R. 
1425 would not only fund reinsurance but would allow States the 
option of investing in targeted ways in their States to reduce 
costs for their consumers. This proposal provides State 
flexibility, State choice, and would lower premiums across the 
board.
    H.R. 1385 would fund States that seek to establish their 
own marketplaces. Now, Covered California benefited from 
establishment funds. We got a lot of money to get started. We 
have paid that off many times over by reducing premiums for 
Californians. Other States need funds to get set up.
    The final legislation is to support navigator funding. As 
you consider this, I would look back at not only the dramatic 
cuts that we have seen federally, but California has a robust 
navigator program. That program we have funded at about $6.5 
million for each of the last 4 years. But you need to consider 
this program in concert with our broad, $100 million 
investments in marketing and outreach and our support for over 
12,000 licensed insurance agents. All of those should be done. 
All of those are necessary tools to keep robust enrollment, to 
keep premiums down by having a healthy risk mix.
    So I would close by noting that we really are at a pivotal 
time in healthcare. To the extent Federal policy discussions 
can now turn to building on, repairing, fixing, and having the 
Affordable Care Act work better, we are at a good place for 
California and for the Nation. I look forward to your 
questions. Thank you very much.
    [The prepared statement of Mr. Lee follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you, Mr. Lee, excellent testimony.
    Now I would like to recognize Mr. Wieske for his 5 minutes 
of testimony. Welcome and thank you.

                   STATEMENT OF J. P. WIESKE

    Mr. Wieske. Thank you, Chairman Eshoo and Ranking Member 
Burgess, for the opportunity to testify on the issues 
surrounding the Affordable Care Act and more specifically the 
individual health insurance market through the proposed 
legislation regarding exchanges, reinsurance, and navigators.
    When I spoke before the committee in February of 2017, I 
focused on the nature of the individual market. Since that 
time, little has changed. It has remained a very small market, 
less than 5 percent of almost every State's population, dwarfed 
by employer coverage, Medicaid, and Medicare. In 2019, we have 
seen a drop from the very sharp rate increases, but premium 
rates remain too high. Of course the subsidized insurance 
market consumers have largely been insulated from those rate 
increases. In some cases, consumers even have the option of 
choosing no premium Bronze plans due to the issue of silver 
loading, a process by which a State allows insurers to apply 
cost-sharing reduction expenses exclusively to on-exchange 
plans.
    The question before the committee is the same as it was in 
2017. The ACA has done many good things for consumers, but it 
has also created new problems. So how can we fix this market? I 
think you can see from my written testimony that we support the 
same goals. We need to stabilize the insurance market. We need 
more outreach. We need more States' flexibility and State 
ownership of the ACA.
    Please allow me a brief aside. Last November I attended an 
InsureTech conference. It was filled with innovators from 
across the globe looking at insurance problems. And I was 
struck by one----
    Ms. Eshoo. Excuse me. What was that conference? I didn't 
get----
    Mr. Wieske. An InsureTech conference.
    Ms. Eshoo. InsureTech?
    Mr. Wieske. InsureTech conference, correct.
    Ms. Eshoo. I see.
    Mr. Wieske. InsureTech conference, and I was struck by one 
presentation in particular. It was from an entrepreneur who had 
figured out how to provide crop insurance to rural Africa 
through their nonsmartphones. What was fascinating about this 
is that this innovator had found a way, is unlikely to make any 
effort and make any money off his effort, but that wasn't the 
goal. The goal was to provide financial stability to rural 
farmers in Africa. A financially stable farmer is better able 
to provide for his family and for his neighbors. The solution 
did not come from government. It came from a private company 
looking to solve a problem. Similarly, the goal of reinsurance, 
exchanges, and navigators is not just to provide money for 
those programs, but to stabilize the market, encourage 
consumers to make an informed decision in purchasing health 
insurance coverage.
    While I still hope you read my eight pages of testimony, I 
can encapsulate it this way. CHC has long supported reinsurance 
and ACA 1332 waivers to improve the markets, including Collins-
Nelson and Alexander-Murray efforts in the Senate who recognize 
that reinsurance doesn't reduce costs directly, it shifts who 
pays. We addressed the long, hard work of improving risk pools 
and lowering costs in a letter we recently sent to Senator 
Alexander which we would be happy to make available to members 
of the committee.
    Navigators, again our experience in Wisconsin was that 
navigator approach didn't have a huge impact. In my written 
statement I recommend both closer engagement with traditional 
brokers and agents as well as new technologies to help 
consumers find coverage. Finally, we recommend going beyond 
State exchanges to allow private exchanges and web-based 
alternatives and direct enrollment to connect people with 
coverage. Again thank you for the opportunity to testify and I 
will be happy to answer any questions.
    [The prepared statement of Mr. Wieske follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. We thank you, especially for not attempting to 
read eight pages of testimony into the record.
    Now I would like to recognize Ms. Audrey Morse Gasteier. Am 
I pronouncing your name correctly?
    Ms. Gasteier. Gasteier, that is right.
    Ms. Eshoo. Thank you very much for being here and you are 
recognized for 5 minutes.

               STATEMENT OF AUDREY MORSE GASTEIER

    Ms. Gasteier. Thank you. Good morning, Chairwoman Eshoo and 
Ranking Member Dr. Burgess, and members of the subcommittee. My 
name is Audrey Gasteier and I serve as Chief of Policy and 
Strategy at the Massachusetts Health Connector. Thank you for 
the opportunity to testify today and share perspectives for 
Massachusetts on expanding coverage and lowering costs.
    Massachusetts has a unique history of bipartisan health 
insurance expansion efforts spanning several decades. The 
advantage of time has given us perspective on what health 
reform and State marketplaces can look like when given stable 
regulatory environments and tools to promote affordability and 
enrollment. This historical view may be useful as the 
subcommittee builds upon the initial years of ACA 
implementation.
    Today Massachusetts enjoys a strong health insurance market 
and the Health Connector is a high functioning and competitive 
marketplace with nine carriers and 280,000 enrollees. Three key 
building blocks have been critical to our market's success. 
First, one of our most effective tools for promoting 
affordability is our ConnectorCare program for individuals 
earning up to three times the poverty level.
    ConnectorCare provides additional State subsidies in 
addition to ACA subsidies. Enrollees have access to zero or 
low-dollar premiums, zero or low-dollar copays, and no 
deductibles. This level of affordability assistance helps 
retain widespread enrollment among a population that would 
otherwise be at higher risk of uninsurance.
    Second, for decades our market has featured the basic 
protections consumers have come to expect following the ACA, 
such as protections for people with preexisting conditions, 
guaranteed issue and renewability, community rating and strong 
standards for minimum medical loss ratios. In addition, our 
State has its own market rules and coverage standards and 
engages in robust market monitoring which together results in 
little room for noncompliant plans, keeping our risk pool 
stable and our residents in coverage that is there for them 
when they need it.
    Further, since 2007, the Commonwealth has had its own 
individual mandate ensuring that people do not buy coverage 
only when they expect to need it, driving up premiums for 
everyone else. Third, the Health Connector has seen firsthand 
the powerful role that outreach and consumer assistance play in 
drawing residents into coverage. Outreach is an integral part 
of successful coverage expansion and an essential component of 
stable risk pools by drawing healthier risk into the 
marketplace, improving affordability for all.
    The Health Connector runs a robust navigator program 
partnering with 16 organizations with longstanding, trusted 
presence in their communities. These three building blocks of 
reform have resulted in a number of successes for our 
residents. Specifically, Massachusetts has achieved nearly 
universal coverage with 97 percent of our residents now 
covered.
    The Massachusetts Health Connector had the lowest average 
premiums of any marketplace in the country in 2018 at $385 per 
member per month before any subsidy was applied. We note for 
the subcommittee that these lowest-in-the-Nation premiums are 
situated within a State market with robust benefit requirements 
and protective cost-sharing limits, clarifying that cost 
savings need not come at the expense of consumer protections.
    Further, we note that Massachusetts' overall healthcare 
system is one with relatively high medical costs, illuminating 
that the marketplace model has the potential of bending the 
curve for consumers even while the State and Nation still have 
work to do in bringing down the underlying healthcare costs 
that drive premiums. We support this subcommittee's interest in 
ensuring that States have resources and tools to foster 
stability and affordability.
    We support the proposed State options for further advancing 
affordability for consumers whether they are low and moderate 
income, and affordability would be achieved through a State 
wrap program designed to meet State and local needs or a 
reinsurance program that could lower premiums across the 
commercial market helping unsubsidized enrollees as well. Each 
State's affordability challenges are likely to be unique and it 
is important for States to have flexibility to address the 
needs of their populations and market conditions above and 
beyond the baseline protections of the ACA.
    With respect to the navigator proposal, the Connector's 
experience suggests that a robust navigator program is a vital 
component of ensuring coverage for the populations that need 
the most help getting insured and that the work they do 
contributes to the overall stability of the commercial market 
risk pool.
    Lastly, the Health Connector recognizes the subcommittee's 
interest in supporting States that are interested in 
establishing new State-based marketplaces. The successes 
Massachusetts has experienced would simply not be possible 
without a State-based marketplace. Working side by side, day in 
and day out with market participants, State-based marketplaces 
can successfully bring the promises of health reform and 
coverage expansion to life.
    Thank you again for the opportunity to speak with you today 
and your interest in hearing about our experiences in 
Massachusetts. I look forward to working with you and welcome 
your questions.
    [The prepared statement of Ms. Gasteier follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you very much.
    Congratulations to each one of you. You did really well 
with your allocation of 5 minutes.
    My question of the three of you is we are considering the 
three bills today, 1386, 1425, and the SAVE Act. Do you all 
support the three bills? Do you think that they are going to 
make a difference to reduce costs and allow for more choice and 
more people being enrolled and being insured with good health 
insurance policies?
    Mr. Lee?
    Mr. Lee. Covered California doesn't take positions on 
legislation and so I am speaking more to the substance of what 
is in the bills that may take different forms. I noted in my 
testimony reinsurance is a valuable tool, reduces premiums and 
also directly addresses the issue that the individual market 
will always be more expensive than the rest of the market. 
Bringing those costs down through reinsurance is a good 
vehicle.
    I noted also that navigators provide a vital piece of a 
broader whole for market----
    Ms. Eshoo. I do. I think we all agree to that. Yes. I have 
learned that people know exactly what their premium costs, but 
they don't know always what they are buying.
    Mr. Lee. Right.
    Ms. Eshoo. And so navigators are so important to assist 
people and answer the questions that they have.
    Mr. Wieske?
    Mr. Wieske. I think I have some concerns with the navigator 
piece. I mean I think we have seen some value.
    Ms. Eshoo. Why?
    Mr. Wieske. We have seen some limited value in the State of 
Wisconsin related to navigators, so, you know, I think as a 
program there is some value there. I think it has been much 
more effective to use agents. I think our understanding is most 
of the navigators, a lot of the navigators and certified 
application counselors in the State of Wisconsin actually refer 
a lot of clients to agents.
    Ms. Eshoo. What about the rest of the country? You are 
naming Wisconsin. What about the rest of the country?
    Mr. Wieske. My impression from other States is that there 
are some concerns with the navigator program in other States as 
well.
    Ms. Eshoo. But it is in and around whether they are 
licensed agents. Is that what you are referring to?
    Mr. Wieske. Correct, licensed insurance agents.
    Ms. Eshoo. Thank you.
    Ms. Morse Gasteier?
    Ms. Gasteier. Like Mr. Lee, we don't take positions on 
specific legislation, but the tools and the concepts I think 
promoted here are ones that we recognize in our own experience 
that the availability of navigators' in-person assistance, 
being a State-based marketplace, and tools like reinsurance are 
very powerful and evidence-based.
    Ms. Eshoo. I want to just take a moment and recognize all 
the white coats that are in the hearing room today. Welcome to 
you and thank you for your professionalism and what you do for 
people across the country. I don't know where you are from, but 
I have no doubt that wherever you are from that you do 
magnificent work, so thank you. We all want to thank you for 
that.
    What of the three of you believe would be the most 
effective tool in order to create affordability for those that 
are in the private market and to afford a good health insurance 
policy? What are the most effective tools? I know you don't 
want to take a position on legislation, but just maybe spend a 
minute each telling us what you think is the most effective 
tool.
    Mr. Lee. So then I will start and----
    Ms. Eshoo. The middle class has taken a hit. There is no 
question in my mind about that. And that is not acceptable for 
any of us.
    Mr. Lee. I think that you are absolutely right, Chairwoman, 
that middle-class people who make more than 400 percent of 
poverty, but that doesn't mean they are rich, have been hit 
hardest. They don't get Federal subsidies. So the two things 
that could be done, well, there is three things, I think, could 
be done. Number one is reinsurance. That lowers premiums for 
everybody. It saves the Federal Government money, but it saves 
money for people that over 400 percent of poverty. Second, 
targeted subsidies. Governor Newsom in California has proposed 
providing State subsidies and tell the Federal Government act 
to get rid of the cliff for people that make from four to six 
hundred percent of poverty.
    Ms. Eshoo. Thank you.
    Mr. Lee. We have people in northern California in your 
district who are being forced to spend 30 percent of their 
income to afford insurance. They can't afford it. So directed 
subsidy--and the third thing is market and outreach. Health 
insurance must be sold. You need to remind people, cajole, 
nudge, those three elements are needed; would make a vital 
difference.
    Ms. Eshoo. Mr. Wieske?
    Thank you, Mr. Lee.
    Mr. Wieske. I would just add onto the discussion that I 
think there needs to be some movement to fundamentally improve 
the risk pool. I think California has indicated they have a 
good risk pool, Wisconsin on the other hand does not. The 
average age is much higher than the average ages across the----
    Ms. Eshoo. Are you from Wisconsin?
    Mr. Wieske. I am from Wisconsin, yes.
    Ms. Eshoo. I see.
    Mr. Wieske. So that is----
    Ms. Eshoo. What was my first clue? All right.
    Mr. Wieske. So, and across the country it varies State to 
State, but it can be very expensive. So changing the dynamics 
of that risk pool to get more younger folks in is a sort of 
key.
    Ms. Eshoo. Healthy people, good mix.
    Ms. Morse Gasteier?
    Ms. Gasteier. Thank you. I would agree on reinsurance and 
keeping risk pools stable and broad and not allowing for the 
proliferation of plans that will siphon healthier people out of 
the risk pool. And I think the flip side of that is outreach to 
the people who because they are price-sensitive and maybe 
younger, people who don't anticipate having health needs, 
whether you have tools that promote continuous enrollment or 
whether you are doing very proactive outreach to those 
populations to bring them in, I think those can be very 
powerful tools.
    In Massachusetts we have also found that applying 
additional subsidies to lower-income individuals can, in fact, 
incentivize very competitive dynamics for carriers that also 
bring down costs for unsubsidized enrollees as well, although 
there is more work to do there.
    Ms. Eshoo. Thank you very much.
    The Chair now recognizes the ranking member, Dr. Burgess, 
for his 5 minutes of questioning.
    Mr. Burgess. Thank you, Chairwoman.
    And I would also just like to make a general statement to 
all of the physicians who are in the audience. This is the 
committee who brought you Cures for the 21st Century, so those 
tools that you are going to have at your disposal that no 
generation of doctors has ever known, this is the committee 
that helped you achieve that goal. This is also the committee 
that brought you the Affordable Care Act, so there is obviously 
some good along with the bad. But you all are smart and young 
and you have got good computers, and I trust that you will help 
us figure this out.
    Mr. Lee, let me just ask you on the individual mandates 
since you referenced it, we had another panel of witnesses here 
earlier that Mr. Tom Miller from AEI who suggested that zeroing 
out the penalty for the individual mandate was as a practical 
matter no significance because no one really paid the penalty 
in the individual mandate.
    Do you have a sense of the number of people who paid the 
individual mandate penalty in California and what the dollars 
collected were?
    Mr. Lee. In California, because of the removal of the 
penalty, we think we have dropped coverage by about 300,000.
    Mr. Burgess. Prior to the----
    Mr. Lee. The penalty, paid penalty in the last year we know 
was about $500 million. So there were people that paid it that 
did not take insurance, but also it provided that economic 
nudge to about 300,000 people that the market has dropped and 
because of that I note last year our premiums went up about 9 
percent. Half of that increase was health plans pricing for a 
sicker population because of the drop of people because of the 
mandate.
    Mr. Burgess. $500 million and they still have no money to 
put to their healthcare and they still get stuck with silver 
loading.
    Mr. Wieske, you have--and it is really a shame you couldn't 
read the entirety of your statement into the record. I may just 
take the time to do that myself. But there is one line here 
that really caught my attention. And in your discussion of 
navigators you talk about a number of factors that have 
contributed including a robust economy, very low unemployment, 
which should lead to higher rates of employer-based insurance 
coverage.
    In the last 2 years we have seen a significant increase in 
the number of people employed, people coming out of the ranks 
of long-term unemployed to perhaps having the availability of 
employer-sponsored insurance. I have not gotten, been able to 
get the Congressional Budget Office to give us coverage numbers 
for what would be the result of that increase in employment. Do 
you have a sense of that?
    Mr. Wieske. So I don't. Unfortunately there is a 
significant lag in looking at coverage issues, and with the 
time and the CBO it is usually about a 2-year lag, so it will 
take some time to figure out.
    Mr. Burgess. So as if--and I have a number of questions and 
I will have to ask for written responses. Also in your written 
responses, if you have an inclination as to where we might look 
for that information outside of the CBO if there is any outside 
group that might have looked at that, I think that would be 
helpful information for the committee to consider.
    Let me, because I am going to run out of time, let me ask 
you, Mr. Wieske--and I appreciate your testimony here in 
February of 2017. Many people forget that we actually had 
hearings before we did our healthcare bill, and your testimony 
on the experience you had on risk pools in Wisconsin was very 
helpful in crafting that part of the bill that dealt with 
reinsurance, that plus the Health Affairs article that dealt 
with the hybrid plans in the State of Maine, the risk pools 
reinsurance hybrid that came about in that State.
    So yesterday--this phenomenon of silver loading, I mean I 
get more complaints. Yes, I get people who are concerned about 
preexisting conditions, but the overwhelming number of 
complaints I get in my office are people who are outside the 
subsidy window, phenomenon of silver loading that affects them. 
In my district, a teacher and a policeman with two children are 
both in the individual market because of the way insurance is 
structured in our State for those professions, and they don't 
get any help. They get no subsidy. So the cost of the benchmark 
silver plan increases--``What, me worry? I have a subsidy, so 
my premium didn't go up''--but that teacher and policeman now 
are really, really strapped.
    So are there ways that this Congress and this 
administration can increase the options for those Americans?
    Mr. Wieske. So the silver-loading issue is caused by the 
cautionary reduction subsidy. It is not paying the cautionary 
reduction subsidy. There is no budget, Federal budget number 
that was attached, no appropriation, and so that would affect 
the silver loading from that standpoint that, if that were 
funded, then States would not be required to do silver loading.
    Mr. Burgess. Let me just ask unanimous consent to include 
for the record the article from the Kaiser Family Foundation 
and yesterday's Washington Post, the Daily 202, which 
referenced how risk pools and reinsurance may actually help 
this situation, and again urge members to look at H.R. 1510 as 
a vehicle to achieve that, and I will yield back.
    Ms. Eshoo. I thank the ranking member.
    Is Mr. Pallone--no, not here.
    I now have the pleasure of recognizing the gentlewoman from 
California, Ms. Matsui.
    Ms. Matsui. Thank you very much, Chairwoman Eshoo and 
Ranking Member Burgess, for holding this important hearing, and 
to our three witnesses for being here with us today. And I am 
particularly happy to welcome Mr. Lee, who is from my home 
State of California and who I see an awful lot in Sacramento.
    I was struck by a few things that all our witnesses agree 
upon. We all agree that the ACA has resulted in numerous 
positive changes for Americans, consumer protections, expanded 
access to coverage, and historic lows in the number of 
uninsured Americans. We also agree there is an opportunity to 
build on the law, the remaining gaps in coverage, affordability 
challenges for consumers, and market challenges for insurers.
    As we heard from Mr. Lee, California has made a significant 
investment in marketing outreach and enrollment assistance for 
consumers. A key component of this investment was funding the 
California navigators program, which plays an important role in 
enrolling populations especially underserved populations in 
health insurance. A new law taking effect this year in 
California bans the sale of short-term, limited-duration 
insurance in the State. Last month our committee held a hearing 
on these types of junk insurance plans and learned how 
consumers can be duped into buying these products without 
knowing they don't cover preexisting conditions or certain 
essential health benefits.
    Mr. Lee, does California's navigator program help 
Californians enroll in these types of junk insurance plans?
    Mr. Lee. Thank you for the question. Absolutely it does 
not. They cannot. The short-term plans, actually, in California 
are not allowed as a matter of law and we make sure that our 
navigators and our certified agents are promoting policies that 
actually provide good essential benefits.
    Ms. Matsui. So you don't at all advocate, great.
    Like California, we have heard about the success of 
Massachusetts at achieving nearly universal coverage. As we 
heard from Ms. Morse Gasteier----
    Ms. Gasteier. Gasteier.
    Ms. Matsui [continuing]. This happened through strategic 
investments, outreach, and policy. Ms. Morse Gasteier, in your 
testimony you note that the Massachusetts Health Connector uses 
data to better understand and reach individuals without 
coverage and communities at greater risk of uninsurance. Can 
you elaborate on how you reach these populations and help them 
enroll in affordable coverage?
    Ms. Gasteier. Thank you for the question. We do, we use 
both national U.S. Census Bureau and local sources of data to 
understand population and demographic dynamics around 
populations that have a higher risk of uninsurance and then we 
use that data to actually select our navigators that we include 
in our program. We work with 16 navigators and they are 
strategically selected to help us make inroads in those 
particular populations. Not just because of their physical 
presence and their sort of trusted role in the community, but 
because they have particular tools to overcome the barriers 
that we think people in those specific populations may be 
facing, whether it is language barriers or accessibility to in-
person assistance.
    Ms. Matsui. That is wonderful. I am pleased that Covered 
California--and we have Mr. Lee here joining us to share in the 
State's success story. As we heard today, Covered California 
has been on the front lines of implementing the ACA, serving 
over 3.4 million Californians since 2014, lowering our eligible 
uninsured rate to 3 percent, and working to keep our premiums 
about 20 percent lower than the national average.
    Mr. Lee, what are the unique characteristics of Covered 
California that allowed you to steadily increase enrollment and 
keep costs low and maintain competition?
    Mr. Lee. Well, first I would note we aren't unique. We were 
thrilled to do this report jointly with the State of 
Washington, the State of Massachusetts, other States that have 
leaned in, have used all the tools----
    Ms. Matsui. Right.
    Mr. Lee [continuing]. Specific to their State. But I would 
note it has been number one, focusing on market and outreach. 
Number two, having common patient-centered benefit designs that 
when people sign up for our plans whether they pick Kaiser, 
Blue Shield, or Anthem, they have the same knowledge that when 
they go to see a doctor there won't be a deductible they need 
to pay before they see the doctor. That means consumers see the 
value of insurance.
    That, and finally I would note we actually focus on the 
underlying cost of care. We have contractual requirements with 
our 11 health plans to have them look at the delivery system 
making sure people get the right care at the right time. Those 
factors together we think are part of our formula for building 
what we hope will be success for over the long term.
    Ms. Matsui. Thank you.
    Ms. Morse Gasteier, your State has also taken a proactive 
approach going back to before the ACA. What lessons can you 
continue to apply from Massachusetts to the Federal 
marketplace?
    Ms. Gasteier. So I would say that we focused again on 
trying to bring in healthy, low-risk people into the 
marketplace by doing data-driven outreach to them and also 
really work to have a very stable regulatory environment where 
we keep our eyes on the road in terms of keeping the markets 
stable. We work really closely with our carriers which is 
something that we are able to do as a State-based marketplace 
in being in very close contact with them.
    And I would just say more broadly in Massachusetts we have 
had sort of a bipartisan cross-stakeholder support for our 
health reform and that has continued through the 13-year 
experience of our coverage expansion efforts which has been 
critical.
    Ms. Matsui. Well, thank you very much and----
    Ms. Eshoo. I thank the gentlewoman. I now would like to 
recognize the gentleman from Michigan, and a gentleman he is. 
He is a former chairman of the full committee, Fred Upton.
    Mr. Upton. Well, thank you, Madam Chair. It is a delight to 
be here, obviously, and I appreciate the testimony from our 
witnesses.
    Mr. Wieske, I would like to go back to your very beginning 
of your statement talking about how States could have more 
flexibility, and to date I would note that 14 States have 
submitted waivers under section 1332. Eight of the States have 
active waivers, seven of which are for State reinsurance 
programs. And I would have to say that it is my understanding 
that these waivers are budget-neutral to the Federal 
Government. Is that correct?
    Mr. Wieske. That is correct, sir. It is a requirement of 
the 1332.
    Mr. Upton. And it is also true that States have 
demonstrated that they can take steps under section 1332 to 
stabilize their markets without new Federal money? In fact, the 
pass-through funding or savings generated from those market 
stabilization programs can be reinvested onto the program 
further reducing premiums. Is that correct as well?
    Mr. Wieske. Correct. We use the program in the State of 
Wisconsin to do exactly that.
    Mr. Upton. Yes. Now, Dr. Burgess--I am sorry he left, but I 
know he is coming back--yesterday introduced legislation that 
would provide additional Federal resources for States to 
establish market stabilization programs. And it is my 
understanding that that would then incentivize additional 
premium reductions across the country; is that right?
    Mr. Wieske. Yes. I think coming from Wisconsin and seeing 
it on the front lines, I think States need a lot of flexibility 
and having a one-size-fits-all program has never sort of 
worked.
    Mr. Upton. I would note that CBO previously projected that 
one of the most effective ways to stretch premium reductions is 
to have a State option with a Federal fallback, which is in a 
sense what Dr. Burgess said does, or a Federal default allowing 
for States to innovate as they see fit.
    Would you agree that States should be given choice instead 
of control when it comes to repairing their markets' damage?
    Mr. Wieske. Yes. I think in my experience in Wisconsin as 
deputy commissioner there, I think it was important for us to 
have a lot of flexibility and I think a lot of the problems 
that we face in the ACA would have been made better if we would 
have had more flexibility in how we implemented it.
    Mr. Upton. In your experience in Wisconsin, what other 
States would you highlight are on that same path?
    Mr. Wieske. So our reinsurance program was copied from 
Minnesota's almost whole cloth. We made some changes which was 
moved off of Alaska's. So I think in a lot of cases States are 
talking to each other. And we talked when I was there, still 
there, we talked to a number of States about our program as we 
were going through the development.
    So I think through the NAIC, National Association of 
Insurance Commissioners, and other pieces, there is a lot of 
discussion among States to sort of get commonality and to 
figure out what the best approaches are and the best approaches 
are not necessarily the same State to State.
    Mr. Upton. Great.
    Yield back, thank you. Thank you, Madam Chair.
    Ms. Eshoo. I thank the gentleman. I now would like to 
recognize the gentlewoman from Florida, Ms. Castor.
    Ms. Castor. Thank you, Chairwoman Eshoo, for scheduling 
this hearing on how we lower healthcare costs for our neighbors 
and provide meaningful coverage for American families.
    I want to start by thanking our hardworking, nonprofit 
partners who have fought with us for affordable healthcare over 
the years and to ensure that independent, unbiased navigators 
are available to American families, especially Rob Restuccia, 
the longtime executive director of Community Catalyst, who died 
over the weekend from pancreatic cancer. Rob was a champion of 
empowering consumers to fight for better healthcare and he will 
be missed.
    And I want to thank the witnesses. After reading your 
testimony I was really struck by how difficult it has been for 
American families to keep up. The Trump administration has 
really socked it to them. We were making such good progress on 
lowering the uninsured rate and lowering healthcare costs and 
now, you know, it is like death by a thousand cuts.
    Removing the individual mandate and promoting junk 
insurance plans, a tax on the insurance pool, whittling away 
the protections for preexisting conditions just have really 
socked it to consumers in their wallet and we want to get back 
to doing everything we can to lower healthcare costs for them. 
The Trump administration also has slashed funding for our 
independent, unbiased navigators who are very effective. Yes, 
they work in concert with agents and brokers, but you need them 
both on the field. There is just no substitute for that 
independent, unbiased advice.
    So my bill, H.R. 1386, Expand Navigators' Resources for 
Outreach, Learning, and Longevity, the ENROLL Act, will secure 
vital services for navigators so that they can continue serving 
our neighbors. And I want to thank my colleague Congresswoman 
Blunt Rochester along with Representatives Wilson, Crist, and 
Murphy for being original cosponsors on this important bill.
    Families across the country have been aided by unbiased 
navigators to help them determine the best health insurance 
option for them. Unfortunately, the Trump administration 
attacked this crucial initiative by slashing it by over 80 
percent since 2016, as well as big cuts to outreach and 
advertising efforts.
    So my ENROLL Act will guarantee that navigators remain on 
task to ensure that our neighbors understand the financial 
assistance and coverage options available to them. 
Specifically, the ENROLL Act will fund the navigator initiative 
in the Federal ACA marketplace at $100 million per year. It 
will require HHS to ensure that grants are awarded to 
organizations with demonstrated capacity to carry out the 
duties of a navigator. It would reinstate the requirement that 
there be at least two entities at each State; that they have a 
physical presence in the State. Oftentimes, navigators 
determine that the more appropriate and affordable option might 
be the Children's Health Insurance Program or it might be 
Medicaid, so it would clarify that navigators can provide that 
advice on enrollment.
    In Florida we are very fortunate that the University of 
South Florida has been the lead navigator and has worked with 
other nonprofit partners all across the State and their efforts 
have paid great dividends to families across my State. We 
continue to lead in the number of enrollees in the healthcare 
marketplace.
    But they have told me this year that those dramatic cuts 
had a very serious impact. That they were not able to get out 
especially into rural areas to make sure that families 
understood what their options were and had the ability to sign 
up. This directly impacts affordability for everyone.
    And, Ms. Gasteier, could you speak to the importance of a 
broad-based insurance pool to lowering costs and the role that 
navigators play in that?
    Ms. Gasteier. Thank you for the question. We believe in 
Massachusetts that we all do better when everybody is in the 
same market and the same risk pool with strong comprehensive 
standards sort of holding up that market so that people know 
that the coverage they have they can count on. And we see 
outreach as an effective, proven method for drawing in people 
who might otherwise think that they can go out without coverage 
who may tend to be younger people.
    And so we have found that those efforts are very important 
both for those people so they are protected, even though they 
may not expect something to happen to them and that we think 
that that has been part of why we have been able to keep our 
premiums so stable in Massachusetts.
    Ms. Castor. And, Mr. Lee, do you agree with that?
    Mr. Lee. Very strongly and including in particular your 
note that it is not just navigators, it is navigators with 
agents. Twelve thousand agents in California, but we have 100 
nonprofit groups we directly fund to fill in the gaps. We 
target them to serve areas that are not well served by agents.
    Ms. Castor. And that investment helps everyone by lowering 
costs; is that correct?
    Mr. Lee. Absolutely. We have lower costs in California 
because of the effective outreach, and again we use navigators 
to target where agents aren't effectively reaching. So it is 
not an either-or, agents in California get paid $130 million in 
commission payments. It is a lot of money. We pay our navigator 
program about 6.5 million. And so, yes, they enroll fewer than 
agents, great, but we target them to outreach to Spanish-
speaking communities, African American communities, LGBTQ 
communities, rural communities. So that is the role that 
navigators--to pick up the gaps that agents and other outreach 
isn't addressing effectively otherwise.
    Ms. Castor. Thank you very much. I yield back.
    Ms. Eshoo. We thank the gentlewoman for her legislation.
    I now would like to recognize Mr. Shimkus, the gentleman 
from Illinois and a good friend and my E911 partner and----
    Mr. Shimkus. Yes, ma'am.
    Ms. Eshoo [continuing]. Away we go.
    Mr. Shimkus. Thank you, Madam Chairman. This is a great 
hearing, and I appreciate you all being here.
    Mr. Lee, I want to--and the way I like to do it, I like to 
breeze through the testimony, but I like to hear the questions 
and answers and I scribble a lot of notes and questions taken 
off of--so you mentioned that because the individual mandate 
was not enforced, 300,000--is that the right--300,000 dropped 
off.
    And then I think I heard through the other questions is 
that California, and I think my colleague Ms. Matsui mentioned 
California has a law that says you can't have other than the 
standard ACA-type plans. So these 300,000 have no option then, 
is that--I am trying to figure where they--are they covered 
somewhat?
    I mean, a lot of States have options. I have been through 
the whole debate. I was here when we passed. A lot of folks 
liked the plan they had, the Congress and the President decided 
to change that. So then they got thrown into plans that they 
didn't like that was so too costly and the premiums were high 
and the deductibles were ridiculously high. And they just 
begged for me--and I have four from just recently in October 
and November and December--to just go back to the plan they had 
in the past, a lot of my constituents.
    So I am trying to figure out where is the--does these 
300,000 have no coverage?
    Mr. Lee. Our understanding is the vast majority go to be 
what we call bare. They go without insurance. And again, this 
happens also in the employer market. About 20 percent of the 
people who----
    Mr. Shimkus. Yes, I got that. But wouldn't something be 
better than nothing?
    Mr. Lee. In many cases not, because the issue about that 
something, often that something, a short-term plan may mean 
that if they get cancer it is not covered. So often it is faux 
coverage. The point of encouraging people to sign up for 
coverage that matters is to encourage people to get coverage 
that will be there for them when they get sick.
    Mr. Shimkus. Right. And we had a hearing earlier as was 
identified and I brought up associated health plans as an 
option with either associations--I mean California is a big 
State, Illinois still a relatively big State. If our farm 
bureau decides to either State-wise to develop a covered pool 
in associated health plans that has the same requirements as 
outlined under the ACA, does California support association-
type health plans?
    Mr. Lee. Again I don't speak for the State of California. 
What we have done in California as a State though is try to 
make sure that the insurance offerings will be there when 
people need them. And so examples of, there are products today 
in California that are under sharing ministries that mean you 
buy it and there is a $250,000 lifetime cap per incident.
    Mr. Shimkus. Right, OK. Fine, I got that.
    Mr. Lee. And so that is part of the----
    Mr. Shimkus. I want to get to another couple questions, but 
I would just from my experience in my district is many people 
lost insurance that they liked and was thrown into insurance 
that they couldn't afford and they couldn't use. And I want to 
go to Morse Gasteier for a second, because you mentioned how 
Massachusetts really changed the Affordable Care Act in one 
interesting provision.
    When we had this debate in the legislation, what was 
mandated was if you get sick you can immediately buy. And I 
think I heard either in your testimony or in response to a 
question you said we have changed that. How have you changed 
that and what did you do?
    Ms. Gasteier. Thank you for the question. I am not sure we 
have changed anything. We had our own individual mandate 
already in Massachusetts prior to the Affordable Care Act so 
there was----
    Mr. Shimkus. Can people--I think one of the problems was 
people were if they got sick today they could go buy insurance, 
which when you are talking about pools and people buying in 
that escalates costs.
    Ms. Gasteier. It does. So we have always used open 
enrollment periods to try to make sure that people are not sort 
of, quote unquote, jumping and dumping and coming in and out of 
coverage just when they get sick or think they may need an 
expense. And we have found that having tools like that in the 
market where there is sort of an expectation that everybody is 
always in the pool has helped keep----
    Mr. Shimkus. So I may have misunderstood that response to 
your question.
    Ms. Gasteier. That is fine.
    Mr. Shimkus. So then I apologize. That is what I wanted to 
ask.
    Mr. Wieske, this silver loading--no. I don't want to ask 
that question. I want to ask, do you have empirical data on the 
benefits or the lack of benefits that you have seen in that 
navigator population? I am a big dealer and broker, folks. I 
understand spreading it out. But, really, the question is cost-
benefit analysis and are they really delivering for what versus 
kind of what we hear?
    Mr. Wieske. There may be a difference between States that 
have an exchange and can control their navigator programs and 
States that don't. What we saw as a problem in Wisconsin is we 
never knew what was going on with navigators despite 
requirements for licenses, despite requirements for CAC 
licenses and registration of assisters.
    We had numerous occasions where we had to investigate 
navigators who we later found out in some cases were and in 
other cases were not navigators, were holding this out. So it 
was a little bit confusing for us despite the fact that we had 
some regulatory authority.
    Mr. Shimkus. Thank you, Madam Chairman, appreciate the 
time.
    Ms. Eshoo. Thank you, Mr. Shimkus.
    I have to excuse myself from the hearing for a bit, but 
certainly all the doctors in the audience will be pleased to 
know that we have M.D.s on both sides of the aisle. And so Dr. 
Raul Ruiz is going to take this chair.
    Mr. Ruiz [presiding]. And with that I would like to 
recognize Congressman Schrader from Oregon for 5 minutes.
    Mr. Schrader. Thank you very much, Mr. Chairman. I 
appreciate the hearing today. It is a great hearing, actually, 
indicative of hopefully where this Congress is going to go in 
terms of fixing some of the problems, a few of the problems 
with the ACA and recognize that it serves a great deal of value 
for a lot of folks.
    And I am a proud cosponsor of 1425. It is probably the 
single most important thing we can do to help stabilize the 
individual marketplace which, based on the Republicans' work in 
the last Congress, would be a goal of theirs as well as a goal 
of Democrats, so a nice area of bipartisanship.
    I wanted to also note that earlier this week I led a letter 
with 76 other of my colleagues from the New Democrat 
Coalition--Chairman Pallone, Chairman Scott, and Chairman 
Neal--making it a priority for this Congress to bring down 
costs and make sure that healthcare is affordable to everybody 
through the Affordable Care Act, which as I said went a long 
way to getting us there.
    So I would like to ask consent, unanimous consent, that we 
can enter that letter into the record.
    Mr. Ruiz. So ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Schrader. OK. Thank you, Mr. Ruiz, Dr. Ruiz.
    I would also like to note for the record that Blue Cross 
Blue Shield is also a big supporter of 1425 because they 
recognize the value of reinsurance also.
    I guess a basic question for Mr. Lee, a number of States 
pointed out by the ranking member and others have established 
their own reinsurance programs through the 1332 waivers, which 
I think is a great thing, everyone has testified, and I think 
everyone here acknowledges is a great opportunity for States to 
innovate, you know, not a one-size-fits-all.
    But there are probably some limitations and some 
opportunities that a Federal reinsurance program or high risk 
pool type of thing could offer. Could you talk a little bit 
about how that might relate to what some of the States who are 
already doing some reinsurance programs and how it might help 
them?
    Mr. Lee. Yes, I would be happy to, thank you. So first, as 
you note, seven States have done the State-based reinsurance, 
but they range in what the Federal Government has matched to a 
low of 30 percent, meaning the State had to come up with 70 
percent of the dollars, other States got a hundred percent, 
others 70. And most States are struggling with their own State 
budgets, so that is one uncertainty.
    The other thing I would flag is the 1332 provisions, as was 
noted earlier must be deficit-neutral. Now I understand the 
importance of deficit neutrality, but that actually means a 
State that uses a program and enrolls more people is hit 
because enrolling more people will affect the deficit. The goal 
of the Affordable Care Act should be to get more people 
covered.
    And that is one of the reforms I think that isn't on the 
table, but in thinking about to use a 1332 waiver mechanism 
that in essence punishes a State for getting more people 
insured is a bad mechanism. So those are two problems.
    The other is--and I want to really appreciate the 
thoughtfulness in your legislation--is some States will say 
reinsurance, reinsurance if we use California by the formulas 
in your bill would reduce premiums by about 7 percent. That is 
a lot. But it might be better invested to target those people 
just from four to six hundred and your allowing a State the 
flexibility to do that I think gives State flexibility, which 
is exactly what many States like California would look to do.
    Mr. Schrader. Thank you very much for the response, and I 
agree. I mean, there is a nice synergy here between the Federal 
Government supporting some of these programs in a thoughtful 
way and enabling the States to use it in a flexible manner that 
best serves their needs. That was the genesis of the work that 
the New Democrats did with their solutions over politics in the 
last Congress. It is the genesis of the bipartisan legislation 
came out of the Problem Solvers Caucus. It included 
reinsurance, had the cost sharing subsidies, and expanded 
exactly what you are talking about, the 1332 waivers.
    But it kept the essential benefits package that you guys 
have also acknowledged is critical so that consumers aren't 
being deceived. And the more people you get into the 
marketplace, the more the risk is shared, the less cost 
shifting that goes onto these individual marketplace people 
that are suffering, if you will, under these premium/deductible 
increases while other people are benefiting.
    The last comment I would make real quick is to the Hyde 
language. I mean I really hope that my colleagues on the other 
side of the aisle are willing to move past that. I would point 
out that in our previous legislation, whether it was the ACA or 
the Problem Solvers one, we did not try and get rid of the Hyde 
Amendment, you know, that has been a longstanding agreement, or 
by both sides of the aisle. We recognize people have different 
faith-based concepts and support that.
    I think it is a little unfortunate that some of our 
colleagues on the other side of the aisle are trying to, you 
know, prevent States from using their own funds or nonprofits' 
funds or individuals' funds in the arena of family choice. That 
is unfair. That is an expansion of the Hyde Amendment that I 
think makes fixing the Affordable Care Act and fixing the 
marketplace, getting at the preexisting condition thing a real 
problem. And I yield back. Thank you.
    Mr. Ruiz. Next is Congressman Guthrie.
    Mr. Guthrie. Thank you very much. Thanks, Chairman, for 
yielding. I appreciate the opportunity and all of you to be 
here today.
    I want to focus on the background of the State-based 
marketplaces. The State-based marketplace grants were awarded 
between 2010 and 2015 in compliance with the law. No planning 
or establishment grants could be awarded after December 31st, 
2014. I think we all agree with that. In all, CMS awarded over 
5\1/2\ billion to 49 States, the District of Columbia, and four 
territories for the purpose of planning and establishing health 
insurance exchanges.
    The available money was unlimited, the amount of money was 
unlimited, and in definite authorization and appropriation the 
5\1/2\ billion included grants for exchange planning, exchange 
establishment, early innovators and administrative supplements 
to any of these grants. Every State except Alaska applied for 
these grants.
    Florida and Louisiana were awarded planning grants but 
later returned their entire grants. Other States returned some 
of the money they received but kept some. For 2018 planning 
year, 34 States had Federally Facilitated Marketplaces, 12 
States had State-based marketplaces, and 5 States had State-
based marketplaces using the Federal platform.
    So in all, 17 States have 12 based marketplaces or State-
based marketplace that uses the Federal platform. Those 17 
States accounted for roughly 4.5 billion of the 5\1/2\ billion, 
but only 12 States had their own State-based marketplace. So in 
summary, of the 5\1/2\ billion dollars awarded in grants, 12 
States have exchanges.
    So, Mr. Wieske, when you with Wisconsin's insurance 
department--and this gets--I think you talked about some 
innovative things you wanted to do when Congressman Upton asked 
you questions. But my question is, when you were with 
Wisconsin's insurance department, if you were given a slice, 
your slice of the 5.5 billion without all the mandates that 
came with it, what creative and efficient ways would you choose 
to utilize Federal dollars?
    Mr. Wieske. We actually started going down that path at one 
point and we actually are one of the States that returned the 
money. What we found was there was some lack of flexibility in 
the ability for us to design the exchange and it was going to 
be very expensive. And let me be more specific. We were looking 
for a single-door entry into both our Medicaid and our State 
system. We were looking a variety of other pieces to make it 
easier for consumers. Unfortunately, the requirements that the 
Federal Government had in place made it impossible for us to 
continue and we ended up dropping off of that.
    So I think at that time we were looking at a single-door 
entry, I just didn't think we under the Federal rules think it 
was possible. On top of that, the cost of doing it for a 
smaller population in a State like Wisconsin where there is 
about 200,000 people enrolled in the exchange, if you look at 
$20 million a year to spend that is $100 a person, $100 a 
person to be able to afford the exchange. That is a very 
expensive fee on top of what the overall costs were. So the 
risks were very high for us as well.
    Mr. Guthrie. Thanks. When we were debating the Affordable 
Care Act and repeal and replacement of it, Wisconsin came to 
the forefront in preexisting condition coverage and a lot of 
debate here was talked about what Wisconsin did and how people 
who had, particularly cancer survivors and so forth, had better 
coverage under the Wisconsin pre-ACA model than after the 
mandate, after the ACA. Would you kind of talk about what you 
guys did for preexisting conditions?
    Mr. Wieske. Yes. I think the important message here, I 
think, from a State perspective is that States have an interest 
in insuring their residents as well. I think both, you know, 
everybody here at the table understands that and believes that. 
And Wisconsin actually had a very comprehensive high-risk pool. 
You could see any doctor in the State. We subsidized that high-
risk pool. It was expensive, make no mistake. It was more 
expensive than standard coverage because we didn't subsidize 
it, so there should have been pieces that--there were pieces 
that could have been improved upon.
    But I think we still have some folks who have an interest 
in going back to that. However, moving forward, you know, it is 
clear that the ACA has provided some subsidies for folks who 
had affordability issues in that market as well. So, you know, 
Wisconsin could have done a bit more if they had more 
flexibility.
    Mr. Guthrie. Thank you.
    And, Ms. Morse Gasteier, you talked about continuous 
coverage and tools for ensuring continuous coverage. I 
understand the open enrollment gives an incentive. Is there 
other tools that you would suggest? I mean just in open 
enrollment if I have guaranteed issue and I don't sign up and 
then I get sick, then I can buy health insurance coverage when 
open enrollment comes again. I get you are in it for the 
interim. Is there other tools that you would suggest to be able 
to do?
    Ms. Gasteier. Thank you for the question. I think we take 
the allure of affordability very seriously in Massachusetts and 
have tried to construct a very competitive marketplace that in 
addition to those tools incentivizing people to keep continuous 
coverage we see as drawing people into the ranks of the insured 
through our exchange which covers 280,000 people now. And I 
have noted some of the policy features of the way we have 
approached our subsidized program also has benefits for 
unsubsidized individuals as well who also have access to these 
lowest-in-the-Nation premiums.
    So we see all those tools as working together, those 
incentives through our individual mandate to incentivize 
coverage as well as making sure affordability is of paramount 
significance and presence for people in our market.
    Mr. Guthrie. Well, thank you. My time has expired and I 
yield back.
    Mr. Ruiz. Thank you.
    Representative Kuster, you have 5 minutes.
    Ms. Kuster. Thank you very much. And thank you to our panel 
for being with us. I want to start by associating myself with 
the remarks of Representative Schrader. I think we do have 
options to shore up the Affordable Care Act and they are 
bipartisan and we should work together to get that done. I am 
very concerned about the efforts of this administration to 
sabotage the Affordable Care Act, and I do agree that some of 
our colleagues on the other side of the aisle are trying to 
throw, really, a monkey wrench in terms of the status quo of 
the Hyde Amendment and trying to disrupt our ability to provide 
health insurance for all Americans.
    I want to talk about H.R. 1425, the reinsurance bill, and I 
am a proud supporter cosponsor with my colleagues Angie Craig 
and Scott Peters. Why would a State--and I will direct this, 
Mr. Lee, at you--why would a State seek to develop its own 
reinsurance program if there was a Federal reinsurance? That is 
a place to start.
    Mr. Lee. A really good question, I think, that a State 
wouldn't. If the mechanism was reinsurance they would probably 
go with a Federal administration. The issue is if 
proportionately a State could get the same amount of funds that 
would have been used for reinsurance and instead target it in a 
different way, States might do that.
    I gave the example of our Governor Newsom has said we want 
to bring back a penalty and expand subsidies, targeting people 
right above the cliff. We have working middle-class Americans; 
I am sure, in New Hampshire as well in California that really 
need help. Reinsurance lowers costs for everybody, saves the 
Federal Government a lot of money, but it may make a State, for 
a particular State to say we want to target particular 
populations, but it would not make sense to me. I can't imagine 
a State that would take the money and just do reinsurance.
    Ms. Kuster. And I agree with you we want to target that. I 
was visiting with a hospital the other day that has dropped the 
uninsured population showing up at their hospital from 9 
percent down to 3 percent, but it is how to get at that 3 
percent, the working low-income people and younger people, 
honestly.
    You mentioned the increased riskiness of the individual 
market making reinsurance a tool to control costs. Is there a 
point at which the market becomes too risky for even 
reinsurance to work--and again back to the sabotage by this 
administration--making these markets unstable?
    Mr. Lee. I think there is. I am not sure what it is, but 
you look at it again--Massachusetts, California, Washington, 
other States with State-based marketplaces--we have maintained 
enrollment over the last years. Federal marketplace States have 
seen mammoth drops in new enrollment. Many of those States have 
seen premiums rise so high that people without subsidies are 
largely only sick people because healthy people have been 
priced out entirely.
    Reinsurance would help. I don't think in many of those 
States it would help enough. A 7 percent reduction in premiums 
when those States have seen an 85 percent premium increase in 
the last 5 years is good, but is it enough, probably not. And 
so I think one of the challenges, it is reinsurance is a tool, 
but it needs to be part of a broader issue of doing outreach, 
doing outreach, a whole range of things that in much of the 
Nation is not currently happening.
    Ms. Kuster. And I want to get out the sabotage again 
because they have created a catch-22. This administration is 
sabotaging the Affordable Care Act and then turning around and 
saying rates have gone up. But you mentioned the proliferation 
of junk health plans and other efforts by the Trump 
administration to sabotage.
    Are you concerned that the efforts of this administration 
over the last year may push these markets past a tipping point, 
and again tying into your comment about how reinsurance can be 
helpful?
    Mr. Lee. Well, I think absolutely encouraging healthy 
people to buy products that look cheap but might not be there 
for them when they get sick both is risky for those individuals 
that buy the products and damages the risk pool, raises costs 
for everybody. I do think--I am not sure what a tipping point 
is, because while we continue to have the subsidies people that 
get subsidies will always have a market. The only problem is 
without doing marketing they won't even know it is there.
    Ms. Kuster. And I do have legislation around the 1332 
waivers that to try to keep us from reaching that point.
    Ms. Morse Gasteier, as a New Hampshire neighbor to 
Massachusetts I am especially interested, why didn't 
Massachusetts seek a 1332 waiver for reinsurance?
    Ms. Gasteier. It is something we have looked at. 
Massachusetts, you know, looks at different options for 
flexibility and if we find opportunities that can help our 
market in terms of affordability and stability, you know, we 
are interested in those so long as they don't, you know, 
deteriorate any of the important market conditions or consumer 
protections that we have long held as critically important.
    Our market right now is largely stable. We will continue to 
look at opportunities for reinsurance. But as Mr. Lee noted, it 
does require at present a lot of State resources to invest in 
these 1332 waivers. So it is something we will continue to look 
at, but to date hasn't struck us as compelling for our market.
    Ms. Kuster. Well, and hopefully if we can get this 
bipartisan legislation passed you will have that option, so 
thank you.
    I yield back, Mr. Chair.
    Mr. Ruiz. Thank you.
    Now Representative Griffith, you have 5 minutes.
    Mr. Griffith. Thank you very much, Mr. Chairman. I do 
appreciate it. This committee had significant concerns about 
and accordingly extensively studied the navigators program in 
the previous administration. And I would like to introduce into 
the record the following letters sent by the committee in 2013: 
an April 12, 2013 letter to Secretary of HHS Kathleen Sebelius; 
a June 28, 2013 letter to then-Secretary of HHS Kathleen 
Sebelius; an August 29, 2013 letter sent to 51 grant recipients 
in 11 States that received 61 percent of navigator dollars at 
the time and a list of those grant recipients who received the 
letter; and a September 20th, 2013, letter to then-Deputy 
Administrator and Director of the Center for Consumer 
Information and Insurance Oversight, CCIIO, at CMS, Gary Cohen.
    May that be admitted, without objection?
    Mr. Ruiz. So ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Griffith. During plan year 2017, navigators received 
more than $62 million in grants and enrolled only 81,426 
individuals, less than 1 percent of the total enrollees but at 
a cost of over $750 per person. By contrast, agents and brokers 
assisted with 42 percent of federally facilitated exchange 
enrollment for the plan year 2018, which cost the FFE only 
$2.40 per person or per enrollee to provide technical and 
training assistance.
    So, Mr. Wieske, I have questions about whether we should, 
you know, be putting more good money after bad results. H.R. 
1386 would redirect a hundred million annually to the failed 
navigator program. Based on your experience in Wisconsin, can 
you speak to whether the navigator program was a good 
investment for taxpayers there?
    Mr. Wieske. Look, what we saw in the State is if you look 
at the other lines of insurance they have moved away from sort 
of the face-to-face. They have moved into different methods to 
get customers. And while navigators have some value, certainly, 
in certain populations, I don't think we had a feeling that 
they had a strong presence in our rural communities that were 
also largely uninsured and in other spots. So, you know, we 
felt that agents were much more effective and that there were 
other methods to encourage enrollment.
    Mr. Griffith. Thank you. During your time as deputy 
insurance commissioner of Wisconsin, did Wisconsin experience 
any fraud, waste, or abuse within the navigator program?
    Mr. Wieske. So we had a number of cases that we had to 
investigate. Mostly people who were posing as navigators who 
were not, in fact, navigators, that had problems. We didn't 
actually have any problems, we had a----
    Mr. Griffith. So you didn't have any problems with the real 
navigators, it was with the fake navigators.
    Mr. Wieske. Real navigators. We had problems with fake 
navigators, correct.
    Mr. Griffith. All right. And based on your experience with 
the navigator program, do you believe that redirecting a 
hundred million annually to the navigator program as H.R. 1386 
intends to do would be a wise investment for the taxpayer?
    Mr. Wieske. I think we are hoping to encourage more 
flexibility in the way consumers can sign up for coverage, 
should get them where they actually buy coverage today.
    Mr. Griffith. All right, I appreciate that. I did think it 
was interesting to note that several of my colleagues have 
talked about the cost of the insurance. Mr. Lee spoke about 85 
percent in most of the Federal markets, the price has gone up 
in the States that have their own markets that is less than 
half of that, about 39 percent, in his written testimony, and 
that this really affects the middle-class family, the average 
family that are above that 400 percent of poverty level rate.
    What is interesting about that is that when this plan was 
being discussed, and it is one of the things that we have to 
look at when we are looking at the new promises to lower rates, 
people of my district were promised--that the President came to 
the district when he was campaigning and said he was going to 
reduce the average cost of healthcare for the average family by 
$2,500 a year.
    And now we are talking about if we pass new bills we might 
get a 7 percent reduction in an 85 percent increase. Clearly we 
are not anywhere near the goals that this plan promised and we 
are experiencing--and my constituents complain all the time. 
And so I appreciate you mentioning that, Mr. Lee. You know, 
their copays have gone up, their out-of-pockets have gone up, 
and their insurance premiums have gone up and they have just 
been hit hard and it is a whole lot more expensive than what 
they were facing before Obamacare.
    Hopefully we can find some bipartisan resolutions to bring 
down these costs, but I don't think that it can ever get to 
that point where the families actually see, average American 
family sees a reduction under Obamacare, as he promised at 
Virginia High School in my district, a $2,500 decrease. I yield 
back.
    Mr. Ruiz. Ms. Kelly, you have 5 minutes.
    Ms. Kelly. Thank you, Mr. Chair, and thank you all for your 
testimony today. Since the Affordable Care Act's passage, 
approximately 20 million Americans have gained health coverage 
through the laws' various coverage protections. An additional 
nine million low- and moderate-income Americans receive health 
insurance subsidies that help them pay for healthcare. In 2019, 
more than 7 in 10 consumers on the ACA marketplaces can get 
coverage for $75 or less per month after tax credits. These tax 
credits make healthcare affordable for millions of Americans.
    Ms. Morse Gasteier, thank you for your testimony today. You 
discussed Massachusetts' subsidy program known as ConnectorCare 
which supplements ACA subsidies and helps your State's 
residents pay for healthcare. You briefly mentioned how the 
program benefits consumers who are not eligible for subsidies. 
Can you describe how the program helps lower premiums for all 
enrollees in your State?
    Ms. Gasteier. Absolutely. Thank you for the question.
    So our program ConnectorCare provides subsidies, extra 
State subsidies on top of Affordable Care Act subsidies and 
further brings down the cost of premiums and cost sharing for 
individuals up to 300 percent of the Federal poverty level. And 
those products that become available through that program are 
built on top of a commercial silver market tier plan. And what 
the structure of the program does is it strongly incentivizes 
participating carriers to lower premiums to compete to be in 
that program because they show up to as the lowest cost plan 
and they get a lot of enrollment by being very cost-
competitive. The benefit for unsubsidized individuals is those 
low-base silver plans then become available to unsubsidized 
enrollees as well.
    And in Massachusetts we also have small businesses in the 
same risk pool, so small businesses also benefit from those 
lower premiums that carriers are competing to get the attention 
of price competitive shoppers with. So that is one of the ways 
the program itself is helpful both to those low-income 
enrollees who are enrolled in the program as well as middle-
class unsubsidized enrollees as well and small businesses too.
    Ms. Kelly. Thank you. For other States that are looking at 
this, what are some of the challenges that they might face?
    Ms. Gasteier. So of course coming up with the funding to 
create those State wrap dollars is critical, so I would think 
if another State were pursuing something like this that would 
be sort of priority one for them to determine how to finance 
that. We, I think are very advantaged by being a State-based 
marketplace. In administering something like this we are able 
to aggregate all the different funding streams, the Federal 
subsidies, the State subsidies, the enrollee contributions and 
we are able to do that by doing premium aggregation which is a 
benefit of being a State-based exchange.
    And so States that are pursuing things like this would need 
to think about the mechanics of how it all works together and 
we would certainly be happy to provide technical assistance to 
any State interested in that. But I would say resources are the 
top order issue for a State pursuing something like this.
    Ms. Kelly. And just share how you did come up with the 
resources and just--OK.
    Ms. Gasteier. Absolutely. So it was a number of different 
funding sources that the State identified and this was all a 
part of our original State reform effort back in 2006. So we 
worked with our Medicaid program and Federal partnership with 
CMS. There are a number of State-based revenue streams that 
come into a trust fund that our Connector administers. And so 
that has kind of gone back to 2006 and then we restructured the 
program in 2014 to complement the Affordable Care Act.
    Ms. Kelly. Thank you. And I want to thank you and I commend 
you for all the work you are doing to help make healthcare 
affordable for your State's residences. A lack of funding is 
certainly challenging for States which are interested in 
setting up similar programs, but hopefully you will get some 
phone calls.
    Ms. Gasteier. Thank you.
    Ms. Kelly. Thank you and I yield back.
    Mr. Ruiz. Thank you.
    Mrs. Brooks, you are up for 5 minutes.
    Mrs. Brooks. Thank you, Mr. Chairman.
    Mr. Wieske, in your testimony you mentioned that many 
insurers who were offered coverage in the individual market 
just a few years ago have left. Can you discuss further why, 
from your studies, why these insurers are finding business in 
the individual market untenable?
    Mr. Wieske. Yes, I think in the State of Wisconsin they 
lost roughly $500 million in the individual market and that 
made it absolutely unaffordable for them to provide coverage. I 
think we saw a market that just became--it was interesting. In 
my home city of Green Bay, the second-least-cost silver went up 
105 percent from 2016 and 2017. And that became--2017 to 2018--
that became an untenable sort of solution. And the concern I 
think that the insurers had was that the market had 
deteriorated so far that they didn't want all of the risk even 
in a given region. So it was just unaffordable for them to 
continue to maintain coverage.
    Mrs. Brooks. Can you elaborate on ways in which the section 
1332 waivers have actually increased access to care that have 
those approved waivers?
    Mr. Wieske. And I will say, you know, in my home State, 
since I worked on it directly in my former role, so we had a 
$200 million reinsurance program that we went through in a 
bipartisan effort through the legislature and got it passed. 
That reduced the premiums by 11 percent over where they would 
otherwise have been, a net 5 percent decrease year over year, 
so not just a decrease of the increase, but an actual decrease 
year over year on average. And we believe that that expanded 
coverage in the State of Wisconsin from where it otherwise 
would have been.
    Mrs. Brooks. Can you talk a little bit about what else the 
Federal Government might be able to do to increase enrollment 
in health insurance aside from spending more money on marketing 
and navigators? How else can we be bringing people into--
because we all want people to have access to health insurance 
and understand their options, but what else might we be doing?
    Mr. Wieske. Sure. And in my prior role I think, you know, 
we dealt with life insurers and health and P&C insurers. And if 
you look at those other lines of insurance they are becoming 
increasingly active in other spaces to provide coverage and 
becoming increasingly active in their consumer's life to 
provide broader opportunities. There are even groups that are 
having individuals in shopping malls to download apps in order 
to buy coverage. And people are purchasing their entire 
coverage on an app, through their phone, and getting everything 
delivered.
    That seems to be, you know, while there is some 
availability, and there is some availability in the health 
space, that doesn't seem to be as much widely available in the 
individual market as it is in other lines of insurance and in 
employer coverage. So I think a lot more flexibility on the 
State level for States to be able to do some different things 
and to have different options, because States operate very 
differently and look very differently. Massachusetts is very 
different than Wisconsin and California is very different than 
Wisconsin as well.
    Mrs. Brooks. I am curious, Mr. Lee, excuse me. Do you have 
any other ideas of how we might be increasing enrollment in 
healthcare?
    Mr. Lee. Yes. First, I would note that we in California 
have 11 carriers, have had since day 1. Massachusetts, I 
believe, eight; Washington nine. So the experience of many 
States that have not done marketing things that have worse risk 
pool is unstable for plans. We want a market that works for 
consumers which means plans competing, so that is number one, 
competition works.
    Number two, I would note, and I mentioned it earlier in my 
testimony having patient-centered benefit designs. In 
California, our standard benefit designs mean there isn't a 
$2,000 deductible between patients and their primary care 
doctor. That means even healthier people don't say it is not 
worth me having insurance. They see value.
    The third thing I would note is subsidies. Healthcare as 
many of us have noted is too expensive in America. And even at 
what Massachusetts has done, below 400 expanding subsidies, 
above 400 percent subsidies--California, we issued a report to 
our legislature on how to improve affordability. A lot of it is 
subsidies, it is reinsurance with a penalty, but it is too 
expensive. People need financial help and I would encourage the 
committee to look at this report as options.
    Mrs. Brooks. Thank you. I yield back.
    Mr. Ruiz. Thank you. The Chair now recognizes himself for 5 
minutes.
    Thank you all for your testimony. Since day 1 the Trump 
administration has taken actions that have increased premiums 
and out-of-pocket costs for Americans. I am just going to list 
a few here since there has been so many administrative actions 
to change, repeal, and sabotage the ACA.
    In 2017, the Trump administration stopped the cost-sharing 
payments that helped reduce out-of-pocket costs for low- and 
middle-income Americans. This act alone increased premiums by 
20 percent. Health insurance companies and CEOs said that it 
would, the action was taken, and they did. While subsidized 
consumers are largely protected from these premium increases, 
unfortunately many unsubsidized middle-class consumers bear the 
brunt of this and have of these premium increases.
    Last year, the administration expanded these junk plans, 
harming Americans who need comprehensive coverage and get their 
health insurance through the ACA. They offer these very 
inexpensive premiums, relatively speaking, but they don't cover 
much so deductibles are very high and a lot of out-of-pocket 
costs are incurred by the patients. In States that opt not to 
regulate these plans, consumers will see their premiums 
increase and their options dwindle.
    The administration issued new 1332 guidance that would 
allow States to raise healthcare costs for individuals with 
preexisting conditions and undermine the consumer protections 
for people with preexisting conditions. The administration 
sabotages raising the cost of healthcare for hardworking 
Americans.
    Mr. Lee, I understand that 2018 premiums in California 
increased by double what it would have otherwise been because 
the Trump administration terminated these cost-sharing 
payments. Is that correct and can you elaborate?
    Mr. Lee. Absolutely, it is correct. But I think it is 
really important to note that stopping direct cost-sharing 
payments meant that States across the Nation did what is called 
silver loading, but it is actually a CSR surcharge. Plans have 
to pay for that benefit. What we did in California is direct 
our plans to not put that surcharge on the off-exchange 
product. So in California and many States, unsubsidized 
individuals did not have to pay that 12 percent surcharge that 
plans had to put on to cover their costs of that program which 
is required.
    Mr. Ruiz. Did other States that couldn't do that were those 
costs then given to the consumers?
    Mr. Lee. In many States they had policies to protect off-
exchange individuals, other States did not. Some of the 
concerns that we have with the potential of Federal policy to 
ban silver loading is it would shift the cost of paying for a 
required program on unsubsidized Americans and lower coverage, 
raise costs for everybody.
    Mr. Ruiz. Can you discuss how these actions by the Trump 
administration has impacted access to affordable healthcare 
particularly for Americans who are not eligible for the ACA 
subsidies?
    Mr. Lee. Well, again the----
    Mr. Ruiz. Do you have any numbers in terms of people who--
--
    Mr. Lee. I don't have numbers, and again there is a number 
of policies that have had big effects, the CSR rollback and 
caused confusion, many States have worked around that. Bigger 
issues in Federal marketplace States are not doing marketing 
and promoting plans that don't offer coverage that encourage 
healthy people to buy a product that they think is a good deal 
that isn't.
    Mr. Ruiz. Yes.
    Mr. Lee. It is going to cost them later. It costs all of us 
in the near term.
    Mr. Ruiz. Ms. Gasteier, can you describe the impact of the 
Trump administration's termination of these cost-sharing 
payments on your State's residents' access to affordable 
coverage?
    Ms. Gasteier. Yes. So similar to California, we did 
everything we could to try to avoid that outcome where the 
Trump administration stopped making those CSR payments which 
they announced right before the beginning of open enrollment 
2018. But we had worked with our Division of Insurance to 
prepare for a plan B in the event that they did that. Similar 
to other States, we permitted carriers to add that load of CSR 
value onto the silver tier plans only on exchange and then we 
worked with the population of impacted, unsubsidized people to 
make sure they understood they had other options.
    But it was incredibly disruptive to our market, of course, 
and Massachusetts actually stepped in to cover the cost 
exposure of our carriers in the last quarter of 2017.
    Mr. Ruiz. One of the things that I want to make clear is 
that oftentimes these cost-sharing reduction payments get 
characterized as industry bailouts. They are not industry 
bailouts, because they are point of care only when needed by 
people who only meet certain criteria to help them pay for 
their care. So it is not a health insurance bailout, especially 
when health insurance companies are making record profits 
during this entire time.
    I yield back the time and next speaker is Mr. Carter from 
Georgia.
    Mr. Carter. Thank you, Mr. Chairman. And thank all of you 
for being here, we appreciate your attendance.
    Mr. Wieske, I am going to start with you. You testified 
before this committee, I believe, before the subcommittee in 
February of 2017 and talked about how States could improve our 
healthcare system and the role that they could play in 
improving it. Beyond reinsurance, what are some ways that you 
think we could use stability funds to help patients in the 
exchange marketplace?
    Mr. Wieske. Yes, I think from the perspective that I came 
from then and the perspective that I come from now, I think 
there are ways to design more affordable benefit options for 
consumers to add some flexibility. I think there are ways to 
provide some risk sharing. I think if you look at some of the 
issues that we have seen with younger folks who are not signing 
up for coverage, you know, we may have 13 carriers in the State 
of Wisconsin, but they are regional and in some cases we are 
seeing no younger folks signing up because of value 
propositions.
    Redesigning those sort of subsidies, I think re-looking at 
the way we, you know, the cost-sharing reduction subsidy issue 
related to whether or not you use, you know, payments or 
whether or not you use an account-based solution that would 
provide some value to consumer, I think there are ways to sort 
of, you know, for States to become laboratories of democracy 
and experiment and find out what the best solution would be 
similar to the way Massachusetts started.
    Mr. Carter. OK. Well, thank you for that. Let's move on to 
the State-based exchanges bill, the one that we are discussing 
here. And correct me if I am wrong, but I believe that you of 
the 12 State-based exchanges that you said that only half of 
them received, that over half of them received a D or an F 
grade; is that correct?
    Mr. Wieske. Yes. I think we had some issues with the level 
of information that is available through the exchanges. And 
this is part of the reason why we support looking at some 
private competitive versions in the State and new ways to 
enroll. That, you know, what we are looking at now is different 
than what we looked at in 2014 and time has moved on for a lot 
of the ways consumers shop.
    Mr. Carter. And I believe you said that almost three-
fourths of them were worse, or scored worse than the Federal 
exchanges.
    Mr. Wieske. Yes. And we are seeing that you know, States 
are certainly making efforts to improve, but it is a very 
expensive process and it is very intensive. And the people who 
are bearing the cost of those in a lot of cases, either the 
State through general tax revenue or more likely it is through 
the consumers who are purchasing coverage through the exchange 
for access to that Web site.
    Mr. Carter. OK. All right, let's move on to talk about the 
navigators. In 2017, we spent 62\1/2\ million dollars on 
navigator grants and it yielded us only a 1 percent increase in 
ACA enrollment out of those grants? That doesn't seem like it 
is a very efficient use of money to me.
    Mr. Wieske. Again what we have seen in other lines of 
insurance and in other places that there are different ways for 
people to get access to coverage, so it is not just that. So I 
think navigators are important, a small important piece of that 
to do outreach for underserved consumers, but consumers are 
buying their coverage in different ways. And a 22-year-old, 27-
year-old is not going to go into a navigator in the same way 
other folks are.
    Mr. Carter. Right. And the same thing in rural areas. Am I 
correct?
    Mr. Wieske. Correct. Correct.
    Mr. Carter. So that is really something we need to be 
concentrating on, younger people as well as our rural areas.
    Mr. Wieske. Mm-hmm.
    Mr. Carter. Well, thank you for that. I appreciate it.
    Mr. Chairman, and I realize you are sitting in for the 
chairman, so but I do have to get this on record. And that is 
here we are in our third hearing in the subcommittee that has 
the broadest jurisdiction over healthcare of any subcommittee 
in Congress, and yet already the Oversight and Reform Committee 
has had a drug pricing hearing. The Ways and Means Committee 
has had a drug pricing hearing and they are on their second one 
this week. The Senate Finance Committee has had two hearings. 
And this week, the Senate Committee on Aging is having two 
hearings on drug pricing.
    Now this committee, the Energy and Commerce Committee, has 
a record of working in a bipartisan fashion. We have come up 
with Cures. We have come up with 21st Century Cures. We have 
come up with a number of different things in a bipartisan 
fashion. Can you give me an idea or at least relate to the 
chairman an idea of when we are going to start talking about 
drug pricing that impacts all----
    Mr. Ruiz. Yes, sir. Yes, sir.
    Mr. Carter [continuing]. Americans and it is a bipartisan 
issue?
    Mr. Ruiz. Yes, sir. Yes, sir. And I recognize you are the 
one pharmacist in our committee.
    Mr. Carter. Yes, sir.
    Mr. Ruiz. So I appreciate your concern. It reminds me of a 
scene in ``The Karate Kid'' where the Master told the Karate 
Kid, patience, Daniel-San, patience.
    Drug pricing will be a priority in this committee. In fact, 
the first hearing is going to be next week and we are going to 
tackle this issue straight on and you are going to be gleaming 
with happiness when we do.
    Mr. Carter. Thank you, Mr. Chairman. I yield back, Daniel-
San.
    Mr. Ruiz. Great.
    Next, Ms. Blunt Rochester, please.
    Ms. Blunt Rochester. Thank you, Mr. Chairman, and thank you 
to the panel.
    Over the past 2 years, the Trump administration's funding 
cuts have prevented marketplace navigators from providing 
counsel to consumers looking to enroll in health insurance 
plans that work best for them. In Delaware, only one navigator 
organization received Federal funding for 2019 open enrollment, 
making it even harder for Delaware families to sign up for 
coverage. Navigators help communities in my State learn about 
their coverage options and enroll in affordable healthcare.
    According to the Kaiser Family Foundation study, 40 percent 
of uninsured Americans are unaware of the marketplaces and over 
75 percent of consumers sought help from navigators because 
they either lacked confidence to apply on their own or needed 
help understanding their plan choices. For many of the 24,000 
Delawareans participating in the individual marketplace, 
enrollment specialists are a trusted source they can rely on 
when making deeply personal decisions about their health 
insurance plan.
    Ms. Gasteier, I understand that uninsured Americans are 
less likely to be aware of the availability of coverage or even 
that subsidies can help them pay for coverage. Is that true?
    Ms. Gasteier. That is correct. We found that in 
Massachusetts and we work with our navigators to make sure that 
we have in-person resources available to educate people about 
how affordable options can be for them and people are often 
surprised when they find out what they qualify for.
    Ms. Blunt Rochester. And can you describe how gutting this 
funding for the program, the navigator program, impacts 
enrollment, because we just heard from Mr. Carter that it was 
only a 1 percent increase in enrollment. Can you talk a little 
bit about that?
    Ms. Gasteier. Absolutely. So that doesn't square with what 
our experience has been in Massachusetts where our navigators 
provide immense in-person support in the communities that need 
the most help getting into coverage.
    So just as an example, our navigators this past open 
enrollment period held 400 informational events around the 
State educating people about their options, and we find that 
the uninsured population even in a well-covered State like 
Massachusetts is always churning. It is a new group of people 
that need assistance and so their in-person presence in those 
communities where they are sort of trusted leaders for many 
other services are really key.
    I would also like to note that navigators do more than just 
get people into coverage once and then walk away. They provide 
year-round support to people who need to make updates to their 
income information, add a baby, had a life change, and we find 
that that assistance for particularly low-income populations is 
key to not just getting into coverage but staying covered as 
well.
    Ms. Blunt Rochester. You know, I was going to ask you, you 
brought up the term ``churning,'' and I saw that in your 
testimony and was going to ask you if you could expand a little 
bit on the concept of churning, the population churning.
    Ms. Gasteier. Absolutely. So we find in Massachusetts, 
again even with a less than 3 percent uninsurance rate, the 
uninsured population is a mix of some people who are 
chronically uninsured, but also people who have gaps of 6 
months, 12 months in between other kinds of coverage who kind 
of fall through the cracks. And that could be because somebody 
loses a job and loses job-based coverage, somebody who moves to 
Massachusetts from another State and doesn't really know kind 
of where to go for help.
    And so we try to kind of catch people, you know, people who 
may be weighing a COBRA option if they are leaving a job, or 
people who may be in between some other kind of life 
circumstance, getting a divorce, et cetera. And we find that 
that kind of active presence to make sure that the new people 
coming into the ranks of the uninsured we are there to catch 
them right away.
    Ms. Blunt Rochester. Excellent. And my last question was 
really another thing I noticed in your testimony was about the 
diversity of your State, but also all of the players that are 
involved in helping to do the outreach. You mentioned 
everything from focusing on 21 different languages to the 
different community-based organizations, 16 of which--can you 
talk a little bit about that as well?
    Ms. Gasteier. Absolutely. So like most States, 
Massachusetts is diverse and we have very dense urban 
population areas as well as rural areas in the western part of 
our State and our navigators are spread out to be present in 
places where we know there is a higher risk of uninsurance. 
And, for example, in urban areas we find language access and 
awareness about affordability programs is a key thing for those 
navigators to work on. In our rural areas we will work with 
navigators to make sure they are sending people out into the 
community.
    So in our more rural Greenfield area, for example, the 
Franklin County Community Health Center will send their folks 
out to drive 20, 30 minutes to meet people at food pantries and 
farms and make sure they are providing the kind of assistance 
people in those less populated areas need.
    Ms. Blunt Rochester. Thank you so much. I yield back.
    And well, before I yield back I did want to say I am a 
proud cosponsor of this bill and thank Ms. Castor for that and 
also the support on the MORE Health Education Act. Thank you.
    Mr. Ruiz. Thank you.
    Now, Mr. Long, you have 5 minutes.
    Mr. Long. Thank you, Mr. Chairman. I appreciate also my 
friend Larry Bucshon, here, next to me who yielded his place in 
order. I was a little late and missed the gavel. I was actually 
cleaning up a spill out in the hallway and somebody said did 
you spill something? And I said no, but I am cleaning it up so 
somebody else doesn't fall. So, you know, no good deed goes 
unpunished, so I was late for the gavel.
    Mr. Wieske, if memory serves, when we were talking about 
implementing the Affordable Care Act and talking about 
navigators, it is in the back of mind it seems like navigators 
were not allowed to be navigators if they had any background in 
the insurance field. And to me that would be kind of like 
taking your car to a mechanic, but oh, you have to pick a 
mechanic that has never worked on a car before.
    So that being said, you said that the loss of agents in the 
individual health insurance market has created many problems 
and that navigators are just not a substitute for driving 
enrollment. Could you talk about the differences in how agents 
and brokers operate compared to navigators both before and 
after consumers purchase their insurance and why are not 
navigators a substitute for agents?
    Mr. Wieske. Yes. When we looked at creating our own 
navigator program, which by the way in Wisconsin we are going 
to call badgigators, we saw the same issue that you saw that 
there was some limited ability for folks with ongoing industry 
background to be able to be a navigator, so that created a 
concern.
    I think in the individual market we have seen insurers stop 
paying commissions to a lot of agents in Wisconsin. Again that 
reflects at $500 million of lost revenue as they have exited 
the market. We may have 13 carriers but they are regional in 
nature. They are all small carriers, so those expenses are very 
high. That makes it difficult for the folks in the community to 
be able to access sort of coverage and expertise. And the 
expertise that we require a navigator to have in Wisconsin in 
their license is nowhere near what we require what an agent is 
required to have.
    Mr. Long. You also note that the Federal navigator program 
operates largely outside of the current healthcare system and 
in many cases the navigator program is centered around large 
population centers which we kind of talked about earlier in not 
serving the rural areas. What effect does this have for those 
rural communities and how important is the role of agents and 
brokers in advising consumers out in these rural areas? I 
represent a lot of rural areas in Missouri.
    Mr. Wieske. We had two sort of issues. We had navigators 
come in who were under a navigator grant that we had no idea 
existed and were papering a local community with, papering a 
local community and we were never told, they were never 
registered. They turned out to be licensed through a different 
entity so they were OK, we had some concerns with that.
    I think rurally, I think in places like Rhinelander, 
Wisconsin where my wife is from, there is just not as much 
availability. There is just not as many people. They have to 
drive hours just to get to a dermatologist, let alone anything 
else. But that is an issue in those reasons that they are 
primarily served by their local insurance agents.
    Mr. Long. And could you talk about how the medical loss 
ratio is affecting agents and brokers? Is it inhibiting agents' 
and brokers' ability to operate?
    Mr. Wieske. Yes. I think again in Wisconsin prior to us 
doing the $200 million reinsurance program, our insurers had 
loss ratios in excess of a hundred percent after the various 
government programs provided reinsurance back to them. That 
means that you know, the medical loss ratio, those losses made 
it unaffordable for them. They had to cut expenses somewhere 
and largely they have cut it out of agents.
    And I think in other States where you are cutting it closer 
to the 80 percent, we have seen agents, you know, the loss of 
agents serving individual consumers, you know, across the 
country.
    Mr. Long. And do you think that instead of focusing solely 
on navigators, which enroll less than 1 percent of the total 
enrollees for the plan in the year 2017, we should be 
considering amending the medical loss ratio provisions to 
ensure greater access to agents and brokers in order to drive 
enrollment?
    Mr. Wieske. Yes, I think that would, you know, from our 
perspective I think that would provide some value. And I think 
on top of it, I think allowing some flexibility in enhanced 
direct enrollment and some private exchanges, some other folks 
who are incentivized to find people who are uncovered and have 
some incentives to get there.
    It is certainly, you know, different approaches work in 
different States so what works in California and Massachusetts 
may not work in Wisconsin. But I think incentivizing States to 
have a different approach would make some sense.
    Mr. Long. OK, thank you. And once again I would like to 
thank my friend Larry Bucshon for giving me his slot here. And, 
Mr. Chairman, I yield back.
    Mr. Ruiz. Thank you.
    Mr. Cardenas, you have 5 minutes.
    Mr. Cardenas. Thank you very much, Mr. Chairman. I would 
like to thank all of you for testifying today and thank you for 
bringing your expertise and your perspectives on this very 
important issue. Since the ACA's passage I would like to remind 
America that 20 million Americans have gained coverage that 
otherwise didn't have it before then. The uninsured rate fell 
from a high of 18 percent in this country to 11 percent at the 
end of 2016.
    What is unfortunate is that this Trump administration has 
been actively undermining the law and attacking Americans' 
access to healthcare. For example, the administration cut their 
advertising enrollment budget from $100 million to $10 million, 
then they gutted funding for the navigator program by 80 
percent. This program helps American families learn about the 
coverage options that are available to them.
    As anyone can tell you, understanding different healthcare 
plans can be difficult and, thankfully, under the Affordable 
Care Act we have these navigators, these medical professionals 
who can guide people over the phone on the different options 
they have to protect their families is very important. This 
program is critical for people who might have difficulty 
understanding the difficult options or who might be short on 
time, for example, single patients working multiple jobs, 
families already struggling with their finances, and Americans 
who don't speak English as their first language.
    English was not my first language but English is now my 
most dominant language. I have gone to college, I have an 
electrical engineering degree. But going through the coverages 
before the Affordable Care Act when I used to provide 
healthcare for my employees was always complicated and 
difficult. Now that I have my own coverage as a public servant, 
it is still very difficult to navigate through that.
    So let me make that very, very clear. The Affordable Care 
Act did not make healthcare complicated in America, it was 
already complicated. The good thing about it is, it is still 
complicated. However, 20 more million Americans now have 
healthcare that otherwise didn't have it.
    I grew up when I was born under healthcare when my father 
was a union worker. Later on he became a self-employed 
gardener. I was number 11, child number 11, and shortly 
thereafter he went off to be a private business owner and that 
is when healthcare coverage was unaffordable to them. Now 
people in my district like my father who are gardeners now have 
access to healthcare and these navigators are very, very 
important.
    So with that, Mr. Lee, can you describe how navigators help 
Californians access affordable coverage? Can you give us a good 
example that is working well in California?
    Mr. Lee. I absolutely can. I think that--I want to note 
that we use agents, licensed agents, 12,000. They cost a lot, 
1.7 percent of premium goes to paying agents. That is a lot. It 
is over $130 million. We have a $6.7 million navigator program 
where we target communities that don't have as many agents 
serving them, in particular Spanish-speaking communities.
    We do a lot of studies and looking at the fact that agents 
are less apt to be serving Spanish-speaking people, so we 
specifically contract with entities that serve Spanish-speaking 
communities. Similarly, we have seen agents are less apt to 
serve African Americans. We target grants to navigators 
anchored in the Crenshaw district, anchored in parts of the 
community that are otherwise underserved.
    So it is very much a complement to a broad program and it 
is not just to be scored by enrollment, scored by doing 
outreach. The outreach function as you heard from Ms. Morse 
Gasteier is part of getting the word out that is particularly 
important in Federal marketplace States that as you noted have 
abandoned doing marketing. We in California spend $60 million 
on marketing and advertising. The Federal Government now spends 
10 for 39 States. That money means people know to find 
navigators, know to find agents, so it is a complementary 
program.
    Mr. Cardenas. So basically navigators are helping people 
potentially save money, also end up getting coverage that is 
more applicable to their situation and their family, and then 
on top of that does it translate into Americans having better 
access to healthcare when a navigator helps an individual get 
to that point?
    Mr. Lee. So we study this closely, people that use 
navigators or agents make better decisions. They are more apt 
to choose a health plan that is right for them than those that 
do online only. Whether a web broker or whether other, getting 
help means they make a better choice. It also means more people 
enroll, they are healthier which lowers costs for everybody. So 
it really is one of those things, investing and helping people 
understand insurance and get insurance and use insurance means 
they get access to care when they need it, better, and lowers 
costs for everybody.
    Mr. Cardenas. Are navigators needed in rural areas?
    Mr. Lee. Absolutely.
    Mr. Cardenas. Are navigators, when available, are they 
utilized at high rates in rural areas?
    Mr. Lee. By high rates--we actually are going to be, we are 
re-upping our navigator program in California to fund more 
navigators. In some rural areas we don't have enough. So it is 
one of the issues we do that we base on analysis and target 
where the needs are.
    Mr. Cardenas. Thank you very much, Mr. Chairman. I yield 
back my time.
    Ms. Eshoo [presiding]. I thank the gentleman from 
California, excellent questioning. And it really, I think, 
brings together a highly diverse State and one that may not be 
diverse, and how navigators work it is instructive.
    I now would like to recognize 5 minutes for questioning, 
the gentleman from Indiana, Mr. Bucshon.
    Mr. Bucshon. Thank you.
    Mr. Wieske, H.R. 1386 seeks to significantly increase the 
funding for the navigator program. In the 2016 and 2017 
enrollment year in Indiana, the total amount of grant funds for 
navigators was $1,635,961. Three entities in the State were 
awarded grants. The total estimate for the number of 
individuals who would be enrolled in the ACA the estimate was 
3,314, but in reality only 606 people were enrolled for a cost 
of nearly $2,700; to be exact, $2,699.61 per enrollee. If the 
grant recipients had met their goals, the per enrollee cost 
would have been $493.65.
    So do you know of any requirements that grant recipients 
attain their enrollment goals or penalties for nonattainment?
    Mr. Wieske. I am not aware of any.
    Mr. Bucshon. OK, neither am I. Do you think there should be 
a per-enrollee cap and that assuming we have navigators and 
that any unspent funds should be returned to the government?
    Mr. Wieske. So, you know, I think the funds, to be honest, 
are spent at the time that they are granted. The awards come 
very, very late. It is very difficult for the navigator 
entities to be able to plan ahead based on when they have 
received those grants. And so there have been issues and this 
goes back, all the way back to 2014. So, you know, if they are 
not spending the money, yes, they should.
    But I think, by and large, they are almost required to 
spend it the day they get it. And I think, you know, in 
Wisconsin we had less than 50 navigators registered, I think, 
year to year in any given year.
    Mr. Bucshon. Yes, I mean I have strong concerns that it 
seems like there is really an incentive to enroll fewer people 
because there is no penalty and the legislation doesn't seem 
to, this legislation doesn't seem to address the problem. I 
mean it seems to me that $2,700 per enrollee is quite a lot 
when you were expected to be less than $500 per enrollee. And 
it seems like we need to maybe have some guardrails in that 
program.
    Mr. Wieske. I think what we hope as an organization is that 
there are more opportunities for other entities to be able to 
enroll, that some of them are much more effective especially 
with distinct populations.
    Mr. Bucshon. OK.
    Mr. Wieske. And so we are hoping for more enhanced direct 
enrollment and more private exchanges, more other options, more 
flexibility for the individual plans to be able to sign people 
up and make it easier from a path perspective instead of making 
it harder, especially through the Federal exchange.
    Mr. Bucshon. Thank you.
    Mr. Lee, California has spent roughly a hundred million 
dollars every year for the last 3 years, I think it was 99; 
that I mean this year it is estimated at 111.5 million on 
advertising. Three years ago, how many people were in 
Obamacare, enrolled in Obamacare in California?
    Mr. Lee. In the individual market, about 2.4 million.
    Mr. Bucshon. OK. And how about after 3 years of a hundred 
million in marketing, what is the number?
    Mr. Lee. About the same because 40 percent of the people 
leave our market every year. So we have to market with a 
hundred million because people leave job-based coverage and you 
have got to bring them in. So this is like any product, if we 
stop marketing we would dwindle away. And by staying constant 
we have kept that risk pool which again is 20 percent healthier 
than the Federal marketplace which translates directly into 20 
percent lower cost, so our 1 percent of premium goes to 
marketing.
    Mr. Bucshon. OK, so I get that.
    Mr. Lee. OK.
    Mr. Bucshon. So, but the national experience hasn't been 
the same with a large amount of marketing. It really didn't 
change the overall enrollment nationally, which is your 
experience in California. Three years, a hundred million 
dollars, and you have the same number of people. They may not 
be the same people, I get that. But that seems like a lot of 
money. That is your decision, I am fine with that.
    Do you think there is anyone in America that doesn't know 
that they have an option to get healthcare on the exchanges, on 
Obamacare?
    Mr. Lee. Sadly, yes. I know that even in California, where 
with our advertising the average Californian sees or hears us 
59 times during open enrollment, even in California.
    Mr. Bucshon. Well, the question was, is do you think there 
is anyone in the United States that doesn't know that if they 
don't have healthcare they can't get it on the exchange under 
the ACA?
    Mr. Lee. Yep. There are absolutely many Americans in 
California and across the Nation that don't know that, that 
are----
    Mr. Bucshon. Yes, I would be interested in you submitting 
that estimate to the committee, because I would argue that I 
don't know anyone that I come across that doesn't know that 
after all the years and the debate on the national level about 
Obamacare both pro and con that doesn't know that if they don't 
have health coverage--you know, it is one of those things 
where, you know, it is not like McDonald's.
    You drive by McDonald's and you say, hey, I am hungry, I am 
going to stop and get something, right? It seems like 
healthcare is more of a destination restaurant where you 
decide, hey, I am hungry and I am going to go to this 
restaurant specifically, you are not driving by. And I think to 
many, in many respects, that maybe you don't agree with that, 
that you know, people understand that they can get healthcare 
through the exchanges and it is a decision they are making not 
to or to do it. I just----
    Mr. Lee. I would be happy to----
    Mr. Bucshon. That is why I want to say, at the national 
level, I just don't see it is justified to spend millions and 
millions of dollars marketing something that everybody knows 
about.
    Thank you, I yield back.
    Ms. Eshoo. I thank the gentleman.
    Just as an aside, there are millions of people in the 
country that don't know that the ACA and Obamacare are one and 
the same. So, hard to believe, but it is still the case.
    I now would like to recognize the chairman of the full 
committee, Mr. Pallone, for 5 minutes of questioning.
    Mr. Pallone. Thank you, Madam Chair. In his testimony, Mr. 
Wieske recommends that we dismantle the Federal and the State-
based marketplaces where of course millions of Americans 
receive health coverage. So I wanted to get a response to that 
from Mr. Lee and Ms. Gasteier.
    Mr. Lee, can you comment on Mr. Wieske's recommendations 
that we shut down the marketplaces and privatize it instead, 
and then I am going to ask Ms. Gasteier to answer the same 
question.
    Mr. Lee. Certainly. So Covered California partners closely 
with hundreds of licensed agents, many of which are web-based 
entities, web-based brokers. We believe there is a vital role 
for them in the private sector. But we are also deeply 
concerned that private entities have one purpose, to earn money 
based on commissions paid differentially by different insurance 
companies and different insurance products.
    We in the public sector have one purpose, to lower health 
costs for Americans or specifically to California. Web-based 
brokers are--I have known them well--are good, bad, and ugly. 
There are some great ones. There are some really lousy ones. 
And some of their tools are good, some are terrible. But they 
have a very different motivation.
    Our job in the public sector is to help millions of 
Americans get public dollars to lower healthcare costs and to 
make healthcare more affordable. Web-based brokers are seeking 
to get a best return, and I will note some agents might get 20 
percent for one product, 2 percent for another. I would be 
quite nervous about what is going to happen to consumers. We 
put them first all the time.
    Mr. Pallone. And, Ms. Gasteier?
    Ms. Gasteier. Similar. We find that having a publicly run 
exchange is really critical for the integrity that people know 
they will find when they come and shop for products on our 
shelf. We offer a curated, competitive marketplace experience 
for people that people know when they come and get coverage 
from the Health Connector in Massachusetts or healthcare.gov 
they are getting safe, trustworthy coverage. And that they can 
make apples to apples comparisons, that is helpful for 
everybody in terms of affordability and understanding their 
options.
    I would also say part of the exchange's responsibility is 
to administer taxpayer dollars in the way of subsidies and so 
we think there is an important role for the public oversight 
component of being a public entity and doing that and ensuring 
that there is program integrity to these important functions.
    Mr. Pallone. I appreciate that because, I mean, obviously, 
as you said, the Federal and State-based marketplaces have to 
certify plans to ensure that only the products that offer 
comprehensive coverage are available for sale and the exchanges 
verify eligibility to ensure that low- and moderate-income 
Americans who qualify for financial assistance receive the ACA 
subsidies.
    But let me ask Mr. Lee kind of in the same vein, can you 
discuss the risk to consumers if the marketplaces are 
privatized?
    Mr. Lee. Well, first, we do look very closely at every 
health plan that wants to be in our marketplace. They have to 
be clear they have good networks, the right benefits and, 
sadly, healthcare is one of the areas that has actually failed 
consumers. Web-based brokers can sell not just qualified health 
plans, but in many States that offer skimpy benefits and they 
may get better commissions, those could be looking right next 
to products that are there and meaningful. Consumers don't know 
and may not know.
    And again the danger of the incentive for one agent or 
broker is very different than a group like ours which is 
publicly accountable. We bring together consumer advocates, 
doctors, and others to say what are the right benefit designs, 
how do we position plans so that consumers can choose right. I 
would be very concerned about many consumers being steered 
wrong if we just threw it to the market.
    Mr. Pallone. I mean, I agree, you know, many people, you 
know, from what I can see end up buying these junk plans and 
then have no idea of the lack of coverage.
    Ms. Gasteier, similarly, can you discuss the risk of 
shifting this responsibility to private insurance companies 
given billions of dollars, you know, in subsidies that are at 
stake?
    Ms. Gasteier. Sure. So I think again it comes back to 
exchanges play a really important role in being a source of 
trusted, comprehensive coverage where people know what they are 
getting is not going to be something that exposes them to costs 
if they get sick or that there is sort of tricks in the 
coverage itself in terms of what is sold to people. And so in 
having a place that is publicly accountable where we are 
engaging with carriers, consumer advocates, providers, and 
others to design products that are safe and trustworthy for 
people, there for them when they need it, is really a critical 
component of the public role for exchanges and we found that to 
be very effective in Massachusetts.
    And again similar to California, we have placed a real 
premium on standardizing benefits so that we can ensure that 
people when they shop and compare their options really 
understand what they are getting and what the differences may 
or may not be, but that everything there is safe and reliable.
    Mr. Pallone. And I agree. I mean I am very concerned that, 
you know, we have billions of dollars in Federal subsidies and, 
you know, they could be at risk from fraud, abuse, and waste. 
That is my concern.
    Thank you, Madam Chair.
    Ms. Eshoo. I thank the chairman.
    I now would like to recognize the gentleman from Montana, 
Mr. Gianforte.
    Mr. Gianforte. Thank you, Madam Chair, and thank you for 
the panel being here today. Time and time again I hear from 
Montanans about the rising cost of healthcare in our State. For 
many in Montana, Obamacare has been unaffordable. Watching 
their premiums and deductibles continue to grow, while their 
benefits shrink has been a frustrating and in some cases a 
devastating experience for them. Thankfully, the Trump 
administration has proposed real solutions to halt the rise in 
healthcare costs. Improving access to short-term, limited 
duration insurance plans, eliminating the individual mandate 
penalty, and expanding association healthcare plans is giving 
choice back in control to Montanans and putting them back in 
charge of their healthcare needs.
    Unfortunately, the ENROLL Act is not innovative and is a 
prime example of policies that misunderstand the needs of rural 
communities. Our rural hospitals in Montana are hurting. And 
across this country since 2010, 98 rural hospitals have been 
closed and almost 700 are vulnerable to closure. Our 
communities depend on these vital institutions. When a hospital 
closes in a rural community, not only do we lose access to 
care, but the community is less sustainable. The region loses 
jobs and financial viability.
    We need to be working to make sure that people not only 
have coverage but also have access to care. A navigator won't 
be around to help when a farmer needs emergency medical 
services and their local hospital has closed. We need to ensure 
that our rural providers are stable and available in case of 
emergencies and I look forward to working together to continue 
encouraging innovation, affordability, and access to care for 
all.
    Mr. Wieske, I would like to direct a couple of questions to 
you. In your testimony you say that navigators are typically 
centered around large population centers with limited 
availability in rural communities. Can you speak as to why the 
navigator program is less effective in rural areas and frontier 
communities like Montana?
    Mr. Wieske. I mean it is a matter of economics. I mean the 
population is not there and the ability to drive the number of 
people you can see in a given time frame in a rural community 
is, you know, the distances as you know are significant and so 
the effectiveness is an issue.
    Mr. Gianforte. OK. In our business we are constantly 
looking for ways for continual improvement. When we found a 
program in our business that wasn't working we would stop 
focusing resources on that program and look to invest 
elsewhere.
    Mr. Wieske, do you believe that there should be a shift in 
our resources away from navigators to other areas that provide 
better outcomes for Americans?
    Mr. Wieske. I do think there are other ways that we can 
provide better access in rural communities in the same way that 
you are seeing other insurance lines, you are seeing medical 
care and other things delivered in different ways in those 
rural communities in order to give them access, so.
    Mr. Gianforte. So there might be better ways to use the 
money----
    Mr. Wieske. Yes.
    Mr. Gianforte [continuing]. In rural areas in particular. 
OK.
    And then, Mr. Wieske, you also talked in your testimony 
about transparency in the navigator program. And I constantly 
hear from Montanans that they want--they are frustrated with 
the lack of transparency, generally, in our healthcare system. 
What changes could we make from your experience to make this 
program more transparent?
    Mr. Wieske. I think for, you know, I think one of the 
issues that we have seen is that this is something that States 
should be primarily responsible. I think California and 
Massachusetts certainly highlighted the way they deal with the 
navigator program. I think if States are responsible for the 
navigator program directly, I think that will make it a much 
more effective program because they understand how the State 
works, where the needs are, work with the Medicaid department, 
work with the insurance department in order to make that work 
better.
    Mr. Gianforte. So as we look at public policy, we should 
really have a design requirement around more local control at 
the State level. You would agree with that?
    Mr. Wieske. Yes.
    Mr. Gianforte. OK. Thank you so much.
    And with that I yield back--yes, I would.
    Mr. Burgess. You know, you have reminded me that one of the 
principal failures of the Affordable Care Act was when we 
allowed Speaker Boehner, Leader Reid, President Obama, to 
remove Members of Congress from being forced to go into the 
exchanges. That was a mistake.
    I did not accept the subsidies that all Members of Congress 
get for going in the DC exchange. I went through 
healthcare.gov, one of the most miserable experiences I have 
ever been through in my life, but it would be important for 
Members of Congress to experience what our constituents were 
feeling as they faced the very dire prospects of healthcare.gov 
not working on its rollout, and then of course the very 
expensive and unsubsidized premiums that we faced in the 
individual market.
    And I am just like anybody else, I bought on price. I 
bought a Bronze plan. I had a $6,800 deductible, never 
understood why I couldn't couple that with a Health Savings 
Account. It was difficult to do that. We could have made it 
easy and that would have been easier had we all been required 
to go through what we were putting our constituents through.
    I thank the gentleman for yielding and yield back to him.
    Mr. Gianforte. And, Madam Chair, I yield back.
    Ms. Eshoo. I thank the gentleman.
    I think, Dr. Burgess, you made a big mistake by not 
enrolling because it is terrific. It works beautifully for me. 
It has gone beyond my expectations because of its coverage.
    Mr. Burgess. But if I----
    Ms. Eshoo. No.
    Now I would like to recognize the gentleman from Florida. I 
did see him, where is he? There, way down there.
    Mr. Soto, you have 5 minutes to question.
    Mr. Soto. Thank you, Madam Chairwoman. And, first, I am 
from Florida, home of the largest Federal exchange for the ACA 
in the Nation, with over 1.7 million Floridians. We had an 
increase this year. One of the big reasons that the ACA has 
been so successful in Florida is because we don't have a lot of 
folks with access to employer-based health insurance. So, for 
large States like us, this was made to help. My wife and I are 
on the insurance plans from the DC exchange. She recently had 
surgery which was pretty much covered, so it has been a good 
experience for the Soto family.
    I want to go through each of the five ways that President 
Trump has sabotaged the Affordable Care Act and get an idea 
from our witnesses whether it increased or decreased access and 
what it would relate to costs. So starting just brief answers 
with each of our witnesses going through first the five ways, 
one is, it eliminated cost sharing; two, ending high-risk 
corridors; three, cutting enrollment dollars and marketing 
dollars in half; four, eliminating the individual mandate; and 
five, eliminating mandatory Medicaid expansion.
    So let's start with the first of these five plagues on 
Obamacare, the eliminating of the cost-share subsidies.
    Mr. Lee, did this increase access or decrease access by 
eliminating the subsidies?
    Mr. Lee. I think on the margins it decreased access. But 
the fact of silver loading meant some consumers with subsidy 
actually had more money to work with so it is actually a trade-
off. It definitely cost the Federal Government more money. It 
caused confusion that I think in many markets led health plans 
to pull out of their markets, so it is a market-by-market 
issue.
    Mr. Soto. So, but you would say overall it decreased 
access?
    Mr. Lee. Overall, decreased.
    Mr. Soto. Ms. Gasteier, did it increase or decrease access 
or costs?
    Ms. Gasteier. It reduced access for the unsubsidized 
middle-class population.
    Mr. Soto. And, Mr. Wieske, did it increase or decrease?
    Mr. Wieske. It increased costs and created some 
instabilities.
    Mr. Soto. What about on ending the high-risk corridors, Mr. 
Lee? How did that affect access and costs?
    Mr. Lee. That I think also ended up having--well, I am 
actually, I am not sure.
    Mr. Soto. OK. You are not sure.
    Mr. Lee. So I will pass.
    Mr. Soto. What about Ms. Gasteier? How did it affect access 
or costs?
    Ms. Gasteier. I would say all of the reductions or 
disruption to any of the three Rs--risk corridors, reinsurance, 
and risk adjustment--have been, have reduced access and 
stability just in general to the extent that each of those 
programs have either been ended or they have hit turbulence in 
various ways.
    Mr. Soto. And, Mr. Wieske?
    Mr. Wieske. I think with the three Rs, I think the decision 
early on to federalize them and not to go State by State 
created significant issues in the market outside of it, which 
predates most of the issues surrounding it.
    Mr. Soto. What about cutting marketing dollars and 
enrollment time, Mr. Lee? How did that affect access and costs?
    Mr. Lee. Dramatically reduced access, dramatically has 
increased premiums across much of the Nation except for those 
States that have State-based marketplaces that continue to do 
marketing.
    Mr. Soto. And, Ms. Gasteier, how did that affect costs and 
access?
    Ms. Gasteier. I would presume elsewhere it has reduced 
access. Like California, Massachusetts has been able to stay 
level with respect to its investment in outreach and marketing 
so has stayed the same.
    Mr. Soto. Mr. Wieske?
    Mr. Wieske. We just didn't see that effect, that negative 
effect.
    Mr. Soto. OK. What about eliminating the individual 
mandate? Mr. Lee, how did that affect access and cost?
    Mr. Lee. It has raised premiums across both California and 
the Nation and decreased enrollment. Many fewer, hundreds of 
thousands of fewer Californians have insurance because of that.
    Mr. Soto. Ms. Gasteier?
    Ms. Gasteier. We have stayed insulated from those impacts 
in Massachusetts because we have our own individual mandate, 
but we imagine if we didn't have a tool like that either State- 
or federally based it would reduce access.
    Mr. Soto. Mr. Wieske?
    Mr. Wieske. Specifically in Wisconsin, our rates were so 
high that we are not convinced that it had a significant impact 
on enrollment.
    Mr. Soto. OK. And, finally, not requiring Medicaid 
expansion, I realize the courts helped in that, how did that 
affect access and costs?
    Mr. Lee. Well, I think that in States like Florida, the 
reason you have a big exchange is you have many, many 
Floridians who do not benefit from the Medicaid program, and I 
think Californians benefit. I think there are millions of 
Americans not benefiting from that coverage expansion.
    Mr. Soto. Ms. Gasteier?
    Ms. Gasteier. Similar, I think the Affordable Care Act put 
puzzle pieces in place with the assumption that Medicaid 
expansion would catch a particular population of people and 
ensure that they had guaranteed coverage, so obviously 
Massachusetts has taken advantage of that to great effect. And 
so I would expect that that has dramatically reduced coverage 
elsewhere where that has not been mandatory.
    Mr. Soto. Mr. Wieske?
    Mr. Wieske. And we haven't seen a negative impact from that 
in where I was in Wisconsin. We saw a positive impact.
    Mr. Soto. Thank you.
    Mr. Wieske. And we had a unique approach.
    Mr. Soto. Thank you. My time has expired.
    Ms. Eshoo. I thank the gentleman for his excellent 
questions.
    Now I have the pleasure of recognizing Mr. Bilirakis from 
Florida to question for 5 minutes. And I would like to note 
that for those that may not know, his father preceded him in 
Congress and was the chairman of this subcommittee, a wonderful 
chairman and still a wonderful friend. So you have 5 minutes to 
question, Mr. Bilirakis.
    Mr. Bilirakis. Thank you. I appreciate that. Thank you so 
very much. It is an honor to serve on this committee and to 
serve under you as the chairwoman, and also the ranking member. 
I won't forget that.
    So anyway, thank you very much and thank you for your 
testimony. I appreciate it very much.
    Mr. Wieske, in your testimony you talked about how in 
Wisconsin the insurance markets were damaged by the exchanges. 
The number of insurance companies withdrew from the market and 
premiums kept moving up. That problem isn't isolated just to 
Wisconsin. In Florida we have less participation in the 
exchange today than 2014 and the majority of counties only have 
one insurance carrier. As a matter of fact, the county that I 
represent, I represent three counties, one of the counties only 
has one insurance and it is a carrier and it is--I think the 
population is close to 500,000.
    Last year, Wisconsin received a 1332 State innovation 
waiver to reestablish a reinsurance program and other States 
have applied or received a waiver for reinsurance in other 
programs. Are 1332 waivers still available for States to use? 
This is for again Mr. Wieske.
    Mr. Wieske. They are, yes.
    Mr. Bilirakis. They are. OK, thank you.
    Does it make sense to move a standalone reinsurance bill by 
itself with no reforms in it, and wouldn't it be better to move 
legislation to reform the 1332 State innovation waiver to give 
greater flexibility to States to reform and repair their 
insurance markets? What do you think of that?
    Mr. Wieske. Yes, I think given the issues surrounding the 
risk pool that we have all sort of talked about especially in 
States like Wisconsin, Iowa, and other States, I think it is 
important not to just look at reinsurance. Reinsurance shifts 
who pays, as I stated, but we need to find some new ways to 
sort of improve that risk pool. So I think a broader 1332 will 
have some value for States.
    Mr. Bilirakis. OK. This question is regarding State 
exchanges again.
    Mr. Wieske, one of the bills under consideration today 
would spend $200 million for more State-based exchanges. 
Wouldn't it make more sense to have private entities running 
the exchanges rather than government entities? What do you 
think of that?
    Mr. Wieske. I think Wisconsin and a lot of other States 
like it could not afford with the 200 million to run its own 
exchange. So in order to have a first-class experience, I think 
looking at private entities to be able to offer additional 
options makes a lot of sense.
    Mr. Bilirakis. OK. Wouldn't it make more sense again as you 
said to have the private entity running the exchanges rather 
than the government entities? Can we have businesses assume the 
financial risk of running an exchange rather than the Federal 
Government bankrolling the States? What are the barriers to 
having private exchanges provide this particular service?
    Mr. Wieske. I think one of the things to understand is that 
there is still a State regulatory process in place that reviews 
the plans, reviews the insurers, licenses the agent, licensing 
the insurers, checks their financial solvency, does everything 
soup to nuts, currently, in a number of States. And they can 
serve, continue to serve that role and it changes, 
functionally, a Web site and an outreach entity to be able to 
get consumers to sign up for coverage. They existed before the 
ACA. They exist now, after the ACA.
    And I think what our thought is, is that having a first-in-
class experience and having an entity, entities offering with 
State oversight the in-exchange role makes a lot of sense 
financially. There is a lot less risk.
    Mr. Bilirakis. Thank you very much.
    Unless the ranking member would like the balance of my 
time, I yield back.
    Mr. Burgess. Well, thank you. In fact, I would like to take 
just a minute.
    Mr. Bilirakis. I figured you would.
    Mr. Burgess. It is not really the subject of what this 
subcommittee is considering today, but, Madam Chair, I just 
feel like this committee has had such a good relationship with 
Dr. Scott Gottlieb over the last 2 years and certainly I don't 
know what was involved in his decision to make his announcement 
yesterday, but I will just say he will be missed certainly by 
me personally and I believe by the subcommittee generally. And 
we certainly want to wish him well in whatever his future 
endeavors.
    I do not know that we have ever had a brighter witness here 
at the witness table than Dr. Gottlieb and he was never shy 
about telling us that also, but he will be missed. And I really 
appreciated the enthusiasm with which he took the job of 
administrator of the Food and Drug Administration and, really, 
under his leadership some very positive changes occurred at 
that agency.
    So that is all I wanted to say. I will yield back to the 
gentleman from Florida.
    Mr. Bilirakis. And I will yield back, Madam Chair. Thank 
you.
    Ms. Eshoo. Just to thank you, Mr. Bilirakis.
    I would like to add my voice to that of the ranking member. 
I think that our country has been fortunate to have had Dr. 
Gottlieb as the commissioner of the FDA. It is an agency that 
the American people, I believe, trust. They always want it to 
uphold the highest standards because it stands between them and 
God knows what if the wrong decisions are made.
    So I think that we have been more than fortunate to have 
him as FDA commissioner. I think that he has worked very well 
with the committee, both sides of the aisle. In his statement 
he said he was getting tired of commuting from Connecticut. And 
I thought I wished I had known that ahead of time, because I 
would have called him and encouraged to keep commuting, because 
I make a much longer commute across the country every week to 
California, not to Connecticut.
    So I know that on behalf of this subcommittee that we wish 
him well, and we thank him. We thank him for, I think, 
exemplary public service.
    So with that I will ask unanimous consent to enter into the 
record the following, and it is kind of a long list: a 
statement from the American Lung Association in support of 
H.R.1425; a statement from the American Lung Association in 
support of H.R. 1386; a letter from the American Medical 
Association in support of H.R. 1386, 1385, and 1425; a 
statement for the record from the American Cancer Society 
Cancer Action in support of H.R. 1386, 1385, and 1425; a letter 
from the Blue Cross Blue Shield Association in support of 1386, 
1385, and 1425; written from the Asian and Pacific Islander 
American Health Forum in support of H.R. 1386, 1385, and 1425; 
a letter in support of H.R. 1386 from the Young Invincibles; a 
report on ``Exploring the Impact of State and Federal Actions 
on Enrollment in the Individual Market: A Comparison of the 
Federal Marketplace and California, Massachusetts, and 
Washington''; a statement from the American Health Insurance 
Plans; and a letter from the Healthcare Leadership Council.
    So we ask that that--I am asking unanimous consent that we 
enter all of what I just read into the record, including what 
the ranking member had raised earlier.
    Do you have something that you would like to add?
    Mr. Burgess. Yes, if I could be recognized for additional 
unanimous consent.
    Ms. Eshoo. Certainly.
    Mr. Burgess. I would like to ask unanimous consent to 
insert into the record the text of the bill that I introduced, 
H.R. 1510, and I would like to introduce into the record a 
letter from Blue Cross Blue Shield Association in support of 
that Bill 1510.
    Ms. Eshoo. So ordered.
    [The information appears at the conclusion of the hearing.]
    Ms. Eshoo. I want to thank again--I started out by thanking 
the witnesses, I want to close by thanking you. You know, it is 
not very often said around here that we are so dependent upon 
experts in our country. It never ceases to amaze me the 
knowledge that resides in experts on so many issues.
    And so when you come forward and answer our questions that 
all becomes part of the record and that stays there for a long 
time, but it also remains with us because we learn from you. No 
one can say to any of you, you don't know what you are talking 
about. You have lived it. You have done it. You have brought 
your expertise here, and we are, on behalf of all of our 
constituents and the American people, really very grateful to 
you for the time and the expertise that you have shared with 
us.
    So with that the subcommittee is adjourned. Thank you, 
everyone.
    Mr. Burgess. And we have 5 days.
    Ms. Eshoo. Oh, we have 5 days for Members--I said that at 
the beginning of the hearing.
    Mr. Burgess. Oh, OK.
    Ms. Eshoo. But I will say it again--time for Members to 
submit their comments for the record.
    [Whereupon, at 12:32 p.m., the subcommittee was adjourned.]
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