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


                   THE TRUMP ADMINISTRATION'S ATTACK
                   ON THE ACA: REVERSAL IN COURT CASE
            THREATENS HEALTH CARE FOR MILLIONS OF AMERICANS

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


                                HEARING

                               BEFORE THE

                              COMMITTEE ON
                          OVERSIGHT AND REFORM
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION
                               __________

                             JULY 10, 2019
                               __________

                           Serial No. 116-43
                               __________

      Printed for the use of the Committee on Oversight and Reform
      
                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]      

                  Available on: http://www.govinfo.gov
                     http://www.oversight.house.gov
                        http://www.docs.house.gov

                              ___________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
37-313 PDF                 WASHINGTON : 2019  


                   COMMITTEE ON OVERSIGHT AND REFORM

                 ELIJAH E. CUMMINGS, Maryland, Chairman

Carolyn B. Maloney, New York         Jim Jordan, Ohio, Ranking Minority 
Eleanor Holmes Norton, District of       Member
    Columbia                         Paul A. Gosar, Arizona
Wm. Lacy Clay, Missouri              Virginia Foxx, North Carolina
Stephen F. Lynch, Massachusetts      Thomas Massie, Kentucky
Jim Cooper, Tennessee                Mark Meadows, North Carolina
Gerald E. Connolly, Virginia         Jody B. Hice, Georgia
Raja Krishnamoorthi, Illinois        Glenn Grothman, Wisconsin
Jamie Raskin, Maryland               James Comer, Kentucky
Harley Rouda, California             Michael Cloud, Texas
Katie Hill, California               Bob Gibbs, Ohio
Debbie Wasserman Schultz, Florida    Ralph Norman, South Carolina
John P. Sarbanes, Maryland           Clay Higgins, Louisiana
Peter Welch, Vermont                 Chip Roy, Texas
Jackie Speier, California            Carol D. Miller, West Virginia
Robin L. Kelly, Illinois             Mark E. Green, Tennessee
Mark DeSaulnier, California          Kelly Armstrong, North Dakota
Brenda L. Lawrence, Michigan         W. Gregory Steube, Florida
Stacey E. Plaskett, Virgin Islands   Fred Keller, Pennsylvania
Ro Khanna, California
Jimmy Gomez, California
Alexandria Ocasio-Cortez, New York
Ayanna Pressley, Massachusetts
Rashida Tlaib, Michigan

                     David Rapallo, Staff Director
                    Ali Golden, Chief Health Counsel
                           Laura Rush, Clerk

               Christopher Hixon, Minority Chief of Staff

                      Contact Number: 202-225-5051


                         C  O  N  T  E  N  T  S

                              ----------                              
                                                                   Page
Hearing held on July 10, 2019....................................     1

                               Witnesses

Ms. Abbe Gluck, Professor of Law; Director, Solomon Center for 
  Health Law and Policy, Yale University Law School
    Oral Statement...............................................     6
Mr. Frederick Isasi, Executive Director, Families, U.S.A
    Oral Statement...............................................     8
Mr. David Balat, Director, Right on Healthcare Initiative, Texas 
  Public Policy Foundation
    Oral Statement...............................................     9
Mr. Paul Gibbs, Patient/Consumer, West Valley, UT
    Oral Statement...............................................    11
Ms. Casey Dye, Patient/Consumer, Monroeville, PA
    Oral Statement...............................................    13
Ms. Stephanie Burton, Patient/Consumer, Kansas City, MO
    Oral Statement...............................................    15
Mr. Peter Morley, Patient/Consumer, New York, NY
    Oral Statement...............................................    16

Written opening statements and witnesses' written statements are 
  available on the U.S. House of Representatives Repository at: 
  https://docs.house.gov.

                           Index of Documents

                              ----------                              

The documents listed below are available at: https://
  docs.house.gov.

  * Penn Ins Commissioner Jessica Altman Letter, re: Texasv. 
  United States; submitted by Chairman Cummings.

  * Little Lobbyists Statement for the Record; submitted by 
  Chairman Cummings.

  * National Partnership for Women and Families Statement for the 
  Record; submitted by Chairman Cummings.

  * Edward Corcoran Testimony - Advocate; submitted by Chairman 
  Cummings.

  * National Women's Law Center Statement for the Record on ACA; 
  Submitted by Chairman Cummings.

  * 17 Organizations' Letter of Support for the ACA; submitted by 
  Rep. Wasserman Schultz.

  * STAT article; submitted by Rep. Wasserman Schultz.

  * March of Dimes Statement for the Record; submitted by Rep. 
  Lawrence.

  * Questions for the Record to Frederick Isasi, Families USA; 
  submitted by Chairman Cummings.

  * Questions for the Record to Abbe Gluck, Yale; submitted by 
  Chairman Cummings.

  * Questions for the Record Response by Frederick Isasi, 
  Families USA.

  * Questions for the Record Response by Abbe Gluck, Yale.


 
                   THE TRUMP ADMINISTRATION'S ATTACK
                   ON THE ACA: REVERSAL IN COURT CASE
                 THREATENS HEALTH CARE FOR MILLIONS OF
                               AMERICANS

                        Wednesday, July 10, 2019

                   House of Representatives
                  Committee on Oversight and Reform
                                           Washington, D.C.

    The committee met, pursuant to notice, at 10:04 a.m., in 
room 2154, Rayburn Office Building, Hon. Elijah Cummings 
(chairman of the committee) presiding.
    Present: Representatives Cummings, Maloney, Norton, Clay, 
Connolly, Krishnamoorthi, Raskin, Rouda, Hill, Wasserman 
Schultz, Sarbanes, Welch, Speier, Kelly, DeSaulnier, Lawrence, 
Plaskett, Khanna, Gomez, Ocasio-Cortez, Pressley, Tlaib, 
Jordan, Amash, Gosar, Massie, Meadows, Hice, Grothman, Comer, 
Cloud, Gibbs, Norman, Higgins, Roy, Miller, Green, Armstrong, 
and Steube.
    Chairman Cummings. The committee will come to order.
    Without objection, the chair is authorized to declare a 
recess of the committee at any time.
    This full committee hearing is convened regarding the 
Administration's attack on the ACA. I now recognize myself for 
five minutes to give an opening statement.
    We are here today because on March 25, 2019, the Trump 
Administration filed a two-sentence letter with the United 
States Court of Appeals for the Fifth Circuit reversing its own 
previous position in the case of Texas v. United States, and 
asserting for the first time that it would not defend any 
portion of the Affordable Care Act in court. If the Trump 
Administration's position prevails and the entire ACA is struck 
down, there will be catastrophic implications for millions of 
Americans and the entire United States' healthcare system.
    I have often said that voting for the Affordable Care Act 
was the most important vote of my career, and let me tell you 
why. When Congress passed the ACA in 2010, we enshrined into 
the law that all Americans have the right to accessible, 
affordable health insurance coverage. The ACA established new 
protections to end legalized discrimination against 
approximately 130 million people in the United States with 
preexisting conditions.
    The ACA authorized states to expand their Medicaid 
programs, and approximately 17 million Americans gained 
coverage as a result. The ACA created online marketplaces for 
consumers to purchase insurance with financial assistance 
through premium tax credits and cost-sharing reduction 
payments, and today nearly 9 million individuals receive 
financial assistance to obtain coverage through the individual 
market. The ACA improved the quality of coverage for millions 
more by requiring the plans cover a set of essential health 
benefits, provide coverage for preventive services, such as 
immunizations and screen tests, and allow young adults to stay 
on their parents' plans until they turn 26.
    If the Trump Administration is successful, all of these 
Federal protections would disappear. People with preexisting 
conditions, like diabetes, cancer, HIV, asthma, substance use 
disorder, or even pregnancy, could be denied healthcare 
coverage or charged more. Babies born with health conditions 
could be uninsurable for their entire lives. Insurance 
companies in the individual and small-group markets would not 
have to cover essential services, such as preventative care, 
hospitalizations, emergency services, maternity care, and 
prescription drugs.
    However, since President Trump took office in January 2017, 
neither the Administration nor congressional Republicans have 
offered a plan to replace the ACA that would prevent coverage 
losses or the elimination of consumer protections. House 
Republicans have voted 69 times to repeal the ACA. Their last 
proposal, which failed to pass the Senate in 2017, would have 
increased the number of uninsured by 21 million people. There 
is something wrong with that picture.
    During the 2016 campaign, President Trump promised 
repeatedly that he would come up with a plan to replace the 
ACA, but never did. He never did. Now that he is running for 
President again, the promises have now returned, and you will 
be hearing them shortly if you have not already heard them. In 
April he promised to release, and I quote, ``a really great'' 
plan after the 2020 election. Unfortunately, nobody has seen 
it. Ironically, if the Trump Administration is successful in 
striking the entire ACA, it would directly undermine many of 
their own policy goals, including tackling the opioid epidemic, 
lowering prescription drugs prices, and ending the HIV 
epidemic.
    We wanted to hear from the Administration about why they 
suddenly reversed their position in litigation. We wanted to 
know what the Administration's plan is for millions of people 
if they went to court and invalidate the entire ACA. We invited 
the acting director of the Office of Management and Budget, 
Russell Vought, to testify at today's hearing, but he declined. 
Apparently he did not want to answer these crucial questions 
that affect so many millions of Americans with something that 
is very personal, and that is their health.
    I have often said to my proteges, the one thing that we 
must always ask ourselves every day, I think, and that is what 
is the enemy of my destiny. What is the enemy of my destiny? 
What will stop me from reaching where God meant for me to go? 
There is one common denominator that I have noticed that 
applies to all of us: health. Health and enjoying a life where 
you can truly pursue happiness.
    So although the Trump Administration refuses to answer 
these basic and critical questions, we are very fortunate to 
have a panel of legal and policy experts and patient witnesses 
who can tell us exactly what it will mean if the Trump 
Administration is successful in eliminating the Affordable Care 
Act. I ask our entire committee not to be blinded by what we 
see. Don't be blinded. The experts are here. They will let you 
know. They are the witnesses. They are on the front line. They 
deal with these matters every day. And then there are others 
who have gone through and continue to go through difficult 
circumstances.
    I can relate. Now that I am on a walker, I have learned 
what it is to be disabled, and it is a tremendous task in most 
instances just to get dressed. I got it, and I often say to our 
witnesses who have come to share with us your personal stories, 
thank you. Thank you for taking your pain and turning it into a 
passion to do your purpose. Pain, passion, purpose. So they 
have traveled from across the country, from Utah, Missouri, 
Pennsylvania, and New York, to share their stories with us. 
They are here to tell us what life was like for them and their 
loved ones before the ACA was passed. So I thank you again.
    With that, I yield now to the very distinguished gentleman 
from Ohio, the ranking member of our committee, Mr. Jordan.
    Mr. Jordan. Thank you, Mr. Chairman. I, too, want to thank 
our witnesses for making the trek here and being willing to 
share their story. I was hoping today that we could have a 
discussion about real solutions that will make the lives of 
everyday Americans better, talk about the cost of healthcare, 
access to healthcare coverage, preexisting conditions. There is 
no one on this committee who would support denying coverage to 
Americans with preexisting conditions. I was hoping we could 
focus on those issues, but unfortunately like so many other 
hearings in this committee, we are not. Rather than working 
toward bipartisan solutions, this committee is once again 
looking to score political points by attacking anything the 
Trump Administration does to improve the healthcare for 
American people.
    Next door in the Judiciary Committee, we have reported out 
multiple bills that would have had meaningful impact on the 
cost of prescription drugs. The Judiciary Committee spent 
months working on ideas to cut down on red tape and make 
improvements to how affordable generic drugs come to market. 
Those bills were bipartisan, and I was pleased to vote for 
them. In fact, many of them passed the Judiciary Committee 
unanimously. We could be talking about bipartisan substantive 
issues here today. Instead we are going to talk about why the 
Democrats are upset at the Administration, who thinks Americans 
deserve something better than the failed ideas of Obamacare. 
Under Obamacare, make no mistake, Americans saw their premiums 
skyrocket and their healthcare choices reduced.
    The majority's title for today's hearing is ``Trump's 
Efforts to Undermine the ACA.'' Undermine the ACA? Think about 
what we were told when this bill passed now, what, nine years 
ago? I call them the nine lies of Obamacare. Think about this. 
Remember this one? ``If you like your doctor, you can keep your 
doctor.'' Do you all remember that one? How about this one, 
``If you like your plan, you can keep your plan?'' We were told 
by the President of the United States premiums were going to go 
down. We then got more specifics: premiums will go down on 
average $1,500. He said deductibles would decline. Five false 
statements right there.
    Oh, remember this one? This was on in the fall of 2013. 
Remember this one? They told us the website was going to work. 
They told us the website was secure. Your information would be 
secure there. They told us that these co-ops were wonderful, 
end-all, be-all creations. Twenty-three were created. Guess how 
many are still in existence? Four. The other 19 went bankrupt. 
Oh, and you know the 9th lie? First they told us it is not a 
tax, then they went to court and said it is a tax, and now they 
are saying, no, it is not really a tax at all because you can't 
tax them now because the individual mandate is gone and there 
is no penalty.
    Nine different lies we were told about Obamacare, and the 
hearing is titled ``How Trump's Efforts to Undermine.'' How can 
you undermine something that has already failed? I don't expect 
my Democrat colleagues to acknowledge it, but the Trump 
Administration has worked to increase competition, 
transparency, and quality of care in our healthcare markets. 
Increased competition, transparency, and quality of care are 
all goals we all should share. I don't know that there is 
anything the Trump Administration could do, though, that would 
satisfy my colleagues on the other side of the aisle.
    The timing of this hearing is also particularly troubling. 
Just yesterday the Fifth Circuit began oral arguments in a case 
that could invalidate Obamacare due to recent changes to the 
law. The Administration chose not to defend Obamacare in this 
appeal. That decision is entirely consistent with similar 
actions taken by other Administrations in the past for other 
laws, but here we are. Democrats sought to have the director of 
OMB here this morning to testify about how the Trump 
Administration made this decision. We could have had a witness 
from HHS. We could have a witness from DOJ. No, they wanted 
someone from OMB.
    Make no mistake. This isn't about serious congressional 
oversight. This hearing is about trying to manufacture a 
controversy based on anonymous sources and news reports. This 
hearing is just another attack on President Trump, and it is 
disappointing. We could have had a productive discussion today 
about real healthcare policy, and hopefully we can still some 
of that. I hope we can. I know that is what our side is going 
to try to do. We could have had a real discussion about how to 
make healthcare more competitive, more transparent, more cost 
effective, and with better quality of care. I hope at some 
point this committee will stop its relentless political attacks 
on the Administration and actually focus on something that 
makes a real difference in the lives of our constituents.
    Again, I want to thank our witnesses for coming here and 
telling your story, but I think the country deserves something 
better than the lies we were told. Anyone remember the name 
Jonathan Gruber? Remember that name? The New York Times called 
him the architect--the architect--of the Affordable Care Act. 
He is the guy who was caught on tape just a few years later. 
Remember him calling us all stupid, calling Americans stupid 
for buying the lies that the Obama Administration told us when 
they passed this thing? Again, they are not my words. It is 
Jonathan Gruber, the architect of Obamacare, but somehow the 
majority says that this is a hearing on efforts to undermine a 
law that was passed with so many false statements about it. Mr. 
Chairman, I yield back.
    Chairman Cummings. Thank you very much. Let me be clear to 
the witnesses. We want constructive solutions, believe me. Life 
is short. I do not waste people's time, and I damn sure don't 
waste mine.
    Now I would ask that our witnesses stand in a minute, but 
let me introduce them first. Abbe Gluck is professor of law, 
director of the Solomon Center for Health Law and Policy, Yale 
University Law School. Thank you. Frederick Isasi is executive 
director of Families USA. David Balat is director of Right On 
Healthcare Initiative, Texas Public Policy Foundation. Paul 
Gibbs is one of our patient consumers from West Valley, Utah. 
Welcome. Casey Dye is another patient/consumer from 
Monroeville, Pennsylvania. Stephanie Burton is another one of 
our patient/consumers from Kansas City, Missouri. And I will 
yield to the gentlelady from New York to introduce one of our 
constituents.
    Mrs. Maloney. Thank you so much, Mr. Chairman. It is my 
honor and pleasure to introduce my good friend and constituent, 
Peter Morley. Peter is an outstanding patient advocate, the 
most effective I have ever met in my entire life. He is a two-
time cancer survivor living with lupus. Peter is an 
extraordinary advocate for the millions of Americans who can't 
come to Congress to advocate for themselves, but are living 
with preexisting conditions, whose lives depend on consistent 
and sufficient healthcare coverage that is guaranteed to them 
under the Affordable Care Act.
    I first met Peter two years ago on Twitter when he reached 
out to me to ask what he could do to save healthcare. He 
depended on it. Many of his friends depended on it. What can I 
do? I never dreamed how far he could go. He is a true example 
of how one person can make a difference. Peter, I said, become 
an advocate. He started in the city of New York going to 
forums, press conferences, meetings, and then expanded it to 
coming to Congress over 21 times, including today, testifying 
before Congress. He has held over 150 meetings with Members of 
Congress and Senators on both sides of the aisle, and he is 
incredibly effective.
    He is a voice for the many people that need to know what is 
happening on social media. He has a huge following, and he uses 
this platform to lift up the struggles, hopes, and dreams of so 
many people who are struggling with healthcare issues. His goal 
is to save the Affordable Care Act. Thank you so much for all 
your dedication Peter. Thank you.
    Chairman Cummings. Now I want to recognize Mr. Roy for an 
introduction.
    Mr. Roy. I thank the chairman. I just really quickly want 
to welcome David Balat, who is here. He is recently a 
constituent in Texas-21. He works at the Texas Public Policy 
Foundation, which is also in the 21st Congressional District in 
Texas, in Austin, Texas. David has for a long time been 
actively involved in the healthcare industry, and health 
administration, and in other areas of health. He is a great 
expert on health. Glad to have you here, and thank you for 
representing the great state of Texas and Texas-21. Thanks, 
David.
    Chairman Cummings. Thank you very much. Now those of you 
who can stand, stand please, to take the oath.
    Do you swear or affirm that the testimony you are about to 
give is the truth, the whole truth, and nothing but the truth, 
so help you God?
    [A chorus of ayes.]
    Chairman Cummings. Let the record show that the witnesses 
answered in the affirmative. Thank you. You may be seated.
    I just want to let you know that the microphones are very 
sensitive. Speak directly into them. Make sure they are on when 
you speak. There is nothing like testimony that we can't hear. 
And without objection, your written statement will be made part 
of the official record.
    With that, Professor Gluck, you are now recognized to give 
an oral presentation of your testimony. I want to remind the 
witnesses that we all have your official statements. We want to 
try to limit this to five minutes. I know. I know. I know. I 
know, it is hard, but you see all these people here? All of 
them want to ask you all questions. So I just want you to give 
a statement kind of summarizing. Stay within that five minutes, 
and there will be a light that will come on and let you know 
that you need to end, okay?
    All right. Professor Gluck.

 STATEMENT OF ABBE GLUCK, DIRECTOR, SOLOMON CENTER FOR HEALTH 
           LAW AND POLICY, YALE UNIVERSITY LAW SCHOOL

    Ms. Gluck. Chairman Cummings, Ranking Member Jordan, 
members of the committee, good morning.
    Chairman Cummings. Good morning.
    Ms. Gluck. I appreciate the opportunity to testify here 
today.
    Texas v. Azar is unlike any other major case involving the 
Affordable Care Act. This is the first major challenge where 
there has been a consensus among legal experts, including 
prominent ACA opponents, that the lower court decision was 
dangerously wrong. The stakes are enormous. Twenty million 
people will lose their healthcare immediately. Millions more 
will be adversely affected.
    The ACA reaches every aspect of the healthcare system, not 
just people with preexisting conditions. Ten million get 
healthcare through an exchange, 17 million through the Medicaid 
expansion. Seniors on Medicare get billions of dollars in 
benefits. Also losing would be anyone who wants a vaccine. 
Preventative care, substance use treatment, and much more, all 
gone.
    It is critical to appreciate the overreach of the Texas 
decision that the entire ACA has to go and the Administration's 
decision to support it, despite the opposing legal consensus. 
For example, I filed a brief in this case with Jonathan Adler, 
the most influential critic of the ACA during the last major 
Supreme Court case. Another brief was filed by two Republican 
attorneys general. Many other prominent conservatives, 
including Judge Michael McConnell, Michael Cannon of Cato, and 
the Wall Street Journal filed briefs or wrote to oppose the 
case.
    That is because this case is about more than just 
Obamacare. It is about the violation of a century's-old legal 
principle that safeguards congressional lawmaking power. The 
principle is called severability, and unlike the legal 
questions at issue in the other cases, severability is settled, 
nonpolitical law. All nine justices apply the exact same test. 
The doctrine addresses what a court would do if it finds one 
part of a statute invalid. Does it strike down the entire 
statute, or just the offending provision?
    The Texas case, as you know, involves the 2017 tax law in 
which Congress made one change to the ACA. It reduced to zero 
the penalty for failing to obtain insurance. The plaintiffs 
argue that the coverage provision is unconstitutional, but 
that's not what's causing the crisis. That provision is not 
being enforced. What's causing the crisis is they're also 
arguing the entire ACA has to go down with it. That conclusion 
is at odds with unbroken Supreme Court precedent on 
severability.
    There are two parts to the test. First, we presume that we 
save, not destroy. Chief Justice Roberts and Justice Kavanaugh 
both recently wrote that courts must sever to the narrowest 
extent possible. Second, legislative intent. As Justice Alito 
recently wrote, ``Unless it is evident that Congress would not 
have enacted the rest, the remainder of the law remains 
standing.''
    Sometimes the test can be difficult. It's hard to know what 
Congress would've wanted, but this case is not difficult, and 
that's what makes it different. The courts do not have to, and 
are absolutely not permitted to, guess whether Congress 
would've wanted the ACA to stand because here Congress itself, 
not a court, eliminated the penalty and left the rest of the 
statute standing. By leaving the ACA intact, Congress made as 
clear as possible in the text its determination that the ACA 
should continue. It doesn't matter that some Members of 
Congress wished to repeal the law.
    To implement the preferences of those who lost the vote 
would be for the Court to accomplish what Congress could not 
over two years of trying to repeal. That's what the Texas court 
did. To excerpt from the two Republican attorneys general, 
``Congress' 2017 amendment establishes the law is capable of 
functioning without the mandate and that Congress preferred a 
law to no law at all.''
    Moreover, to get the results it wished, the Texas court had 
to ignore the intention of the 2017 Congress and focus instead 
on the 2010 Congress. But the 2010 Congress, I must emphasize, 
is irrelevant. Later Congresses are allowed to amend statues 
passed by earlier Congresses, and courts are not allowed to 
give one Congress more power than the next. The legitimacy of 
Congress' 2017 judgment is not undermined by the fact that an 
earlier Congress might've said something different.
    I've already alluded to the enormity of the consequences. 
In addition to the 20 million who would lose coverage, we would 
again be charged based on health risk, and caps would be 
imposed. Kids couldn't stay on parents' plans until 26. Women 
could be charged more than men again. No more subsidies to make 
insurance affordable. We would lose basic services many of us 
now take for granted that were not provided before: maternity 
care, prescription drug coverage, preventative screenings, and 
the ACA's major drug benefits for seniors. The Administration 
itself can't even accomplish its own initiatives, whether 
ending the HIV crisis or the opioid crisis, without the ACA's 
reforms.
    Mr. Chairman, it is not every day that vigorous legal 
adversaries take a joint position. This case is about much more 
than the ACA or even about dire consequences. It is about 
separation of powers, congressional power, and the limits on 
judges. I thank you, and I look forward to your questions.
    Chairman Cummings. Thank you. Mr. Isasi?

 STATEMENT OF FREDERICK ISASI, EXECUTIVE DIRECTOR, FAMILIES USA

    Mr. Isasi. Chairman Cummings, Ranking Member Jordan, and 
members of the committee, thank you for the opportunity to 
testify today. I'm Frederick Isasi, the executive director of 
Families USA.
    For nearly 40 years, we have served as one of the leading 
national voices for healthcare consumers, both in D.C. and on 
the state level. Our mission is to allow every individual to 
live their greatest potential by ensuring that the best health 
and healthcare are equally accessible and affordable to all. 
Our work represents the needs and interests of families. We are 
extremely proud of our bipartisan work just this year to 
address surprise medical bills, prescription drug costs, and 
improve pricing transparency. With bipartisanship possible, it 
saddens me greatly to be here today to discuss the impact of 
this lawsuit.
    As you've heard, and it bears repeating, if the ACA is 
struck down, 20 million people in America will lose health 
insurance coverage, period. That includes more than 300,000 
people in your home state of Maryland, Chairman Cummings, and 
more than 700,000 people in the home state of Congressman 
Jordan. Beyond that, vital consumer protections will be 
stripped from people with preexisting conditions, women, older 
adults. For those of us who receive our health insurance from 
employers, hundreds of millions of Americans, we could be 
subject again to annual or lifetime limits in our health 
insurance policies, meaning we could lose access to coverage 
when we are the sickest and need it most.
    Further, since the ACA, we've cut the national uninsurance 
rate for adults and children by almost half, including gains 
for families in rural America, for veterans, for older people 
pre-Medicare, and many, many others. And the ACA included a 
host of other improvements beyond private coverage reforms. As 
we've heard, the ACA lowered seniors' cost in Medicare. It 
increased the solvency of the Medicare Trust Fund. The ACA even 
created a pathway for affordable biologic drugs to treat 
devastating illnesses like breast cancer, leukemia, and 
diabetes.
    As you've heard, many will try and shift the focus of 
today's discussion from the vast improvements created through 
the ACA to focus instead on the impact of the ACA on health 
insurance premiums. We at Families USA share the public's deep 
concern about premium costs, and we are working to make 
healthcare much more affordable. However, the data are very 
clear: it is wrong to say that the ACA is the cause of high 
insurance premiums. First, despite all the rhetoric, according 
to the President's own actuaries, premiums in the employer 
market have grown more slowly since the ACA took effect in 
2014. And in the individual marketplace, most families in the 
marketplace are paying less for their coverage. For others in 
the marketplace, we know costs have increased, but--and this is 
important--this is largely because the ACA forbids insurers 
from discriminating against people with preexisting conditions. 
Many more people, both kids and adults, with complex healthcare 
needs can get access to affordable insurance because of the 
ACA, and their costs are shared among all of us.
    Despite the truth that the ACA has lowered premium costs 
for most, we can all agree--we all agree--that health insurance 
premiums were rising too fast before the ACA, and premiums are 
still rising too fast. Health insurance premiums primarily 
reflect the cost of the care paid for by the insurance; for 
example, the cost of prescription drugs, hospitals, physicians. 
As we all know, the underlying costs of healthcare have been 
increasing far in excess of our paychecks for decades, most 
recently because healthcare prices are skyrocketing. No one in 
this chamber or watching from home doubts this. As a Nation, we 
have got to get a handle on healthcare costs, but to blame the 
ACA for out-of-control healthcare costs is like a drowning man 
blaming a life preserver for getting him wet.
    And, Members of the Committee, the public does not want the 
ACA to be overturned. For well over a year, a majority of 
Americans support the law, and when polling on individual 
coverage elements of the ACA, the public support was 
overwhelming, both among Democrats and Republicans.
    Finally, let's not forget how we got here. Republican 
leaders in Congress and President Trump failed to repeal the 
ACA, so they passed a law that zeroed out the individual 
mandate. Partisan attorneys general filed suit to say that 
without the mandate, the entire law should fail. As we've 
heard, both conservative and progressive legal scholars believe 
the litigation is groundless, and many also believe that the 
President has failed in his constitutional duties by choosing 
not to defend the healthcare law. As a result, our basic 
healthcare hangs in the balance, and this is why one of the 
broadest groups of healthcare stakeholders in our Nation's 
history supports the ACA, from the American Medical 
Association, AARP, the American Hospital Association, the 
American Cancer Society, and the American Heart Association.
    At Families USA, we hope this troubling hour will pass, 
that the bedrock protections of the ACA will remain, and that 
tens of millions of families across the country can breathe a 
sigh of relief. They will know that because of the ACA, if they 
or their children get sick or they need to get healthcare, they 
won't lose their home or all the other things they've worked 
for simply to get care.
    Thank you again for the opportunity to testify, and I look 
forward to taking questions.
    Chairman Cummings. Thank you very much. Mr. Balat?

    STATEMENT OF DAVID BALAT, DIRECTOR, RIGHT ON HEALTHCARE 
           INITIATIVE, TEXAS PUBLIC POLICY FOUNDATION

    Mr. Balat. Thank you, Chairman Cummings, Ranking Member 
Jordan, and all the distinguished members of this important 
committee for having me here today. My name is David Balat. I'm 
the director of the Right on Healthcare initiative of the Texas 
Public Policy Foundation. I would also like to thank the others 
that have come here to testify this morning.
    I firmly believe we all want the same things. We want 
affordability. We want accessibly in healthcare. We simply have 
different ideas of how to get there. For those patients that 
are here today who may have benefited from the ACA, thank you 
for your bravery in telling your story because I know the 
difficulty you face in dealing with this broken system. 
Healthcare is an American issue, not a political one. It's 
personal, not partisan.
    My experience as a healthcare as a healthcare executive, 
hospital administrator, and patient advocate precedes my work 
in health policy. My journey coming from the healthcare 
industry into the realm of policy came about because lawmakers 
have consistently conflated and confused health insurance with 
healthcare. I'm here to confirm to this body that coverage is 
not care. As a hospital administrator, I've seen people use the 
emergency department for basic primary care because even though 
they may be insured, they're unable to afford their 
deductibles, which have inflated 200 to 400 percent in the last 
decade. The ACA sought to reduce emergency department services, 
but the unintended consequence has been the opposite, 
particularly in states that have expanded Medicaid.
    Outside the emergency departments, access to care has been 
an issue as well under our current system. It was no better 
prior to the introduction of the ACA, but the problems have 
certainly been exacerbated since its passage. The number of 
providers which accept the plans is minimal and shrinking, 
leaving patients waiting for appointments to see their primary 
care physician. When they do get to see their doctor, they may 
be referred to a specialist, which, again, can prove 
difficulty, especially in finding one in their region.
    The administrative burden created by the ACA has limited 
choice for those who are most vulnerable. In fact, a study in 
February of this year titled, ``The Effect of Health Insurance 
on Mortality: Power Analysis and What Can We Learn from the 
Affordable Care Act Coverage Expansion?,'' it demonstrated that 
there was no reduction in mortality for those that participated 
in the ACA, effectively demonstrating that the enrollment in 
the ACA had the same impact as having other forms of coverage 
or no coverage at all. Even those patients on the ACA exchange 
whose premiums are fully subsidized are left with a sizable 
deductible and co-insurance obligation. These large financial 
obligations left to the patient often leave them in the 
position of not being able to afford going to the doctor, and 
often waiting until they have to go the emergency room, which 
further drives up the cost of care.
    Let me be clear. Insurance coverage under the ACA that has 
driven up the cost of care, it has hurt patients with 
preexisting conditions, not helped them. As an adviser, I've 
been called to help families and patients navigate the 
complexity of hospital care or simply how to read and 
understand their explanation of benefits. There's always a 
common thread in their frustration: they don't get to decide, 
they pay more, and they get less.
    Needless to say, we have a corrupt system full of perverse 
incentives in virtually every segment of the industry. Rather 
than the patient being in charge of very personal decisions, 
government regulations have empowered insurance companies to be 
in charge. The patient and doctor are the main ones who care 
about patient health, and yet they have limited decision power. 
The decisions are being made instead by government 
administrators, the insurance companies, and a number of other 
middlemen. We have a lack of affordability and inefficiency 
because there are entirely too many middlemen who have come 
between the doctor and patient in that relationship. The 
Medicare bureaucracy sets prices for services, and then the 
insurance companies enforce those fixed prices on everyone 
else, even in the private market.
    We need a system in which everyone has a choice and the 
government role is limited to a safety net. The current system 
is failing because it is unaffordable and unreliable. Americans 
understand that the problem is the high cost of healthcare, and 
what they want is to be empowered to make decisions for 
themselves and their families, and to have a sense of peace of 
mind. This doesn't come from government mandates. This is 
evident when people are involved and participating in their 
care management with their doctor.
    We hear about the number of uninsured in this country, but 
not all of them are without care. I am among that statistic of 
the uninsured, but I would assert I get better healthcare as a 
patient because, to repeat my point, coverage is not care. I 
use direct primary care and medical cost sharing for my 
catastrophic coverage for both myself and my family. These 
models, in addition to the many others that have been promoted 
by the Trump Administration, do not have exclusions for 
preexisting conditions, and are demonstrating a higher degree 
of accessibility and affordability.
    The high cost of care in the country increased 
significantly during the time of the ACA. The high cost of care 
is the single-biggest reason why healthcare has become less 
accessible. The high cost of care is what American people care 
about. The high cost of care is the direct result of the 
Federal Government attempting to fix healthcare and failing. 
Choice and competition, not a one-size-fits-all plan, is what 
we need for something as local and personal as healthcare. We 
need a landscape of choices that are as diverse and as personal 
all of us.
    Thank you very much, and I look forward to your questions.
    Chairman Cummings. Thank you. As we now move to Mr. Gibbs, 
let me say to our patient witnesses. Again, I want to thank you 
for being here. I think your testimony is so important. So 
often here on Capitol Hill, we look at statistics, and we read 
about people having problems, but there is nothing like having 
people who go through it every second of their lives. So, Mr. 
Gibbs, I thank you.

  STATEMENT OF PAUL GIBBS, PATIENT/CONSUMER, WEST VALLEY, UTAH

    Mr. Gibbs. Thank you, Mr. Chairman. Thank you, members of 
the committee, for giving me the opportunity to speak today. 
Today I've heard this law referred to as, as it commonly is, by 
the names either the ``Affordable Care Act'' or ``Obamacare.'' 
For me, it's important to call this law by its full name--the 
Patient Protection and Affordable Care Act--because the patient 
protections of the ACA have been a gift from God for people 
like me and families like mine.
    My healthcare story begins in 1974 when my twin brother and 
I were born with serious medical conditions. He had a condition 
called Hirschsprung disease in his intestines, which caused him 
to need 17 surgeries by the time he was five years old. I had 
nine surgeries on my kidneys for a condition called bilateral 
vesicoureteral reflux, which meant that urine was going back up 
the urethra into my kidneys instead of down where it belongs. 
Now the costs of that were severe. My parents never got out 
from under the financial burden of those healthcare costs for 
my brother and me. Within the past 10 years, they've passed 
away with virtually nothing material to their names, but with a 
great legacy of caring for their family as much as anyone ever 
could.
    It was in November 2008 that my doctor told me in a routine 
visit--I thought a routine visit--that I was in end-stage 
kidney failure and needed a transplant as soon as possible. I 
was working. I was going to school. I was doing my best to be a 
contributing member of society, but I had no insurance 
coverage. Now coverage may not be care, but when you need a 
$79,000 surgery, there is no care without coverage.
    I'm a member of the Church of Jesus Christ of Latter-Day 
Saints, a church that's very well known for its generosity in 
taking care of its members, but my church couldn't pay for a 
$79,000 surgery, and I needed two surgeries. My kidneys were in 
bad enough shape that they were considered an infection risk 
for the new kidney, so they had to be removed first 10 years 
ago this week. I've heard opponents of the ACA say people don't 
die in America for lack of healthcare because they can go to 
the emergency room. You can't get a kidney transplant at the 
ER.
    Now I was fortunate. I fit the fairly narrow qualifications 
for Medicaid before the ACA expansion, and I also fit 
qualifications for Medicare coverage. Those allowed me to have 
that life-saving surgery 10 years ago this August, but the 
expenses didn't end there. Every day I have to take 
immunosuppressant medication to keep my own body from rejecting 
the kidney, and I also have to take other medications, which 
deal with the side effects caused by that immunosuppressant 
medication. Also, because my doctors later discovered that a 
chronic distended bladder may have caused my kidneys to decline 
to begin with, I have to use these catheters five or six times 
every day just to be able to empty my bladder. Without the ACA, 
it would be an expensive prospect for me to be able to urinate. 
All of these expenses together add up to almost as much per 
month as my mortgage payments.
    Now I hear talk of protecting preexisting conditions in 
other plans, that everybody wants to protect preexisting 
conditions. Well, the previous plans that have been put forth 
include things like pushing people like me into expensive and 
unreliable high-risk pools. Those are not protections for 
preexisting conditions. Potential lockouts for not having 
continuous coverage are not protections for preexisting 
conditions. I hear talk of relentless attacks on the 
Administration and the ACA. People like me feel relentlessly 
attacked by this Administration and by the members of 
committees like this one who keep attacking the ACA.
    My son Peter, five months old this week, was born with a 
kidney condition similar to mine. He, like Chairman Cummings 
talked about, is one of those babies who could be shut out for 
life. He had a kidney surgery two weeks ago, and without the 
ACA, he wouldn't have the protections to ensure that he could 
receive the followup care he may need his entire life, just for 
being born with a bad kidney. He's one of two sons I have who 
had the chance to be born because of the wisdom of the Patient 
Protection and Affordable Care Act, which gave me this 
coverage.
    In conclusion, I want to say that we are guaranteed in the 
Declaration of Independence the inalienable rights of life, 
liberty, and the pursuit of happiness. ``Life'' comes first 
because without life, all other rights are meaningless. Being 
subject to insurance companies being able to deny us coverage 
or make it prohibitively expensive because we're sick is not 
liberty. And without those protections, without access to 
healthcare, there can be no pursuit of happiness.
    My sons deserved the right to be born, they deserve the 
right to stay alive, and they deserve to have a father who has 
access to the care he needs to stay alive for them. Thank you 
very much.
    Chairman Cummings. Thank you very much, and 
congratulations.
    Mr. Gibbs. Thank you.
    Chairman Cummings. Ms. Dye.

    STATEMENT OF CASEY DYE, PATIENT/CONSUMER, MONROEVILLE, 
                          PENNSYLVANIA

    Ms. Dye. Thank you, Chairman Cummings, and the committee 
for letting me talk today.
    Over the past nine years, my family has faced a lot of 
challenges, but I hope you hear my story and recognize that I'm 
not some unique one-in-a-million story. The challenges my 
family have faced are like so many families who work hard, play 
by the rules, faced as they go through life. As parents, we 
want to make sure we can do the most essential thing for our 
kids and keep them safe and healthy. We also want to know as 
they go through their own journeys they will also overcome 
challenges and continue to pursue their dreams.
    In August 2010, my husband lost his job. We couldn't afford 
COBRA. Between August and November of that year, he and I went 
uninsured. Our one-year-old daughter, Chessie, got coverage 
through CHIP. In 2016, my husband lost a second manufacturing 
job, and thanks to the ACA, we did not have to worry about 
going uninsured again. My employer's health plan would cost 
$1,175 a month, and that's just for the two of us. We pay $60 a 
month for our son, Max, who's on CHIP, and our daughter, 
Chessie, is covered under the PH-95 Medicaid loophole for her 
disability. After my husband lost his job in 2016, we wanted to 
move closer to family in your state, Mr. Jordan, of Ohio, in 
Florida, and Arizona. Guess what, Mr. Jordan? Your state told 
me my daughter wouldn't get the services she needed, so, 
therefore, we have to stay in Pennsylvania.
    We also had to tailor our life around the needs of Chessie. 
For example, my husband is now going back to college to switch 
careers in the healthcare field, which doesn't require us 
moving from state to state to find a job. Thanks to the ACA, in 
2018, I was able to get a mammogram. It showed I had three 
lumps in my left breast. Biopsies were done, and thankfully 
they were all benign. But what if I was uninsured and the 
results turned out differently? This could have been 
financially disastrous for my family. Before the followup this 
year in May, I actually looked at my husband, and I was kind of 
joking and being serious. ``I should just have the doctor 
remove both of my breasts'' because if I get cancer, I might 
actually be uninsured. This is my reality, and this is the 
reality of millions of families in America. And the fact is, I 
don't trust the Republican Party to say that you care about me 
and my family and the rest of the families in America to cover 
preexisting conditions, to cover those with disabilities.
    I also had decided to get a pelvic exam two years in a row, 
and when the doctor asked why I scheduled it this way because 
now you can go between three to five years, I told her the 
truth: I'm worried I'm not going to have coverage next year. So 
she looked at me and she said she was glad that I actually made 
that choice to come in. I am actually an LPN who works in 
pediatric home care, so a lot of the kids I take care of, 
they're on Medicaid. So not only is my job, but the lives of my 
patients are at risk if you guys make cuts to these vital 
programs.
    Our daughter, Chessie, who is right here in the white with 
the little pink headphones----
    Chairman Cummings. Where is she? Oh, okay. All right. She 
seems to be listening to your testimony.
    Ms. Dye. I'm not as important as----
    [Laughter.]
    Ms. Dye. Since she's been 19 months old, she has been in 
therapies. That's for OT for speech, and she also learned sign 
language so she could communicate with us, speech we use in 
everyday life from watching TV, listening to music, reading 
books, talking to our friends, socializing, and work. At the 
age of three, Chessie was seen by three doctors. Two diagnosed 
her with developmental language disorder, DLD, a condition 
where children have problems understanding or using spoken 
language. She will have this in adulthood. The other doctor 
diagnosed her on autism spectrum, but all doctors agree that 
she needs intense speech therapy.
    In school, she receives speech three times a week and OT 
one time a week. She also gets speech and OT once a week 
outpatient. She has a mobile therapist that comes to our house 
two hours per week. A mobile therapist helps Chessie to 
appropriately express her thoughts, her feelings, and work on 
coping skills, practicing social skills and all. Chessie gets 
six therapies week, not including a mobile therapist. If 
Chessie loses her Medicaid coverage and we had to pay, it would 
cost us $1,920 a month just to keep her at her current level of 
therapy. Because my husband is in school and we are on one 
income, we could never afford that.
    The hard work of her therapists in Chessie's life has 
improved her life skills tremendously. Today she talks a lot, 
and she talks to friends on her own. She has made significant 
academic progress. Last year she was a C student. This year at 
the age of 10, she got all A's and one B. In math and reading, 
she is two years behind, and she's in a support room.
    Just to make it clear to kind of break it down to visually, 
imagine a tripod and Chessie is on top of that tripod. The 
three legs represent, one is her parents, two is her 
therapists, and a third one is her teacher and her aides. If 
you guys cut Medicaid, you're going to knock down that tripod, 
and you're going to take away and knock down all the progress 
that she has made. The only chance of her being a productive 
member of our society and being able to get a job and hopefully 
just make minimum wage is these crucial programs that you guys 
have in place right now.
    So I just want you to realize what you guys are doing and 
not just think of my family and my daughter, but the millions 
of families around the United States that you guys are going to 
affect. Thank you.
    Chairman Cummings. Thank you very much. Ms. Burton.

 STATEMENT OF STEPHANIE BURTON, PATIENT/CONSUMER, KANSAS CITY, 
                            MISSOURI

    Ms. Burton. Chairman Cummings, Ranking Member Jordan, and 
the distinguished members of the committee, good morning.
    Chairman Cummings. Good morning.
    Ms. Burton. My name is Stephanie Burton, and I live in 
Kansas City, Missouri. In August 2008, I left my job as a 
probation officer to attend law school. I could not afford 
health coverage, so I was uninsured throughout school. Upon 
graduating in December 2010, like many of my classmates, I was 
unable to find work and was forced to hang my own shingle 
immediately after passing the Bar.
    Starting my own legal practice meant I still had no 
healthcare. As a single mother of four young children, that was 
devastating. My diabetes went untreated for five years. When my 
health got so bad that I could not tough it out, I was forced 
to seek medical care in the emergency room only. As a mother, I 
felt that I had let my children down. I had done everything 
that seemed right by furthering my education, yet I still 
couldn't even afford a routine doctor's visit. Something was 
terribly wrong with this picture.
    The Affordable Care Act changed all of that. On January 1st 
of 2014, I enrolled in a health insurance plan I purchased 
through the marketplace for less than $100 a month thanks to a 
subsidy. I no longer had to decide between paying my mortgage 
and going to the doctor. I've been able to manage my diabetes 
and get the medications I need to stay healthy for my kids and 
my clients. It's a huge load off of my mind. I've been covered 
through the marketplace since the beginning of the first open 
enrollment period, and I found the coverage affordable and easy 
to use.
    When taking a flight, the attendant always says if you're 
traveling with small children, in the event of an emergency, 
first place the oxygen mask over yourself and then over the 
small child. Now to every parent this sounds counterintuitive 
because we consistently put our children first. However, if we 
do not take care of ourselves and our health first, we will not 
be around to care for our children. The Affordable Care Act was 
like that oxygen mask. It allows me to have healthcare to keep 
myself healthy so I can continue to work and provide for my 
children.
    Until March 7 of this year, I was self-employed without the 
option of employer-provided health insurance. Upon accepting 
this new position eight years after having to hang my own 
shingle, I'm now offered health insurance through my employer. 
Though that benefit option is great, I can still say the policy 
that I have through the marketplace is better. I have had the 
same team of doctors since I enrolled in 2014.
    Although the need isn't as urgent for me today as it was 
eight years ago, I can honestly say that the Affordable Care 
Act saved my life. The last five years of coverage have kept me 
the healthiest I have been in the 11 years since I started law 
school. One of the requirements of my current employment was to 
undergo a health physical. I have no doubt that I would not 
have been healthy enough in 2014 to accept the position I have 
now.
    Maintaining preventative healthcare through routine visits, 
thanks to my ACA coverage, has allowed me to continue to treat 
my diabetes without fear of being turned away. Access to 
healthcare should be a fundamental human right to all people. 
There should not be Hobbesian choices when it comes to 
healthcare or housing.
    During this Administration, I frequently wonder what would 
happen if I lost my coverage and what would it mean for my 
children. In the event that I had to return to private 
practice, would I be able to afford my insurance without my 
subsidy? Would I be lucky enough to last without the treatment 
that I receive? This is not a partisan issue. This is what 
happens to families without health coverage issue. It's a why 
are we turning back the hands of time issue. It is a why should 
a single mother of four children be forced to choose between 
housing and healthcare issue. We create another undue burden on 
society if we can't keep parents healthy enough to raise their 
children issue.
    So I ask you and I urge you all, both sides, don't take 
away coverage from 20 million people. Don't return to the 
crisis, the health crisis, that we endured before the ACA. 
Thank you.
    Chairman Cummings. Thank you very much. Mr. Morley?

STATEMENT OF PETER MORLEY, PATIENT/CONSUMER, NEW YORK, NEW YORK

    Mr. Morley. Thank you, Chairman Cummings, Ranking Member 
Jordan, and members of the committee. I am honored to speak 
with you today.
    My name is Peter Morley. In 1997, I had an injury during a 
lapse of insurance coverage. All treatment and medication costs 
were paid out of my own pocket. When I later needed surgery, my 
insurance company considered my injury to be a preexisting 
condition, and all my claims were denied. It was a financial 
burden totaling in tens of thousands of dollars.
    In 2007, I was permanently disabled from an accident. I was 
spared the costly medical bills of four spinal surgeries 
because I had continuous health coverage. In 2011, I survived 
kidney cancer and fought my way into remission after losing 
part of my right kidney. In 2013, I was diagnosed with lupus, 
which causes me severe fatigue, and most days it's a struggle 
to get out of bed. I now manage over 10 preexisting conditions, 
take 38 different medications, and receive 12 biologic 
infusions to slow the progression of my disease. I live on the 
brink of financial ruin and only live modestly thanks to 
insurance and the fact that I can't be discriminated against 
because of a preexisting condition.
    Preexisting conditions are a way of life for me as well as 
millions of others. Thanks to advances in science and medicine, 
most people like me with chronic diseases can live happy and 
productive lives, but only if we are provided access to health 
insurance that can't be taken away because an insurance company 
decides it's in their best interest not to cover something, or 
if Congress decides to repeal our healthcare, or the single-
greatest threat we face to our health today: the Trump 
Administration's refusal to defend the Affordable Care Act.
    As someone who spends the majority of my waking hours in 
doctor's offices, the ACA has meant focusing on healing, not 
bankruptcy. I used to be very private about my health, but once 
President Trump was elected and set out to repeal the ACA, I 
could no longer be silent. In December 2016, I decided to 
foster awareness for lupus and advocate for healthcare. My 
Congresswoman, Carolyn Maloney, has taken up my cause and those 
of people like me. The Trump Administration's reckless support 
for the Texas v. Azar lawsuit to tear down the entire ACA, 
terminating it, as the President has said, is a grave form of 
subversion.
    In the last two years, I have traveled to D.C. 20 times to 
advocate for thousands of people who shared their healthcare 
stories with me. I have met with Democratic and Republican 
Members of Congress alike. My message is simple. If you think 
people don't get hurt when the Administration doesn't defend 
the ACA, think again. We do. I do. Millions do. If you think 
preexisting conditions aren't important, remember someone you 
love could have an accident, be diagnosed with cancer or lupus 
at any time, and that will change how you think about this. I 
know firsthand your healthcare can change in an instant. And if 
you think the ACA isn't perfect, your job as our 
representatives isn't to tear it down. It's to make it better.
    I appreciate the committee holding this hearing today. If 
the Trump Administration can choose not to defend the ACA, 
citizens like me understand that future administrations can do 
that with any law. I put my health at great risk to travel here 
and share these stories. I never know if this is the last time 
I am healthy enough to come to D.C. I would be remiss if I did 
not mention my friend and advocate of medically fragile 
children, Natalie Weaver, whose own daughter, Sophia Weaver, 
passed away in May. Sophia suffered from Rett syndrome and many 
other preexisting conditions and endured 30 surgeries in her 
short 10 years of life. Natalie spent precious time away from 
her daughter for the betterment of healthcare access for all 
children. She will never get that time back. These are the 
sacrifices that we make as advocates.
    That is why I am here today to ask you to protect the 
Affordable Care Act and to hold the Trump Administration 
accountable for not defending health insurance for all 
Americans. Thank you for allowing me the opportunity to 
testify, and I'm happy to answer your questions.
    Chairman Cummings. Thank you very much. Pain, passion, 
purpose. I will now yield to the distinguished lady from New 
York, Ms. Maloney.
    Mrs. Maloney. Thank you. Thank you, Mr. Chairman, for 
calling this very meaningful hearing. I am so proud that one of 
my constituents, Peter Morley, was invited to testify. He is 
the most effective patient advocate I have ever met, and he has 
been a fierce defender of the Affordable Care Act.
    Peter, thousands of patients and their families have 
reached out to you to share their stories and asked you to 
bring those stories to Congress. Can you share what some of 
these stories are like, and is there anyone that stands out to 
you?
    Mr. Morley. Absolutely. There are many that actually stand 
out to me. The most--the hardest stories for me to listen to 
are the people who could have been saved had the ACA been 
enacted, and also the patients who would have, like some of 
these people, these patients have testified here today, they 
would have been diagnosed sooner, their conditions would have 
been more under control, and, in some cases, healed.
    I hear from patients who--excuse me, rather, caregivers who 
are--they have medically fragile children and they get their 
health insurance because of Medicaid Expansion. I hear from 
people in states such as Texas, Florida, North Carolina, and 
Tennessee who don't have that same luxury because their states 
have not expanded Medicaid and they are denied that type of 
coverage, had they lived in a separate state, and they cannot 
afford to move to another state to receive that type of 
coverage.
    Those are the stories that keep me up at night, and of 
course, since I have lupus, anyone who reaches out to me who 
suffers from lupus and tells me, ``Thank you, Peter, for going 
to D.C. I don't know where you get the energy to do it,'' and 
truthfully, I don't know either. I am grateful to be here. It 
is that energy, as these patients have testified. It takes a 
lot of guts and a lot of courage to come here and to share 
something so vulnerable and so personal.
    Mrs. Maloney. I know. I know you suffer from chronic 
diseases and I know personally, from our exchanges, that it is 
very painful for you physically to come here. Why do you make 
these trips?
    Mr. Morley. Because, honestly, Congresswoman, I never 
expect to sit, whether it is a Democratic or Republican 
legislator, I never expect to change anyone's mind. But what I 
have learned from coming down here is it brings me hope, hope 
that there is a chance for change, hope that one person will 
listen, because it really only takes one person, and the hope 
that the people who follow me on social media, they receive and 
they say to me, you know, ``Peter, thank you. Thank you. I can 
feel that something positive may come out of all this sabotage 
that we have witnessed.''
    Mrs. Maloney. Peter, the Trump Administration's recent 
attack on the Affordable Care Act in the form of the Texas v. 
United States court case really threatens health care for 
millions of Americans. What would it mean for your friends, the 
patients and families that you have spoken to, if protections 
for people with pre-existing conditions are eliminated?
    Mr. Morley. In some cases it might limit their access to 
medications and to life-saving infusions and to cancer 
treatments, and it could--I mean, it very well would mean 
death.
    Mrs. Maloney. What about if Medicaid was eliminated? What 
would that mean?
    Mr. Morley. Medical Expansion?
    Mrs. Maloney. Yes.
    Mr. Morley. Yes.
    Mrs. Maloney. What would happen to these families?
    Mr. Morley. A lot of them would lose coverage and access.
    Mrs. Maloney. And what would it mean to the parents of 
medically fragile children who have reached out to you, if the 
entire Affordable Care Act--what would happen to them if the 
Affordable Care Act was eliminated?
    Mr. Morley. I honestly don't know but I do know that they 
experience, just even if that didn't happen, they experience an 
incredible deal of stress. And this, even having to focus on 
that has caused them an undue stress, and it is already stress, 
as we all know, when we have a chronic illness, so it is stress 
upon stress.
    Mrs. Maloney. My time is expired. I am proud to be in this 
fight with you and I so proud of you.
    Mr. Morley. I am proud of you.
    Chairman Cummings. I yield now to Mr. Hice.
    Mr. Hice. Thank you, Mr. Chairman.
    Yes, I think there are two basic reasons why we are having 
this hearing today. No. 1 has just come up. It is an 
opportunity to trash the President, to impugn the President for 
not defending Obamacare, and I get where our witnesses are 
coming from, from that perspective. But that is the purpose--
one of the purposes of this hearing.
    But the reality is Obamacare is failing, and the President 
is not defending a failing policy, a bad policy, and he is 
right not to defend that. I mean, just look at the numbers, and 
it is very clear. Obamacare does not work. It has not worked 
and it is not going to work. We were told that there would be 
some 25 million people enrolled in Obamacare by now. It just 
has not happened.
    The truth, what has happened, insurance premiums have 
skyrocketed--skyrocketed--under Obamacare. Deductibles have 
soared. Coverage networks and access to providers have shrunk, 
in some cases been eliminated. Insurance companies have fled 
the ACA marketplaces. Rural hospitals have suffered enormously. 
I have a number of them in my district, and they have suffered 
tremendously because of Obamacare. Many rural hospitals have 
actually closed their doors.
    And yes, there are people who have benefited. I am not 
going to deny that. Of course, our panel is full of them today, 
and I appreciate the testimony from our witnesses, our 
panelists today.
    But I can also tell you this: for every person who has 
benefited from Obamacare, we can find tons of folks who have 
been hurt from it. You know, I look at the panel today, Mr. 
Chairman, six out of the seven are Democratic witnesses. Where 
are the ones--in fact, I would like, Mr. Chairman, to have 
entered into the record a letter from a constituent back home, 
Ralph, from Greensboro, Georgia, who talks about how he has 
suffered.
    Chairman Cummings. Without objection, so ordered.
    Mr. Hice. Thank you.
    You know, and we are told that--you know, I will just 
reverse it somewhat, of what has been said already today. If 
you think that people don't get hurt by ACA, you need to think 
again. Ralph, for example, before Obamacare he paid $700 a 
month for insurance with a $3,500 deductible. Both of those--in 
fact, he now has a nearly $14,000 deductible and his monthly 
costs are about $1,200 a month. A couple of years ago his two 
children--he has four children--two of them were in an 
accident. He is still paying for $30,000-plus that had to come 
out of pocket. That is before taxes, before groceries, before 
mortgage, before college. So this thing absolutely goes both 
ways.
    The second reason we are here today is really to lay the 
platform for Medicare For All, and that is the attempt that the 
Democrats are putting forth. In spite of the failures of 
Obamacare, the Democratic Party is going to double down and 
push for Medicare For All at a cost of some $32 trillion. It 
would totally eliminate employer-sponsored medical coverage, 
Medicaid, Medicare--all of it, gone.
    Mr. Balat, let me just ask you, what can we expect from a 
government single-payer health system?
    Mr. Balat. You can certainly expect rationing of services. 
That is what we have seen in many other countries that have 
gone this way. Many politicians have said those are models that 
we want to look for, that we want to look toward, to emulate. 
But my experience in being with those countries and working 
with patients--I will give you a specific example, if I may.
    My wife and I were on medical missions in Costa Rica that 
has a single payer, and the wife of the pastor that we were 
with was diagnosed with cervical cancer. She was approved for 
surgery but she had to have an ultrasound first. She could not 
have that ultrasound for 12 months. She asked, ``Well, when 
will I be able to have the surgery?'' and they said, ``Probably 
another 12 months after that.'' She had access. She may never 
get to the point where she has that surgery.
    But rationalizing is an inevitability when you have a 
limited amount of resources, and those resources continue to 
decrease, the more burden we place on the medical professionals 
that are actually delivering the care.
    Chairman Cummings. The gentleman's time has expired.
    Dr. Gluck, would you like to respond to that? Hice said he 
wants to see both sides. He said it is both sides. What is the 
other side of this? I saw you shaking your head. Go ahead.
    Ms. Gluck. So, you know, what occurs to me----
    Chairman Cummings. Your mic. Your mic. We really want to 
hear you.
    Ms. Gluck. Oh, sorry. You know, with respect to discussing 
the case that is the subject of this hearing, one of the things 
that I would emphasize is that the case in Texas is not on 
policy referendum. It is not a case about the benefits or not 
of the Affordable Care Act. It is a case about a settled legal 
principle. The Administration doesn't get to decide whether to 
defend a law based on whether it likes the policy and the law 
or not. That is your job, Congress' job, is to pass the 
policies. The Administration's decision not to defend is only 
defensible under very limited circumstance, unless there is a 
real unsettled legal question.
    As I said in my testimony, what is striking about this case 
is that there is a dramatic legal consensus across both sides 
of the aisle that the principle at issue here, the legal 
principle, severability, is settled, and that there is no place 
not to defend the law.
    I would also just note that, you know, we have heard a lot 
of statistics about the benefits of the Affordable Care Act, 
including dropping the insurance rate by some 46 percent, 
including getting women covered at record rates, and I also 
would point out that the Trump Administration itself is 
actually relying on the statute for a lot of its initiatives. I 
heard this morning that the Trump administration announced an 
Executive Order about kidney disease that depends on the Center 
for Medicaid Innovation. Well, that would be gone if the 
Affordable Care Act is eliminated. The HIV Initiative 
requires----
    Mr. Hice. Point of order, Mr. Chairman.
    Ms. Gluck [continuing]. everything in the Affordable Care 
Act.
    Mr. Hice. Point of order. Whose time is this?
    Chairman Cummings. I am trying to help you, man. You asked 
a question and I----
    Mr. Hice. Not to this----
    Chairman Cummings [continuing]. basically, I--I asked her 
to finish answering the question. She was shaking her head and 
I allowed her to do that, because I know you want a fair 
hearing. I know you want to hear both sides of it. That is what 
you just said. It is my time.
    Mr. Hice. Mr. Chairman, six out of seven is not exactly 
giving a fair hearing.
    Chairman Cummings. Oh, come on, man.
    Mr. Hice. We want a fair hearing.
    Chairman Cummings. Yes, well, you are getting it.
    Are you finished?
    Ms. Gluck. Yes, I mean, that is the point. The opioid 
crisis as well. Virtually all of their own health care policies 
rely on the statute as well. So, I mean, I think that is 
important to recognize that when we are talking about the 
benefits and what the statute has to offer.
    Chairman Cummings. Thank you very much. Thank you for 
giving us both sides.
    Ms. Norton?
    Ms. Norton. Thank you very much, Mr. Chairman. It took a 
lot of chutzpah to hear my friend on the other side go down the 
list of the costs going up of health care, deductions going up, 
when that is a direct result of actions that the Republican 
Congress took when they controlled this House. They are 
complaining about actions that they took to diminish the 
Affordable Care Act.
    Well, one of those actions was to take away the mandate. 
The district I represent, the Nation's capital, the District of 
Columbia, has a rate of about 96 percent covered, which means 
that virtually everybody is covered. That is people going from 
one side or the other who may not be covered. That is because, 
as my Republican friends took actions, that is detailed by my 
colleague on the other side that undermined the Health Care 
Act, in my district they simply made up for them themselves, 
for example, as I indicated, by reinstating a DC mandate, and 
so almost everybody has health care.
    Ms. Burton, I was interested in your testimony because it 
looked to me as though you had done all that anybody could be 
expected to do. You finished law school, you could not find 
employment, and then you did what is really difficult for 
someone just out of law school--you opened your own practice. 
Your children were covered, you said, by Medicaid, but you 
could not get coverage in the individual market, I understand, 
because of a pre-existing condition. Is that true?
    Ms. Burton. That is correct.
    Ms. Norton. Any idea of what the purchase of health 
insurance would have been for you before the ACA?
    Ms. Burton. It was $895 a month, which was more than my 
mortgage.
    Ms. Norton. I was going to ask you, compared to what other 
expenses. You indicated your mortgage.
    So you chose to give up coverage for yourself in order to 
pay the rent and provide for your children. Did that take any 
toll on your health?
    Ms. Burton. Absolutely. As a single mother of four kids you 
do what you have to do to maintain. You do what you have to do 
for their interests, even if it means you sacrifice your own. I 
worked in private practice 80-100 hours a week. I took time 
away from my kids to make sure they had everything that they 
needed.
    I don't have any regrets about that. I would give anything 
to make sure that they are okay. But I am all they have, and so 
if I am gone there is not somebody else willing to step up and 
take over that burden.
    Ms. Norton. Well, then came the Affordable Care Act----
    Ms. Burton. Yes, ma'am.
    Ms. Norton [continuing]. with the Marketplace. What kind of 
coverage were you able to get, and how much did that plan cost?
    Ms. Burton. My plan with my subsidy cost $62 a month, and 
it was----
    Ms. Norton. Compared to--now remind us, compared to----
    Ms. Burton [continuing]. the $895 that I would have had to 
pay for an HMO coverage. The plan that I got through the 
marketplace was a PPO coverage. I was able to choose a doctor. 
I have got a great doctor and a great team of doctors. Because 
I have so many conditions--I have narcolepsy, I have asthma, I 
have diabetes, I have sleep apnea, I have cataplexy--because of 
that I have a team of doctors.
    Ms. Norton. Now--but now you work for the District 
Attorney's Office. Now that is a government agency.
    Ms. Burton. Correct.
    Ms. Norton. And the government agency we work for, the U.S. 
Government, provides health care for everybody who is sitting 
on this podium, so you would have what we would have. So did 
you take your health care that was provided by the District 
Attorney's Office?
    Ms. Burton. My health care that I have through the DA's 
office is supplemental. It is not Federal so it doesn't cover 
the benefits that you guys might have. My policy, through the 
marketplace, is still better than the insurance my employer 
offers.
    Now I did take it for my children.
    Ms. Norton. So you had health insurance offered by your 
employer, you compared that to the ACA, and you decided to 
stick with the ACA coverage.
    Ms. Burton. That is correct.
    Chairman Cummings. The gentlelady's time has expired. Did 
you finish?
    Ms. Burton. Yes, sir.
    Chairman Cummings. Thank you very much.
    Mr. Comer?
    Mr. Comer. Thank you, Mr. Chairman. I would like to 
welcome--I am over here--I would like to welcome all the 
witnesses here today, and I just have three quick general 
questions I would like to ask the entire panel, just with a 
show of hands for the sake of time.
    Do you all support--or how many support eliminating 
employer-sponsored insurance?
    [No response.]
    Mr. Comer. Second question. How many on the panel support 
the current version of Medicare For All, which I believe, if my 
math is correct, 17 members of this committee on the other side 
of the aisle support? Does anyone support Medicare For All?
    [No response.]
    Mr. Comer. Last question. Do you support extending health 
care benefits to illegal immigrants?
    [Hands raised.]
    Mr. Comer. A couple. This is one of the areas that I find 
troubling, because I represent Kentucky. I represent a poor 
district. I represent a district that has a high percentage of 
people on Medicaid. Before the Affordable Health Care Act 
Kentucky had a high Medicaid population. After the Affordable 
Health Care Act, Kentucky expanded Medicaid, and what happened 
when they expanded Medicaid, a significant number of new people 
got on Medicaid. What that did was it cut the pie into very 
small pieces. In fact, 30 percent of Kentucky is on Medicaid 
now. There are so many people on Medicaid that the providers 
continue to get cut and people on Medicaid are finding a hard 
time finding a provider who will actually take them.
    So Medicaid has not been cut in Kentucky. The fact that so 
many people are on Medicaid, the services are automatically 
getting cut. Everybody can't be on Medicaid, and Medicaid in 
Kentucky is free health care, and that is a great deal for the 
people that have free health care. But somebody is paying for 
the free health care, and the people that are paying for the 
free health care are the people that are in the private market. 
They are very upset because the premiums continue to skyrocket. 
So we have a problem with the Affordable Health Care Act.
    Mr. Balat, the reason I asked the question about extending 
health care to illegal immigrants is because I watched the 
Democratic debate the other night, when there were 10 on the 
panel, and they were asked the question, how many support 
extending health care, free health care, to illegal immigrants. 
And if I remember correctly, all 10 raised their hands. That is 
potentially millions of new Americans on what I would presume 
would be Medicaid.
    What happens to the current health care system in America 
if my friends on the other side of the aisle and those running 
for President from the other party get their wish and extend 
free health care to millions and millions of illegal 
immigrants?
    Mr. Balat. Thank you for the question. I am a child of 
immigrants. It is important what we do in this country for the 
people that are here. We, as Americans, have always taken care 
of our communities, and that is our focus. That is who we take 
care of. What it would do to health care, what it would do to 
our communities, what it would do to the medical professional 
community is it would strain it even further.
    Let me tell you what happens in Medicaid today. It is very 
difficult to get in and see the doctor. The wait times are 
exceptionally long, as I said in my testimony. If they do get 
in to see their doctor, getting a specialist referral is very 
difficult, because even less specialists participation in 
Medicaid panels.
    Then, getting the medication that they may need. You know, 
I hear all the time that doctors do not like to take care of 
Medicaid patients. Nothing could be further from the truth. 
They got into that field to take care of patients. They don't 
like the administrative burden that is consistent with how we 
deal with Medicaid and the ACA exchange, and so on.
    It is going to stretch it out. We are going to see less 
people participating on those panels, and it will leave people 
without care, and we are going to see our ERs continue to be 
flooded and increase in population.
    Mr. Comer. Right. Well, I think that is an important part 
that needs to be mentioned in this hearing, is that everyone 
can't have free health care, and we have got a problem with the 
health care system in America. We had a problem before 
Obamacare, it got worse after Obamacare, and, you know, there 
is no way to fix the Obamacare situation, especially in 
Kentucky with the massive expansion of Medicaid.
    So hopefully we will have a discussion in the future in 
Congress about ways to make health care more affordable to the 
working people that are paying, while, at the same time, 
protecting people with pre-existing conditions, which is a 
priority for me, and I think every member of this Congress.
    Thank you, Mr. Chairman. I yield back.
    Chairman Cummings. Thank you very much.
    Mr. Raskin?
    Mr. Raskin. Thank you very much, Mr. Chairman. Professor 
Gluck, let me start with you, because you said something 
extraordinary, which is that your partner in filing an amicus 
brief against this attempt to destroy the Affordable Care Act 
and strip 20 million people of their health insurance, is a 
person who was opposed to the Affordable Care Act and was your 
nemesis, essentially, your counterpart on behalf of the 
Affordable Care Act back in the Burwell case. Is that right?
    Ms. Gluck. Yes, it is. It is extraordinary.
    Mr. Raskin. So you are talking about a distinguished lawyer 
who was opposed to the Affordable Care Act, and thought it was 
originally unconstitutional, but he thinks it would be 
absolutely absurd and outrageous to use the invalidation of one 
provision, which zeroed out the penalty for not purchasing 
insurance, to unravel the entire act. Is that right?
    Ms. Gluck. Correct.
    Mr. Raskin. And you cite a bunch of other conservative 
legal scholars who are on that side. Would you repeat some of 
the ones you mentioned?
    Ms. Gluck. Sure. So there is the Republican Attorneys 
General from Montana and Ohio, Judge Mike McConnell.
    Mr. Raskin. Judge McConnell?
    Ms. Gluck. Yes. Professor Sam Bray, Professor Kevin Walsh.
    Mr. Raskin. In what context is Judge McConnell taking a 
position against the Administration's point of view here?
    Ms. Gluck. Judge McConnell authored an amicus brief with 
two other noted conservative legal scholars arguing that there 
is no jurisdiction to decide the case, and filed the brief not 
on behalf of neither party but actually on behalf of the blue 
states.
    Mr. Raskin. Okay. I want you to underscore this point for 
our colleagues. Obviously, we have a difference about whether 
or not 20 million people should be stripped of their health 
insurance and about the general progress we have made under the 
Affordable Care Act. But let's just get to the point about 
legal severability.
    In 2017, there were efforts to repeal the whole Affordable 
Care Act. I remember that. I was in Congress then, and they had 
voted 69 different times to repeal the Affordable Care Act in 
its entirety. They weren't able to do it because there was a 
massive uprising around the country. I remember people went out 
all the town hall meetings and said, ``Don't do this,'' 
eloquent, riveting testimony, like the kind we have heard today 
from patients, ``Don't do this to our families,'' and they 
weren't able to get enough Republicans to do it, even though 
the Republicans controlled the majority.
    So instead, they passed this one provision zeroing out the 
penalty on the compulsory purchase of insurance policy. That 
was it. And at that point everybody agreed that the Affordable 
Care Act should be saved. Some people thought it was a great 
thing. Some people thought it was a terrible thing.
    But now the proposition being pushed by--I don't even want 
to say conservative Republicans, because a lot of conservative 
Republicans are on our side, but by an extreme faction. 
Apparently, within the Trump administration, there is a 
position that the invalidation of this one provision--or I 
don't know if it is the passage of this one provision--but 
undoes the entire act. So it undoes everything--the protection 
for 26-year-old, pre-existing condition coverage, all of the 
Medicaid provisions, all the provisions that expand people's 
access to prescription drug benefits, closing of the donut 
hole. Everything that is in there, they are saying is now 
toppled because this one provision is gone.
    Now what does that do to the power of Congress, when we 
thought we were passing one thing and now the courts say, well, 
because this one provision is out we are going to strike down a 
2,000-page piece of legislation?
    Ms. Gluck. Yes, I think one of the reasons you see this 
unprecedented consensus--you are absolutely right, that this 
case goes to the power of Congress. To let the court do what it 
did here, the court is taking over congressional lawmaking 
power. The court is being activist. It is usurping 
congressional lawmaking power. Conservative legal scholars and 
liberal legal scholars alike value separation of powers.
    Mr. Raskin. I would not even want to win that way. In other 
words, if I thought that the Affordable Care Act was the 
creature of the devil himself, and I was not able to get it 
through Congress but we were just able to chip off a little 
piece of it, and then, later, some judges say, ``Hey, we are 
going to go ahead and destroy the entire act,'' I would not 
support that, because that is an absolute defeat of legislative 
power, isn't it?
    Ms. Gluck. Well, yes. That is what the Wall Street Journal 
editorial page said. It started saying nobody hates Obamacare 
more than we do, but this is a corruption of the rule of law.
    Mr. Raskin. What are some of the other things that would 
fall if the Administration now gets its position in destroying 
the ACA?
    Ms. Gluck. Well, I don't think it can be overstated the 
reach of the statute. I mean, we have got Medicare prescription 
drugs, we have got no discrimination based on health status, we 
have got the Indian Health Care program, we have got the FDA 
approvals for biosimilars.
    Mr. Raskin. But they would invite us to believe that we all 
knew that when that vote took place, that we were essentially 
going to undo if one phrase or one sentence dropped out of the 
legislation.
    Ms. Gluck. Courts are actually, respectfully, not allowed 
to do that. Courts are not allowed to presume that the 
legislature sowed the seeds of its own destruction into a 
statute. Courts have to interpret statutes deferring to the 
legislature.
    Mr. Raskin. Well, thank you for what you are doing and 
thank you for reaching across the aisle to bring conservative 
scholars in and to work with them on defending this critical 
principle of the severability of provisions that are struck 
down by a court.
    Ms. Gluck. Thank you.
    Mr. Raskin. I yield back, Mr. Chairman.
    Chairman Cummings. Mrs. Miller?
    Mrs. Miller. Thank you, Chairman Cummings, and Ranking 
Member Jordan. Before I begin I would like to read a portion of 
a testimonial from one of Mr. Hice's constituents from Madison, 
Georgia. She writes:
    ``I co-own a small business in Madison, Georgia. When 
Obamacare was first passed we were one of the businesses that 
lost our health care coverage. When finding new coverage, my 
insurance went from $385 a month to $643, due to the fact that 
I am a female, which is an increase of 67 percent. I am beyond 
childbearing ability but I still have to have maternity 
coverage.''
    Mr. Chairman, I ask for the unanimous consent that the full 
statement be entered into the record.
    Chairman Cummings. Without objection.
    Mrs. Miller. Thank you, and thank you all for being here 
today.
    It has been over nine years since the ACA has been signed 
into law. We all know that when a law is enacted that often 
there are kinks or problems that need to be worked out and 
issues that need to be resolved, as we move forward. However, 
the Obamacare has had countless issues since its enactment and 
has harmed health care for citizens across the United States. 
Republicans have been saying, for years, that we need a fix for 
this program to decrease the premiums, stabilize the market, 
increase access to care, and to protect those with pre-existing 
conditions.
    Now my colleagues across the aisle have decided to abandon 
this program completely and chase after a single-payer system, 
which would further increase health care costs on taxpayers and 
inevitably decrease access to care for people who need it the 
most.
    In West Virginia, enrollments in our exchange has 
decreased. While many are now enrolled in employer insurance 
due to the booming economy, many have cited high deductibles as 
a reason for going uninsured. We need to solve this problem and 
a single-payer system is certainly not the solution.
    Mr. Balat, has the ACA lowered monthly premiums for 
Americans?
    Mr. Balat. No, they have not.
    Mrs. Miller. In fact, how much have premiums gone up for 
Americans, on average, since this law was enacted?
    Mr. Balat. It has been significant and it has been a range, 
depending on the part of the country that they are in. But it 
has been 200 to 400 percent in some cases.
    Mrs. Miller. That is terrible. How has the ACA kept 
deductibles the same, or lowered them, for our constituents?
    Mr. Balat. Outside of the exchange or within the exchange?
    Mrs. Miller. Within the exchange.
    Chairman Cummings. Will the lady suspend? Mr. Morley, are 
you okay? Whatever--listen to me. Your health is No. 1. 
Whatever you need, let us know.
    Mr. Morley. It went down wrong.
    Chairman Cummings. All right. Okay.
    Mr. Morley. Thank you.
    Mrs. Miller. Thank you, Mr. Chairman.
    Mr. Balat. The premiums within the exchange have been--they 
have gone up probably closer to 60, 70 percent. Outside, in the 
private market, they have gone up substantially more.
    Mrs. Miller. Thank you. It sounds like what the goals for 
the ACA intended to be have not really been enacted.
    How has the current Administration helped ensure Americans 
to have increased access to health care?
    Mr. Balat. Well, I think some of the examples have already 
been given. You know, people have talked about fixing the ACA, 
and I think some of the measures that have been mentioned are 
attempts at fixing it, such as the opioid, HIV, and kidney 
initiatives. It looks to be that the White House and the 
Administration are looking to improve upon the ACA's 
foundation.
    But they have done other things as well. The Executive 
Order that the President put out in 2017, that would expand the 
already existing short-term limited-duration plans, the 
insurance health plans, extending those for those that may be 
in transition longer than the amount of time that was initially 
prescribed, helping people who are losing jobs, having to move, 
that are going through a divorce. It is allowing them more time 
to go through that transition period.
    Association health plans was another solution that was put 
out there, and they experienced great success. Some reports 
were showing that there were double-digit savings, that people 
were able to pool together and buy employer-style health plans. 
So that was another good innovation.
    Then the HRAs, the health reimbursement arrangements that 
will become effective January 1, that will allow the individual 
market to come back, because that went away, effectively, when 
the ACA was first implemented. Employers will be able to 
dedicate defined amounts of funds that are part of their 
compensation plan for the employee to go out and be a consumer 
of what fits them and their family the best.
    Mrs. Miller. Thank you. Mr. Chairman, I will yield back the 
rest of my time to the gentleman from Texas.
    Chairman Cummings. You have five seconds.
    Mrs. Miller. Sorry.
    Mr. Roy. Mr. Balat, could you expand on your concerns, 
earlier you stated about the Medicare For All and expanding 
coverage in the extent that that would drive up costs of health 
care?
    Chairman Cummings. The time has expired but you may answer 
the question.
    Mr. Balat. The cost of health care continues to go up. The 
more that we have had the government involved in trying to fix 
this entity, this industry, the more we have had the cost go 
up. We see the same thing in higher education. The more Federal 
Government has gotten involved, the higher tuitions have 
become.
    We have seen lots of technology--televisions, iPhones--that 
are not heavily regulated, but those prices go down. Yet when 
the government is involved in an industry, those prices go up.
    What comes with those costs? The reason that they are 
there, all the regulations, the administrative burden, the 
shackles that we put on the people that are doing the work, 
that are on the front line, that are trying to help the 
patients. We are hurting ourselves by doing this.
    Chairman Cummings. Mr. Connolly?
    Mr. Connolly. I thank the chair, and, good Lord, Mr. 
Balat's comments, the role of the Federal Government, that 
would come as news to a lot of the universities and colleges, 
especially the for-profit colleges. Let's just get government 
right out of the way, stop regulating it, and prices will go 
down, and, of course, cheating will stop and people won't be 
embezzled or defrauded with phony credentials or the credits. 
That logic escapes me.
    Professor Gluck, have you looked at the economics of health 
care insurance premiums?
    Ms. Gluck. Yes, to the extent that a law professor can. I'm 
not an economist, but yes.
    Mr. Connolly. So Mr. Balat, to the horror of my colleague 
on the other side of the aisle, says ever since the Affordable 
Care Act premiums have just skyrocketed. Is there, in fact, a 
correlation, and yes, Mr. Isasi, you can answer as well. Is 
there a correlation between the adoption of the Affordable Care 
Act and these, I don't know, all of a sudden, inexplicable 
premium increases that apparently are unprecedented. We have 
never had them before, right? Premiums were not going up before 
the Affordable Care Act. Everything was stable and hunky-dory, 
and, you know, 35 million people didn't have health care 
coverage, but, you know, somebody has got to suffer.
    Professor Gluck?
    Ms. Gluck. So you are correct. The Affordable Care Act made 
insurance more affordable for millions of people, to the extent 
that we have had some premium instability. A lot of that is 
attributable to the actions of the Administration----
    Mr. Connolly [continuing]. and the Republican Congress.
    Ms. Gluck [continuing]. and the Republican Congress itself.
    Mr. Connolly. Yes. This strikes me as really amazing. We do 
everything we can to sabotage the law, and then we are horror-
struck there is gambling here at Rick's, that it has an impact 
on the cost of insurance, because the mechanisms that we put in 
place to try to keep those down and keep it affordable were 
destroyed in the eight years the Republicans controlled the 
Congress, even before Mr. Trump took office. Would that be a 
fair statement?
    Ms. Gluck. Yes, I think it is.
    Mr. Connolly. Mr. Isasi, you have been shaking your head. 
Yes, please comment.
    Mr. Isasi. Yes, I think it is really important that we deal 
with facts in this conversation.
    Mr. Connolly. Oh, no. No. Now you are talking crazy.
    [Laughter.]
    Mr. Connolly. You are in the U.S. Congress, but all right.
    Mr. Isasi. Okay. We actually know the answer to this 
question. We know what happened to premiums, premiums post-ACA, 
and the first thing to say is--and this has been studied. The 
Commonwealth Fund looked and actually surveyed the American 
public, and the percentage of people reporting they could not 
afford health insurance in the individual market actually was 
cut in half after the ACA. One of the essential parts of the 
ACA was support to make sure that coverage was affordable. Most 
people in the exchange are getting that. Most people are paying 
far less for their premiums now than they were before the ACA, 
period, and it is empirical and it is well documented.
    In addition, as you point out, there are a lot of dynamics 
at play, but the No. 1 reason that premiums are high in this 
country is not the Affordable Care Act. It is because the 
health care prices in this country are out of control. It is a 
totally distinct thing, and the American people know this. We 
know we are paying too much for prescription drugs. We know we 
are paying too much for hospital care. We know we are paying 
doctors too much. We know that. But to blame the ACA for that, 
as I said in my opening statement, is a drowning man blaming 
his life preserver because he is wet. It is preposterous. That 
is not the reason that we have high health insurance premiums 
in this country.
    Mr. Connolly. Can you and Professor Gluck just remind us of 
a couple of the successful efforts by my Republican friends 
during their majority tenure here in the House and in the 
Congress, where they succeeded, in fact, in gutting certain 
provisions of the Affordable Care Act that were, in fact, 
directly related to trying to keep pressure down on premium 
increases?
    Ms. Gluck. Sure. So as you know, Congress turned off three 
streams of very important stabilization payments for the 
insurance industry. There was then a lawsuit about the 
continuing ability of the Administration to pay cost-sharing 
reduction payments, which showed dramatic instability into the 
insurance market. There was then an attempt to reduce 
enrollment on the exchange, reduce money for navigators, which 
are critical bridges between individuals and enrollment, and 
recently there has been a vigorous attempt to split the 
insurance pool, divide the insurance markets, and make health 
care more unaffordable for those still in the ACA market.
    Mr. Connolly. Well, Lord Almighty. And here I was thinking 
just we are perverse and the Affordable Care Act just drove up 
prices mindlessly. But now you tell me there is actually, yes, 
there is a cause and effect, but it is not the Affordable Care 
Act. It is, in fact, the insidious, relentless drive to gut the 
Affordable Care Act, which they could not defeat legislatively, 
but they could it both administratively and through amendments 
to laws that made it much harder for the protections, the 
bumpers, that have protected us and buffered us from----
    Mr. Isasi. That is exactly right. In fact, the largest 
percentage increase we saw was after the risk corridor payments 
were stopped. That is when that happened.
    Mr. Connolly. Well, my time is up, but thank you both for 
illuminating my understanding of what really happened.
    Chairman Cummings. Mr. Gibbs?
    Mr. Gibbs. Thank you, Chairman. I don't think anybody on 
this panel, or in this room, or the President of the United 
States does not support applying for pre-existing conditions, 
have that in the bill. I mean, it is a tragedy when somebody 
loses their coverage or health care and can't get it because of 
pre-existing conditions. Unfortunately, in the last Congress we 
had a bill that was passed out of the House that addressed 
that, that protected pre-existing conditions, and it was 
unfortunate that the other side of the aisle would not work 
with us to make that bill better.
    I think it is interesting, when I look at what is going on, 
when we talk about the costs. I had a neighbor come to me, a 
little over a year ago. My county was down to one insurer on 
the exchanges, and she was going to lose her health insurance 
because that was going away. And the other thing I hear a lot 
about is people talking about the deductibles are so high they 
can't afford them. One of the reasons I hear a lot of people 
are uninsured--and I believe there are still 30 million people 
in this country uninsured--is because the deductibles are so 
high and it is a problem.
    I do notice, too, that there have been comments earlier 
about how the Affordable Care Act has failed. Most of the 
people running for President on the other side of the aisle 
aren't running on Obamacare. They are running on Medicare For 
All, which I think would just be a real big disaster.
    I will give you an example. We had a good friend here, a 
few years ago, that on Friday at 4 in the afternoon had severe 
chest pains. At 11 that night she had a quadruple bypass. Mr. 
Balat, what would happen if that was in Canada or anywhere 
else? Would that person get that care that fast, in a system 
where we have Medicare For All or a single-payer system?
    Mr. Balat. In an emergency situation that would be 
different, and that would certainly be considered an emergent 
situation. But if it were a planned procedure, the wait times 
would be exceedingly longer than what we would have in this 
country.
    Mr. Gibbs. Okay. It just amazes me. I know we talk about 
research, and medical research has come a long way, improving 
life expectancies, people having a higher quality of life, and 
if we have a single-payer, government-run system, what happens 
to that research? What happens to the private sector being 
innovative? What do you see happening?
    Mr. Balat. I don't know that I could actually speak to 
that. The one thing that I do want to say is that even when we 
talk about all these other issues we keep going back to 
insurance, and we talk about insurance, and we don't talk about 
the patient. The real victim in this is the patient and the 
cost of care itself. The insurance has contributed to it. Of 
course, the premiums went up after the risk corridor payments 
were reduced, because those risk corridor payments were put in 
place to artificially decrease the premiums in the ACA so it 
looked like it made sense, which it did not.
    So let's look to see what is going to happen to the 
patients themselves. That is the real tragedy of what is going 
to be in the future and how we are going to decide that we are 
going to take care of our citizens in this country.
    Mr. Gibbs. Let me just interrupt you. President Trump did 
an Executive Order to let association plans come back into 
effect, because Obamacare did away with association plans. And 
one of my neighbors--that I actually, you know, helped her get 
insurance through the association plans. Can you tell us what 
is happening with association plans?
    Mr. Balat. They were growing at a good clip. They had a 
great deal of popularity and then there was a suit, and the 
Federal judge essentially said that the association health 
plans were an end run around the Affordable Care Act. They are 
still in operation. There was no injunction, much like what 
happened with the Federal suite in ACA v. Azar. They are still 
able to operate. However, the uncertainty has caused many 
people who want to create those kinds of plans to not proceed 
further because they don't know what is going to happen.
    Mr. Gibbs. But association plans do give individuals the 
ability to have options.
    Mr. Balat. Absolutely.
    Mr. Gibbs. And because of the exchanges, there is no 
competition there. It is just--you know, it is just a 
government-set----
    Mr. Balat. And because it functions like an employer plan, 
there is no exclusion for pre-existing conditions. It is 
affordable because you have got a bigger base, and yes, so 
there are more options. They can choose among different types 
of solutions and not just traditional insurance.
    Mr. Gibbs. Yes, and we know that health savings accounts 
are big part to help that. I have a health savings account on a 
Federal plan and I think it is a big help. It gives me more 
options and a better ability to direct my own health care.
    I will yield--I have got 20 seconds left--to my friend from 
Texas.
    Mr. Roy. With all this time, what can I do?
    Mr. Balat, I guess I would ask one question, is, you know, 
describe a little bit what you say in terms of--what are some 
of the alternatives we could look at with respect to empowering 
patients instead of empowering insurance companies? For the 
life of me I am not understanding why we are seeming to be 
focused on insurance, and my colleagues on the other side of 
the aisle seem more concerned about insurance than care. Can 
you talk a little bit about care and patient access, the 
doctors?
    Chairman Cummings. The gentleman's time has expired. You 
may answer the question.
    Mr. Balat. Thank you, Chairman. Let me just give an 
example, the personal one that I currently use. I use something 
called Direct Primary Care. Insurance has--well, I will say 
this. I will say it this way. The reason health care has become 
more inefficient and more unaffordable is because there has 
been a wedge driven between that relationship between doctor 
and patient. Health care is a very personal situation--I think 
all of the witnesses here have talked about their team--and it 
should be looked upon that way.
    Direct Primary Care is a membership model type of plan. I 
pay on the order of $60 a month for unlimited 24/7 access to my 
primary care physician. No exclusions on pre-existing 
conditions. I can communicate with him via electronic means, 
text, secure video chat, and the like.
    Chairman Cummings. Thank you very much.
    Mr. Balat. Thank you, sir.
    Chairman Cummings. Mr. Rouda?
    Mr. Rouda. Thank you, Mr. Chairman. I do want to level-set 
some information here. There has been talk about government-
backed, single-payer systems. We already have two government-
backed, single-payer systems in the United States. It is called 
Veteran Affairs and Medicare. I am hoping that the members on 
the other side of the aisle are not suggesting that those 
should be eliminated because they are single-payer systems.
    I also want to point out the fact that there is 
approximately 40 industrialized developed countries in the 
world, and 39 of them have universal health care. Only one does 
not--the wealthiest, greatest country in the history of the 
world, the United States of America.
    And, Mr. Balat, I take exception with your testimony that 
when the government is involved in providing health care 
insurance it drives prices up. In fact, those 39 countries who 
have universal health care spend about half of what we spend on 
health care. In fact, we spend 18 1/2 percent of our GDP on 
health care. So we know that we have a very inefficient system. 
And while the ACA may not be perfect, it has certainly brought 
quality insurance to a lot of individuals who did not have it.
    Mr. Isasi--and I hope I am pronouncing that correctly--I 
did want to touch base with you on a couple of areas. With the 
litigation going on in Texas, and the potential that we are 
facing that the ACA could be eliminated as we know it, and the 
protections under it, and some of the other key areas, one of 
them is talking about the donut hole that a lot of seniors face 
in prescription prices. Can you talk a little bit about what 
the impact would be if the ACA was thrown out in totality as 
the impact on senior citizens and prescription prices in 
general?
    Mr. Isasi. You bet. So first of all, if the ACA was 
repealed by these judges, the first thing that would happen is 
the seniors' Medicare costs would go immediately up. Their 
premium costs would go up, their cost-sharing would go up, and 
the Medicare trust fund solvency would immediately be weakened. 
So it would have a very specific and negative effective on the 
Medicare program writ large.
    In addition, the entire pathway to provide low-cost, high-
value biologics, things to treat leukemia, to treat lupus, to 
treat some of the most devastating illnesses in this country, 
would disappear, because that was also part of the law. So it 
would have a very, very negative effect.
    And I do want to say something, this discussion about 
association health plans and other forms of new kinds of 
insurance. Let's be really clear. What we are talking about 
there is hurting people with pre-existing conditions and 
hurting people, letting insurance companies play tricks again 
on consumers. The only reason association health plans are 
cheaper is because it excludes people and it allows insurance 
companies to play tricks.
    We know, and we have done a lot of work across the aisle, 
this Congress, on surprise medical bills. The American people 
are fed up with buying insurance and then not getting financial 
protections. What we are hearing today is a description of 
insurance products that would, for example, exclude hospital 
care, or exclude prescription drugs altogether. It is letting 
insurance companies play tricks on consumers again, and that is 
not a pathway to affordable access for the American people. It 
is a pathway for tricks and for hurting the financial stability 
of our Nation's families.
    Mr. Rouda. And when we heard a member on the other side say 
that everyone here would support the view that the President 
supports coverage for pre-existing conditions, let me point out 
I don't believe that. I believe actions are greater than words. 
If the ACA was struck down in its entirety, wouldn't millions, 
tens of millions of Americans--I believe even over 100 million 
Americans would lose pre-existing coverage?
    Mr. Isasi. That is exactly right, and we know it is 
almost--and, by the way, it is almost half of the people--I am 
sorry--over half of the people before the ACA who went to the 
individual market tried to get coverage but had pre-existing 
conditions and could not get coverage. And it is important. 
This question has actually been answered. Republican leaders 
passed legislation that was an alternative to the Affordable 
Care Act. The CBO told us that 6.3 million Americans with pre-
existing conditions would end up paying much more for their 
health insurance coverage or not be covered. They answered this 
question and they hurt people with pre-existing conditions, and 
that is the truth.
    Mr. Rouda. Professor Gluck, it looks like you are chomping 
at the bit to say something as well, so can you weigh in on 
this as well?
    Ms. Gluck. I just was nodding in agreement because before 
the Affordable Care Act I think the number was some 52 million 
people were denied insurance because of pre-existing 
conditions. So that is a statistic you have right there that is 
readily accessible, and, furthermore, just to emphasize that 
re-enacting just pre-existing conditions alone would not really 
do nearly enough, or really anything, for people who have 
serious medical conditions.
    If you have coverage but that coverage is priced 
prohibitively, it does nothing. If you have coverage but that 
coverage does not include the benefit of the prescription drug 
you need to treat your disease, that does nothing. If you have 
coverage but you don't have subsidy to pay for the coverage or 
you don't have Medicare or Medicaid to pay for the coverage, 
the coverage does nothing.
    So I think the pre-existing conditions discussion is 
important, but it is just the tip of the iceberg.
    Mr. Rouda. Thank you for your testimony. Mr. Chairman, I 
yield back.
    Chairman Cummings. Thank you.
    Mr. Roy?
    Mr. Roy. Thank you, Mr. Chairman. A couple of quick 
questions for Professor Gluck. In respect to the litigation 
that is currently going on with Texas v. Azar, did the Supreme 
Court find the mandate unconstitutional originally--the 
mandate? Yes or no.
    Ms. Gluck. No.
    Mr. Roy. The mandate was not found unconstitutional. The 
mandate itself.
    Ms. Gluck. No. Respectfully, there is no such thing as the 
mandate itself. What the Supreme Court did was it found that 
the mandate was not--could not be construed constitutionally as 
a breach of the Congress' Commerce Clause power, but was 
constitutional as a tax.
    Mr. Roy. Right. That is the point. The mandate is 
unconstitutional, pure and simple. That is what the court said. 
The mandate is unconstitutional, and you did not have the 
power, under the Commerce Clause, that the only power that 
remained was the taxing power. Then what happened? The tax was 
zeroed out, which means what? The tax does not exist. Correct? 
There is no tax. Is there a tax today?
    Ms. Gluck. The tax is set at zero.
    Mr. Roy. There is no tax today. There is a mandate in the 
legislation. The mandate is unconstitutional. The Supreme Court 
said this body does not have the power, under the Commerce 
Clause, to have a mandate to make people, make Americans, go 
purchase a product, in commerce.
    The tax is now zero. The tax no longer exists. Therefore, 
where do we sit today? The very thing that saved the mandate, 
the tax, which is now zero, does not exist. This is the theory 
that underlies the district court's opinion, and this is why we 
are in front of this. This is not because it is a policy 
choice, as some of my colleagues on the other side of the aisle 
have suggested. This is because it is a question. It is a 
constitutional question. It is a question about the power of 
this body, and whether this body can mandate that individuals 
buy something in the marketplace.
    When it was determined to be a tax, the penalty, then you 
have a taxing power question. Now we don't have a taxing power 
question, and this is where we now stand today. Is it not true 
that with respect to severability, that four justices, in the 
opinion, did find it to be inseverable? Is it not true that the 
district court in this case found it to be inseverable?
    Ms. Gluck. I really appreciate that question for two 
reasons. First of all, the mandate--the enforceability of the 
appellancy coverage provision is really not the issue in the 
case. It is not being enforced. What is at issue in the case is 
the district court's application of the next question--what 
happens without that provision? Does the whole statute get 
struck down?
    But your second question is very important, about the 
previous Supreme Court opinions. Those opinions were indeed 
based on the court's perception of the 2010 Congress' view of 
that provision. What is at issue in this case is the 2017 
Congress' amendment. To hold otherwise is to undervalue the 
power of the 2017 Congress, vis-`-vis the 2010 Congress.
    Mr. Roy. Well, reclaiming my time, four Supreme Court 
judges have addressed it and said it is inseverable. The 
district court in this case said it is inseverable. The Obama 
Administration argued, in its filings, that it is, quote, 
``Inextricably intertwined and the entirety of the ACA itself 
has language dotted throughout the ACA saying that the mandate 
is essential to the ACA.'' In fact, in King v. Burwell, SCOTUS 
described the individual mandate as one of a three-legged stool 
without which the ACA should not stand.
    This is what is at the heart of the litigation in question. 
This is why it is before the fifth circuit. That is why the 
arguments were held yesterday. This is why yesterday there were 
great questions from the panels on the judge--the judges on the 
panel, sorry--asking the questions, and it is why, frankly, the 
Carter appointee did not ask a single question, because this is 
a very legitimate litigation, and we will see, then, what 
unfolds.
    With respect to my colleague from California making the 
comment about single payer, that we have Medicare and that we 
have VA, while I am interested that we have got bipartisan 
agreement in the Veterans' Affairs Committee, on which I am 
proud to serve, that we need to make some changes to the VA to 
make it better, and that one of those changes, to rely on 
market forces, to rely on Choice, to rely on the Mission Act, 
to have more market forces and choices for our veterans to go 
out in the marketplace and get access to care, that a single-
payer solution isn't meeting the needs of our veterans who are 
serving this country with valor.
    And that when we talk about the wealthiest and greatest 
country in the history of the world, when we compare ourselves 
to other countries, we are the one outstanding that does not 
have single-payer health care, I would argue that there is a 
reason that we are the wealthiest and greatest country in the 
history of the world, is that we shun the very stateism that my 
colleagues on the other side of the aisle would dare to put on 
the backs of the American people.
    So they are forced to pay premiums they cannot afford, 
forced to give up the health care that they were not able to 
have before, or that they were able to have before, forced to 
be put into a system that is sub-par, forced to say that there 
is now coverage for 20 million people, when the vast majority 
of which is Medicaid coverage, which is driving out the very 
people that Medicaid was designed to take care of in the first 
place.
    This is what we are talking about here, a $32 trillion 
Medicare For All scheme, which will blow up Medicare, which 
will blow up the ability for us to have a health care system 
that is affordable for the vast majority of the American 
people.
    With that I will yield back the five-seconds I have left.
    Chairman Cummings. Thank you very much. Ms. Wasserman 
Schultz.
    Ms. Wasserman Schultz. Thank you, Mr. Chairman. I think it 
is important to note, for the record, that Mr. Roy just came 
out for privatizing the VA, which the overwhelming majority of 
our veterans absolutely oppose, and are quite happy with the 
health care they are receiving and want it to continue.
    That having been said, I would like to ask unanimous 
consent to enter this article from STAT magazine into the 
record----
    Chairman Cummings. Without objection.
    Ms. Wasserman Schultz.--the headline of which says, ``Name 
the Much-Criticized Federal Program That Has Saved the U.S. 
$2.3 Trillion. Hint: It Starts With Affordable.''
    ``One month after the ACA''--and this is from the article--
``One month after the ACA had passed, the Office of the Actuary 
of the Department of Health and Human Services projected its 
financial impact in a report entitled, 'Estimated Financial 
Effects of the Patient Protection and Affordable Care Act as 
Amended.' The government's official record-keeper estimated 
that health care costs under the ACA would reach $4.14 trillion 
per year in 2017, and constitute 20.2 percent of the gross 
domestic product.''
    ``Fast forward to December 2018, notably during the Trump 
administration, when that same office released the official 
tabulation of health care spending in 2017, the bottom line? 
Cumulatively, from 2010 to 2017, the ACA reduced health care 
spending a total of $2.3 trillion. In 2017 alone,'' the article 
continues, ``health expenditures were $650 billion lower than 
projected and kept health care spending under 18 percent of 
GDP. Basically a tad over where it was in 2010, when the ACA 
was passed. It did all of this while expanding health care 
coverage to more than 20 million previously uninsured 
Americans. Compared to the 2010 projections, the government's 
Medicare bill in 2017 was 10 percent, $70 billion less, and 
spending for Medicaid and the Children's Health Insurance 
Program was a whopping $250 billion below expectations, 
partially--but only partially due to the failure of some states 
to expand the program.
    ``The actuary had predicted, in 2010, that employer-
sponsored insurance would cost $1.21 trillion in 2017, but it 
actually came in at $1.04 trillion, a difference of $107 
billion for that year. Put another way, health care spending in 
2017, was $2,000 less per person than it was projected to be, 
and for the 176 million Americans who have private employer-
sponsored insurance, their lower premiums averaged just under 
$1,000 per person.''
    I could go on but we have entered the article into the 
record. So, essentially, we need to be dealing with the facts. 
That is why we have these hearings, and the fact is that health 
care costs have actually been lowered, premiums, on average, 
have lowered for people, and we have added $20 million to the 
health care rolls.
    With that having been said, some of you may know that I am 
a breast cancer survivor. I talk about it very openly. It is 
something that I live with and live in fear--Ms. Dye, I 
understand all of your concern and the thought process you went 
through about potentially having a prophylactic mastectomy or 
any other prophylactic surgery. No matter how assured I was 
that I did as much as I could do to prevent that cancer from 
coming back, I think about it every single day, like every 
single cancer survivor I know.
    So taking care of your health and making sure that you have 
the ability to go to the doctor when you are sick, not worry 
about how you are going to pay for it, which is what the fear 
was for every single uninsured American, or underinsured 
American before the Affordable Care Act, is absolutely 
paramount and what this debate is all about.
    Mr. Chairman, I would like to ask unanimous consent to 
enter this letter from--we have a letter from 17 advocacy 
organizations, plus the American Cancer Society, into the 
record.
    Chairman Cummings. Without objection.
    Ms. Wasserman Schultz. As the letter notes, before the ACA, 
the patients represented by their organizations ``were often 
forced to delay or forego necessary healthcare,'' which is 
simply unacceptable. Yet, that is exactly the world the Trump 
Administration would like to take us back to. Mr. Isasi, is it 
true that before the ACA, more than 40 percent of people who 
applied for insurance were denied coverage?
    I also want to simultaneously ask with the remainder of 
time about the impact on seniors because nearly one-fifth of 
the residents in my district are seniors, and we haven't talked 
a lot about the coverage gap, known as the donut hole, that 
would be reestablished if we actually go back to the bad old 
days pre-ACA. So, Professor Gluck, if you could also tell us 
what would happen to this provision if the Administration 
succeeds in overturning the ACA. Then I am sure my time will 
run out after that, Mr. Chairman.
    Mr. Isasi. So to your first question about the impact of 
the ACA on people with preexisting conditions, your stats are 
exactly right. We had almost half of the people who were 
applying being denied coverage because they had a preexisting 
condition. And that means, and it is important to note this, 
you know. In this country, most of us get coverage through our 
employer-sponsored coverage. When we get sick, we lose that 
coverage, and then guess what? Without protections for pre-ex, 
we don't have anything, right? So this is not just about people 
right now on the individual with pre-ex. It is about every 
single person in this room and watching from their homes right 
now.
    Ms. Gluck. May I answer?
    Ms. Wasserman Schultz. If the chairman is okay.
    Chairman Cummings. Yes.
    Ms. Wasserman Schultz.--remaining time, but I have----
    Chairman Cummings. Yes.
    Ms. Gluck. So, Congresswoman, you are exactly right that 
the Affordable Care Act's protections for Medicare have been 
wildly under-appreciated. Sixty million seniors got access to 
free preventative services under the Affordable Care Act 
without a co-pay. Five million benefited from that coverage 
gap. Before the Affordable Care Act, you only had prescription 
drug coverage up to a low number, around $2,000, and then there 
was a large gap until the coverage benefit kicked back in. We 
call that the donut hole. Seniors had to pay out of pocket. 
More than 5 million benefit from that.
    The Medicare provisions also have a drug negotiation 
component to it that wind up lowering costs by some $26 billion 
in drug costs over the life of the bill. I would say that all 
of that will be gone if this decision is upheld.
    Ms. Wasserman Schultz. Thank you, Mr. Chairman. I 
appreciate your indulgence, and I yield back.
    Chairman Cummings. Before we go to Mr. Norman, I try to 
make sure that I run a fair hearing. Mr. Roy I am going to 
recognize for a minute because you want to clarify something. 
Mr. Roy.
    Mr. Roy. Yes, I would just ask my colleagues, Ms. Wasserman 
Schultz, to maybe re-frame her comments that I was calling for 
the privatization of the VA when, in fact, what I said was that 
the VA needs improvement and that the VA is seeking 
improvement. The Veterans Affairs Committee is seeking approval 
on a bipartisan basis through choice and mission to improve it, 
allowing private sector options to supplement the veterans' 
healthcare. So I think you mischaracterized a little bit what I 
said, and I would just ask if she would be willing to 
acknowledge that that was not what I said.
    Chairman Cummings. I recognize the gentlelady.
    Ms. Wasserman Schultz. I appreciate the gentleman's 
request. If the gentleman is willing to say that he is opposed 
to privatizing healthcare at the VA and making sure that the VA 
can continue to provide the excellent healthcare services that 
it provides, that the overwhelming majority of veterans support 
continuing, then sure.
    Mr. Roy. Well, I am not going to get into a back and forth 
about characterizing it.
    Chairman Cummings. Yes, I am not going to let you.
    Mr. Roy. What I am willing----
    Chairman Cummings. Hey, hey, hey. Whoa, whoa.
    Mr. Jordan. Mr. Chairman? Mr. Chairman?
    Ms. Wasserman Schultz. Then if you are not willing to 
acknowledge that, then I have characterized your position 
correctly.
    Mr. Roy. No, you mischaracterized my position, and you did 
so blatantly when what I said was we have bipartisan support 
for----
    Ms. Wasserman Schultz. Well, Mr. Chairman----
    Mr. Roy. No, reclaiming the time. Reclaiming the time the 
chairman gave me, we have a bipartisan agreement that choice 
and mission are improvements to the VA, that adding market 
forces is a good thing, bipartisan agreement on that. That is a 
mischaracterization of what you said characterizing that I said 
we should fully privatize the VA. We should inject market 
forces and provide more choice for veterans. That is what I am 
saying.
    Ms. Wasserman Schultz. Mr. Chairman, since the gentleman 
has now addressed me, and has taken his time back, and wants me 
to correct how I characterized his position, and he has refused 
to acknowledge that he opposes privatization. That is a simple 
statement. I didn't hear him say he opposes privatization of 
healthcare at the VA.
    Mr. Jordan. Mr. Chairman? Mr. Chairman? Can I be 
recognized?
    Ms. Wasserman Schultz. So if he's not willing to say that, 
the direction that the Republican Party has been taking us in 
with the VA, including the Trump Administration, you know, 
pushing in that direction for more private market forces for 
healthcare coverage at the VA. And by the way, I chair the 
Military Construction and Veterans Affairs Appropriations 
Subcommittee, so I am responsible for the budgeting for the 
entire VA along with my committee colleagues. So you won't say 
that on the record, so I will not re-characterize what I said 
you said.
    Mr. Roy. Well, I am not going to engage in an inquisition 
from the gentlelady----
    Chairman Cummings. Excuse me.
    Ms. Wasserman Schultz. I wasn't trying to----
    Mr. Roy. Yes, you are.
    [Gavel.]
    Mr. Roy. But you mischaracterized my statement----
    Ms. Wasserman Schultz. No, I think you will not say----
    Chairman Cummings. Hello. Hello.
    Mr. Roy. I have not suggested that.
    Chairman Cummings. Hello.
    Ms. Wasserman Schultz. Then why won't you say you oppose 
privatizing the VA?
    Mr. Roy. Will you say you oppose mission and choice?
    Ms. Wasserman Schultz. I did oppose mission and choice.
    Mr. Roy. There you go.
    Ms. Wasserman Schultz. Yes, I did.
    Chairman Cummings. Please.
    Mr. Jordan. Mr. Chairman?
    [Gavel.]
    Chairman Cummings. The committee is not in order. The 
ranking member.
    Mr. Jordan. We can read the transcript. The gentleman from 
Texas did not say he was in favor of privatizing. He didn't say 
anything about it. He just talked about choice. This 
characterization by the gentlelady from Florida was that he 
said he was for privatizing the VA. He did not say that. The 
transcript will be clear because we all heard it. That is all 
he is saying to clarify that simple fact.
    Chairman Cummings. All right. We will take a look at the 
transcript.
    Ms. Wasserman Schultz. He won't say, Mr. Chairman, that he 
opposes it.
    Chairman Cummings. Right now we are going to get ready go 
to Mr. Norman. I tried to work it out----
    Mr. Norman. Thank you, Mr. Chairman.
    Chairman Cummings. It sounds like I couldn't do it, but I 
did the best I could with what I had. Mr. Norman.
    Mr. Norman. Thank you, Mr. Chairman. I sincerely want to 
thank all the panelists, particularly ones that have, I assume, 
preexisting conditions, for taking the time to come here. I 
will take issue with, you know, six of the seven, as Mr. Hice 
said, I think where really the intent was to trash this 
President and to advocate Medicare for All. Ms. Dye, I take 
issue with what you said about all Republicans being against, I 
assume, any type changes in the healthcare. I take issue, I 
think, Mr. Gibbs, you singled out Mr. Jordan's state as not 
covering your particular problem. But, okay, I don't know which 
one of you did.
    But this is not a partisan issue. This is something all of 
us want, Democrats and Republicans alike. But the fact is that 
I think where we have a different world view, all of you raised 
your hand, I think, for health coverage for every illegal in 
this country, every one of you, except Mr. Balat. Everybody 
else. Mr. Isasa, I think you mentioned----
    Ms. Dye. Excuse me. I didn't raise my hand for anything 
because I was uncomfortable with the whole----
    Mr. Norman. Okay. Let me rephrase it. The majority of you 
raised your hand--take Mr. Balat out of it--raised your hand 
for healthcare for everybody. I am sorry. We don't know how 
many illegals are here. Just as six of the seven are 
predisposed to an opinion, let me just say this. I could fill 
this room with everybody behind you with that single mom who 
takes issue with Obamacare. They can't afford the premium jump 
from $400 to, in many cases, $6,000. I could bring a gentleman 
in who happens to be 75 years old who doesn't want a mandated 
maternity healthcare, having to pay for it in his policy. So I 
wish we could have a more balanced panelist because our intent 
is to solve this problem.
    A single provider, as it does not work in the private 
sector, will not work and has not worked with Obamacare. Name 
me one, if each of you had a single provider for, let's say, 
drugstores, one drugstore to shop from. I am sorry, the prices 
you couldn't afford as we can't afford healthcare now. I am in 
the private sector. I am a businessman, and I will say that it 
has not worked for the majority of the businesses. Look at the 
physicians that are leaving. If they are making too much money, 
Mr. Isasi, look at them that are leaving. We are not going to 
be able to get the specialists now that each one of you have 
had if it keeps going like it is going.
    I yield the balance my time to Congressman Roy from Texas.
    Ms. Dye. Excuse me, Mr. Chairman. Can I please acknowledge 
Mr. Norman because he actually brought up my name in his 
questioning or his stance.
    Mr. Norman. I will reclaim my time. I will talk to you 
privately. I yielded my time to Mr. Roy.
    Mr. Morley. Mr. Chairman, can I also state that I was not 
in the room when you asked that question, so I want to have 
that go on record that I did not raise my hand. I have never 
mentioned that I am for Medicare for All.
    Mr. Gibbs. I would also like to make that statement. I came 
here for a hearing about the Affordable Care Act, and it seems 
that most of this has been about Medicare for All. I didn't 
raise my hand in support for Medicare for All. I am not talking 
about Medicare for All. Why do we keep coming back for Medicare 
for All? This is supposed to be a hearing about the Affordable 
Care Act.
    Mr. Norman. Mr. Chairman, I would like to yield my full 
time that I think it was over--it was right at two minutes--to 
go Congressman Roy.
    Chairman Cummings. Sure.
    Mr. Roy. Well, thank you, Mr. Chairman. Mr. Balat, let me 
ask you a question. Was it not true that in 2013, PolitiFact 
said the lie of the year was if you like your healthcare plan, 
you can keep your healthcare plan?
    Mr. Balat. Yes, that is correct.
    Mr. Roy. Millions of people were kicked off their plans 
because Obamacare requires small group plans to provide 10 
essential benefits. And while 22.8 million people gained 
coverage from 2013 to 2015, 6 million lost the coverage they 
had before Obamacare, correct?
    Mr. Balat. That is correct.
    Mr. Roy. Two-point-four million transferred from employer 
coverage to uninsured; 600,000 transitioned from Medicaid to 
uninsured; 600,000 transitioned from non-group to uninsured. Of 
those who gained coverage, of the 20-odd million, was that 
about half-and-half Medicaid and through the ACA, through 
Obamacare?
    Mr. Balat. It was more on the Medicaid expansion.
    Mr. Roy. Right. The original purpose for Medicaid was for 
those who are the most vulnerable, and we are now crowding out 
people. In fact, in Illinois, for example, in 2016, a study 
showed that 762 people died while on a waiting list because 
they were trying to get care because Medicaid was getting 
crowded out by healthier individuals shoved onto the Medicaid 
rolls.
    Chairman Cummings. The gentleman's time has expired. You 
may answer the question, whoever it is directed to.
    Mr. Balat. I have not seen that particular study.
    Mr. Roy. Okay.
    Chairman Cummings. Thank you very much.
    Mr. Roy. Thank you, Mr. Balat.
    Chairman Cummings. As we go on to Mr. Sarbanes, let me say 
this. It seems that my Republican colleagues would love to 
distract us--Mr. Gibbs, you had asked the question--from the 
efforts to sabotage the ACA by focusing on Medicare for All. 
But today's hearing--you are right--is about protecting the law 
of the land and the threat this Administration is opposing to 
the healthcare for millions of Americans. That is what this is 
about. My colleague from Maryland, Mr. Sarbanes.
    Mr. Sarbanes. Thank you, Chairman Cummings. Thank you for 
inviting these witnesses, and I want to thank you, the 
witnesses, for coming. Professor Gluck, welcome. A few minutes 
ago, I think you were trying to point out to Mr. Roy that his 
discussion around some of the Justice's statements about 
severability was fighting the last war, the 2010 war, rather 
than the more current battle that is most relevant to the 
question of severability. So I appreciate you doing that, and 
Mr. Roy's decision voluntarily to go back and fight the last 
war, of course, is his to make. What is not fair is to force 
some of the witnesses, who represent millions of patients 
across the country, to go back and fight the last war, and that 
is what the Trump Administration and Republicans here in 
Congress are doing.
    I remember, Chairman Cummings, when you and others were 
part of and helped to lead hearings back in 2010 where we heard 
all of these stories, but we were hearing them from the 
perspective of people that were desperate to get coverage that 
they did not have. We made a promise that we would do 
everything we could to try to deliver that coverage to them, 
and we did that with the Affordable Care Act. Now they are back 
again telling the same stories from the standpoint of being 
terrified that they could lose the coverage that has been made 
available to them under the Affordable Care Act. I want to 
thank you for that testimony which is extremely powerful.
    I don't know why my Republican colleagues think that it is 
a strong position to argue for taking this fundamental coverage 
away from millions of Americans. I wish them the best with that 
line of argument going forward. I think it is clear from what 
the polls show that Americans don't want to throw away the ACA. 
We can debate what we do from here, but the great majority of 
Americans want to hold on to the coverage that they've been 
given. And by the way, there is no evidence whatsoever that 
there's any kind of cogent, coherent, meaningful replacement 
plan for the ACA, notwithstanding all the attempts, 69 and 
counting, on the part of the Republicans here in Congress to 
repeal the Affordable Care Act.
    Professor Gluck, in your testimony, you discuss the 
essential patient protections and health programs that would 
disappear if the ACA were to be struck down. Does this include 
guaranteed issue and preexisting condition protections?
    Ms. Gluck. Yes, it does.
    Mr. Sarbanes. What about the community rating protection 
that prohibits insurers from charging older adults 
significantly more than they charge younger enrollees? Would 
that go away?
    Ms. Gluck. Yes, it would.
    Mr. Sarbanes. What about premium tax credits and cost-
sharing reduction payments that make coverage more affordable 
for middle-income families?
    Ms. Gluck. That would also be gone.
    Mr. Sarbanes. What about the ACA's Medicaid expansion?
    Ms. Gluck. Gone.
    Mr. Sarbanes. What about the Prevention And Public Health 
Fund? What would happen to funding for essential public health 
programs like those that support safe drinking water, children 
immunizations, and smoking cessation?
    Ms. Gluck. All those funds would be eliminated.
    Mr. Sarbanes. Now let me come back to a point I was 
emphasizing earlier. Has the Trump Administration or 
congressional Republicans put forward any meaningful 
replacement plan for the ACA that would provide the same 
coverage gains and consumer protections that we just went 
through over the last few seconds?
    Ms. Gluck. No, nothing has come even close.
    Mr. Sarbanes. Let me ask you this. Why are preexisting 
condition protections on their own, without the ACA's other 
provisions, not a sufficient replacement plan? I mean, 
Republicans, I give them some credit. They have figured out 
that nobody in America wants to lose the coverage now available 
for preexisting conditions, so they keep invoking that and 
saying, well, we will hold on to that even as we are we are 
jettisoning all the rest of the Affordable Care Act. But can 
you explain why it is important to have other provisions in 
place in order for that to be an effective protection?
    Ms. Gluck. You are absolutely right, Congressman. It is not 
enough just to have insurance, to just be entitled to get 
insurance. You have to be able to afford the insurance, and the 
insurance has to cover the things for which you are sick, 
right? So just having the ability to get insurance doesn't stop 
insurers from charging you more for that insurance if you are 
sick, from creating benefits that don't include, say, your HIV 
drugs. And it doesn't give you the kind of financial assistance 
to make that affordable like the subsidies or the Medicaid 
expansion.
    Mr. Sarbanes. Thank you, and I just want to close by again 
thanking our witnesses and thanking our chairman for bringing 
those witnesses for today. I yield back my time.
    Chairman Cummings. Thank you very much, Mr. Sarbanes. Mr. 
Grothman.
    Mr. Grothman. Mr. Balat, I would like to kind of get a 
handle here a little bit on current problems we are having. 
Could you in general describe what has happened in this country 
for people who are fending for their insurance on their own 
voice, both the cost of insurance and the size of the 
deductibles, over the last five or six years?
    Mr. Balat. I could share with you talking about in the 
private market, premiums have gone up for employer-based plans 
and individual plans when they are available. Those dollars----
    Mr. Grothman. Dramatically?
    Mr. Balat. Pardon?
    Mr. Grothman. Dramatically?
    Mr. Balat. Oh, considerably, yes. Where they used to be 
$300, they are on the order of $1,500. For a family, they could 
be around $2,000 a month.
    Mr. Grothman. Devastating. How about deductibles?
    Mr. Balat. Deductibles, you know, when HSAs came into 
being, they were coupled with high-deductible health plans. And 
there was a reason why that dollar amount was at $3,500, 
because that was considered a high-deductible health plan. 
Deductibles today are, I think, on average $6,000, $7,000, but 
I heard one just recently of $14,000.
    Mr. Grothman. Devastating for people who are not eligible 
for Medicaid, correct?
    Mr. Balat. Oh, without question, and with the majority of 
people in this country that don't have $1,000 in their savings 
accounts, it is just an unreachable number.
    Mr. Grothman. All right. Unbelievable what people out there 
have to put up with. I have heard, you know, stories of 
healthcare problems that I wouldn't have believed 10 years ago 
were possible. It still kind of amazes me, and I wasn't around 
here when the Affordable Care Act was passed, or the 
unaffordable care act, or whatever they call it. But it amazes 
me how people get elected to Congress and think that they are 
so smart that they can take over such a big segment of the 
American economy and make it better.
    Let's look, though, at why those costs have gone up so 
dramatically. First of all, how many Americans are on the 
Affordable Care Act, despite all the hoopla over it? Do you 
know about?
    Mr. Balat. Just over 8 million.
    Mr. Grothman. Okay. I think it is 11 million, 8 million? 
Okay.
    Mr. Balat. On the exchange? It is between 8 and 9 million.
    Mr. Grothman. Eight and 9 million, so you are talking, 
what, under three percent of Americans are on it for all the 
hoopla. Where is the big increase in government involvement in 
healthcare since Obamacare kicked in?
    Mr. Balat. I would say it is the Medicaid expansion.
    Mr. Grothman. Medicaid expansion, okay, in other words. And 
in Medicaid, you are down in Texas, but how much is the 
reimbursement? How much does the government pay people to 
provide Medicaid compared to Medicare and compared to what the 
private sector has charged?
    Mr. Balat. Medicaid is typically your lowest reimbursement 
whether you are a physician or a facility. It is just below 
Medicare rates typically.
    Mr. Grothman. Okay.
    Mr. Balat. And Medicare is about 60 percent of what private 
reimbursement is.
    Mr. Grothman. Okay. So you are maybe saying half, about?
    Mr. Balat. Just north of half.
    Mr. Grothman. Okay. So, in other words, as we change the 
system to put more and more people on Medicaid, what we are 
doing is we are driving up the cost for people not on Medicaid. 
Is that true?
    Mr. Balat. Yes, absolutely.
    Mr. Grothman. Okay. And is the reason, therefore, the cost 
of people who aren't eligible for ACA, the reason they are 
being punished and just put in such an impossible position is 
because the huge number of people now who are expected to get 
their healthcare through Medicaid type plans, who before may 
have gotten healthcare in other ways? Is that what is going on?
    Mr. Balat. If I could ask you to restate the question, 
please.
    Mr. Grothman. Okay. Right now, the reason the cost is going 
up is because more people are getting healthcare through 
Medicaid, people who in the past would have got healthcare 
either through their employer or purchasing on their own. Is 
that accurate?
    Mr. Balat. It is. It is. You know, we----
    Mr. Grothman. So, in other words, this dramatic rocket up 
in costs for people who aren't eligible for Medicaid didn't 
just happen. It was by design almost, or maybe people were just 
so stupid. I can't believe people would be so stupid, they 
didn't realize that that was what was going to happen, but that 
is what happened, right? I will give you one more question 
because we are running out of time. We now hear people talk 
about picking up healthcare for all the illegal immigrants 
flowing through the country. I would like you to describe who 
really is going to wind up picking up the tab for that one.
    Mr. Balat. The American taxpayer.
    Mr. Grothman. The taxpayer or anybody who's paying for 
insurance on their own?
    Mr. Balat. Well, whoever is paying into the system 
currently, and the taxpayer will be the ones that will be 
paying for everybody that is benefiting. You know, a word was 
used earlier. It was talking about being forced into a 
situation they don't want to be in, and that was being patients 
should be ACA be repealed. But we are being forced as citizens 
to participate in programs that we don't want. So that is an 
act of force currently with the ACA in place.
    Chairman Cummings. The gentleman's time has expired. Mr. 
Welch.
    Mr. Welch. Thank you, and I want to thank the witnesses. 
Welcome to Congress. The debate continues, but, you know, the 
heart of this is about patients who need healthcare. I want to 
go back to some of our patients and really thank you for 
coming. Mr. Gibbs, I will start with you. What would it mean to 
you and to your son when he grows up if the ACA's preexisting 
conditions protections are eliminated?
    Mr. Gibbs. Thank you. It would mean that if something went 
wrong and I lost my kidney or something went wrong and Peter's 
kidney declined, that he would have absolutely no guarantee of 
any right to healthcare, any guarantee that he would be able to 
receive treatment for that kidney problem that he was born 
with. It would mean that he was born with a sentence to lose a 
fundamental right, and I do believe that the access to 
healthcare is 100 percent a fundamental right. It is something 
we cannot exist without. I mentioned life, liberty, and the 
pursuit of happiness. Without healthcare, you don't have that 
access to life.
    Mr. Welch. Right, and it is not a choice that you made to 
have this condition or your son.
    Mr. Gibbs. No, it is absolutely not a choice.
    Mr. Welch. The luck of the draw.
    Mr. Gibbs. Yes.
    Mr. Welch. Yes. Ms. Burton, how about you? What would it 
mean to your family if the ACA preexisting condition 
protections are no longer law?
    Ms. Burton. It would mean that I wouldn't be able to afford 
coverage. I have an expense of having four children, and I 
simply could not afford to pay $895 a month for health 
insurance. Before I would do that, I would go without like I 
did previously. I have limited resources, and I use those 
resources to raise the four kids that I brought to this world 
so that they don't have to be a burden on the American people 
and society. I have done everything I can to be responsible.
    Mr. Welch. Thank you very much. Ms. Dye, how about you?
    Ms. Dye. Thank you for the question. Chessie is 10, and for 
her speech, her receptive and expressive, she's two to three 
years behind her peers. It is never going to go away. She is 
going to have this in adulthood. Her speech therapy, she needs 
it in order for her to be a productive member of society. It is 
almost like life support for her. And what a lot of people 
don't understand, and--well, they kind of left--but Republican 
colleagues, they want to talk about [is], like, employer 
insurance.
    Mr. Welch. Yes.
    Ms. Dye. Well, a lot of employer insurance does not cover 
speech at all, and the ones that do, you only get 10 sessions a 
year. So if you can please explain to me, she is two to three 
years behind, how is that 10 sessions a year going to help?
    Mr. Welch. Right. I don't think any of us can imagine, if 
we are fortunate enough that at the moment we don't have a 
preexisting condition. At some point a lot of us will, but if 
you have children and you are really worried about how they are 
going to be affected, it is really existential. All of us can 
identify with that. But I want to ask each of you just to think 
about just emotionally what is it like and how did you feel 
before you had that guarantee of protection, and you had a 
child who was sick, and you had no confidence you could get it. 
Did it feel like it was your fault that your child was sick?
    Ms. Dye. For me, I felt like it was my fault. What did I 
do? Was I not taking care of myself in pregnancy and everything 
like that. But I also felt like my country, the Congress, was 
saying that my daughter doesn't matter, that her life doesn't 
matter, her future. And that is hard for me to take, especially 
when they kept saying that we are the greatest country in the 
world, but yet the greatest country in a world is telling my 
10-year-old daughter she doesn't matter. That is heartbreaking 
for me.
    Mr. Welch. Well, go ahead. I have got just a little time 
here.
    Mr. Gibbs. For me, when my son was born, the ACA was in 
place. Part of me felt like it was my fault because I had a 
kidney condition, and I felt guilty that he may have inherited 
it from me. But part of me also felt it wasn't my fault because 
when I chose to have that child, the Affordable Care Act was in 
place. I made a responsible choice to have a child who could be 
guaranteed the right to healthcare. An irresponsible choice is 
being made, but not by me.
    Mr. Welch. All right. Thank you. And I want to thank all of 
the witnesses, and Mr. Morley, too, for his advocacy. Mr. 
Chairman, what we here is there are life circumstances that 
none of us can control, and if you can't get a fair shot, that 
is about justice. That is not about personal responsibility. 
There are a lot of life choices we do make, and that is on us, 
but when it is circumstances beyond your control--you can't get 
healthcare because the law won't allow it--that is on us. 
Justice requires we protect those preexisting condition 
protections. Thank you.
    Chairman Cummings. And people get sick and people die. Mr. 
Green.
    Mr. Green. Mr. Chairman, Ranking Member, I think most 
everyone knows I am an ER physician, cancer survivor. I am the 
father of a cancer survivor I am also the founder and CEO of a 
healthcare company that, when I left, employed over 1,000 
medical providers and saw 1.5 million patients or so a year. I 
love caring for people and I love being a doctor, so much so 
that I started free healthcare clinics in Clarksville, 
Tennessee and Memphis, Tennessee. I do care, and my opposition 
to the ACA is because I think the ACA is going to crash the 
very system that today's witnesses have praised. But first I 
want to tell everyone about a shift I had in the ER.
    My first patient was a gang member. He had been shot in the 
lower abdomen. The guy was punching at the staff and yelling at 
us all. Meanwhile, we are trying to save his life. After giving 
this guy a world-class care, I walked out thinking, man, at 
least with a government payer, I would get paid for the risks, 
you know, taking care of this patient. But near the end of my 
shift, I had a woman who had just a few days prior got her dose 
of chemo. She was febrile and what we call neutropenic fever as 
the chemo had lowered her immunity system to a point that small 
infections threatened her life. With her were two children and 
a worried husband. The woman was only 35 years old. She didn't 
have insurance. As we stabilized her, I realized that early 
detection had saved this young woman's life.
    In Europe, socialized medicine has delayed early detection 
as care is rationed, and that is why mortality rates for 
specific illnesses are far better in the United States than 
they are in Europe and Canada. That woman would not have 
received timely detection there, and her chances of survival 
would have been significantly less than a socialized system.
    I was working in an ER and met a patient who was a CEO of a 
major corporation in Canada. He had a laceration. He hopped on 
his personal jet, flew to Nashville, Tennessee, and came to my 
ER because he could have been seen faster flying to the U.S. 
than waiting on a government-run healthcare system in Canada. 
True story. In Canada, you can get an MRI for your dog that day 
because there's a free market in veterinarian care, but you 
can't get one for grandma's knee. You are going to wait six 
months.
    Socialized medicine does not work. It does not provide 
better care. Study after study has shown Medicaid patients have 
equal outcomes to patients without insurance at all. Those are 
the real numbers. The ACA is not socialized medicine. What it 
does is it takes money from taxpayers and increased rates for 
small businesses. Yes, it has raised rates. I was on the 
insurance committee of Tennessee State Senate. We had to 
improve those insurance increases hundreds of percent, and it 
takes those cost-shifted dollars and gives that money to 
patients who can't afford care and allows them to do what? 
Purchase health insurance and participate in the incredible 
care other Americans are getting either through their employer 
or out of their own pocket.
    But unfortunately, that is not going to last. You have 
given great testimony about how it works. It is not going to 
last. You see, either by intention or accident, the ACA creates 
pressures on the healthcare system that are crashing the very 
system that the witnesses today were praising. You like your 
ACA insurance-based care, and I appreciate you sharing it 
today, but the ACA is driving the cost shifting to a point that 
small businesses can't afford it, and more people are shifted 
to government systems.
    As this dynamic pushes people onto the government care--
Medicare, Medicaid, all of that--we move to more and more 
socialized medicine. And at some point, the shifts cause the 
system to crash. That means the insurance-based system that the 
ACA is providing you and that you have given great testimony on 
today is going to go away. It can't last. But maybe that is 
exactly what the leaders of the Democrat Party want.
    Medicare for All will be abysmal. It will be akin to the 
VA. I am a veteran, I know. Ask your veterans: $32.6 trillion 
over 10 years. If you tax 100 percent of income earners at the 
top levels, you only get $700 billion. Seven hundred billion 
versus $32.6 trillion. It doesn't add up. Yet the ACA is 
driving us toward that system, I repeat, either intentionally 
or accidentally.
    The government is not the answer. Government healthcare is 
rationed care, late detection, and, worse, mortality. We need 
solutions to healthcare. My plan, I have written, and it is a 
bill this year, to create a healthcare swipe card. Unlike what 
Mr. Sarbanes said, it would fix the problem and allow us to 
provide help to even more people. I encourage, particularly my 
freshman Democrats, to go look at my plan. I think the people 
that I have talked to love it, even Democrats.
    But the healthcare you are getting is insurance based. You 
love it. You want to see it continue. Help us get rid of the 
Affordable Care Act, which is driving us to a single payer. 
Thank you.
    Chairman Cummings. Although the gentleman's time has 
expired, Ms. Gluck, you seem like you were shaking your head. I 
thought you were going to shake it off.
    Ms. Gluck. Not unless you would like me to respond to 
something.
    Chairman Cummings. No, did anyone have a response? Mr. 
Isasi.
    Mr. Isasi. Yes, I think, again, it is important that we 
actually have information and facts in this conversation. What 
we know in this country, and now there are a few things, one, 
if you look at the information comparing the U.S. to other 
countries, our babies are dying at faster rates. Our moms are 
dying at faster rates. We have more preventable medical 
injuries occurring in United States than other countries. That 
is the truth. That is what the data show.
    Two, right now in this country, the reason that healthcare 
is so expensive, and the studies are super clear on this, is 
not because we have brought everyone in and then given them 
access to health insurance. It is because the health insurance 
sector is increasing prices at astronomical rates, and we know 
this. The American people know this. They see what is happening 
to their prescription drugs . They see what is happening when 
they get those hospitals bills. That is why the system 
currently is unsustainable. The notion that ensuring that 
everybody has a shot at getting healthcare when they need it is 
breaking the bank is preposterous.
    Chairman Cummings. Thank you.
    Mr. Green. Mr. Chairman, he brings up a point that kind of 
contradicts something, and if I could just clarify. I will take 
30 seconds.
    Chairman Cummings. Thirty seconds.
    Mr. Green. Yes, sir.
    Chairman Cummings. Yes.
    Mr. Green. You have to make sure you compare apples to 
apples. When we compare life spans and things like that in our 
country versus others. I mean, they eat less fried chicken in 
Europe, okay? I mean, they smoke less than us. It is not just 
the healthcare system. It is the healthcare system plus 
lifestyle and all that. So while some of the stuff that was 
just mentioned about the cost of drugs and all that stuff. I 
get it. But you can't compare apples and oranges. You have to 
compare apples to apples. Thank you, Mr. Chairman.
    Mr. Isasi. Just responding to that point.
    Chairman Cummings. No. No. No. No.
    Mr. Isasi. Okay.
    Chairman Cummings. Mr. Kelly? I mean, and I am not trying 
to be rude. I am trying to move the hearing along, okay?
    Ms. Kelly. Thank you, Mr. Chair. I just get amazed every 
time I come back to this committee. I was not here when my 
colleagues voted for or against the Affordable Care Act, but I 
know that since I have been here, no Democrat thought that was 
a perfect bill, but I know since I have been here we have never 
been given the chance to work on the bill, especially when 
President Obama was the President. All we have had a chance to 
do is, you know, repeal, repeal, repeal, repeal. And I know 
that, you know, he wanted more things in the bill, but in 
trying to get one Republican to support the bill, you know, he 
made concessions, and then no one wound up voting for the bill, 
as you guys know. Then we spent, I think over, 63 times trying 
to repeal it.
    Also I am glad you mentioned about maternal mortality and 
infant mortality. It was safer to have a baby 25 years ago, and 
it is not just from people eating fried chicken. That is not 
the reason. I know you were going there, but so, you know, I 
just want to add that for the record. I wanted to ask you, Mr. 
Isasi, how do the uninsured rates in states that have expanded 
their Medicare programs compare to those that have not?
    Mr. Isasi. Well, and, you know, it is an important point to 
make that what we do know, we actually know, is earlier the 
witness next to me cited a study that said that that access to 
health insurance had no impact on mortality. That study 
actually says, in the published study it says, ``Our results 
should not be interpreted as evidence that health insurance has 
no effect on mortality.'' What we do know from the IOM, and it 
was published in the in the journals of medicine, is that when 
people have access to health insurance, when people have access 
to Medicaid, they live longer lives and they are healthier, and 
that is the truth.
    I will also say that we have heard a lot about this 
question of hospitals closing in districts and people losing 
access. Before working at Families USA as the executive 
director, I ran healthcare for the National Governors 
Association, and I worked with Governors, Republican and 
Democratic, across this country. The No. 1 way to make sure 
that a rural hospital doesn't close is to expand Medicaid. And 
the Congressman who was speaking about his concerns about his 
hospitals is in a state that did not expand Medicaid.
    Ms. Kelly. Exactly. And now has the public health improved 
in states that have expanded Medicaid?
    Mr. Isasi. Right. Well, what we know is that not only are 
people healthier, not only are people able to get the care they 
need, but we also see a larger movement from people from public 
insurance into employer-sponsored coverage as they get jobs. It 
is all connected. It is all interlinked.
    Ms. Kelly. Also I wanted to thank the witnesses for sharing 
your personal stories. I know it is not easy to do, and I 
really appreciate it. Also, I am married to a doctor. He is an 
anesthesiologist, and he supports the ACA.
    Mr. Isasi. Right, and I think it is important, as I said in 
my opening statement. It is supported by the American Medical 
Association. It is supported by the American Hospital 
Association, the Heart Association, the Cancer Society. So we 
have one doctor who says he doesn't like the ACA, but all the 
associations that represent providers are saying this is really 
important for the American people and for us.
    Ms. Kelly. Also, I mean, they are right in the fact that, 
yes, you can find someone that believes this and someone that 
believes. It is personal experiences, but we have to look 
holistically and overall that what is the greatest benefit. 
Professor Gluck, what would happen to Medicaid expansion if the 
Trump Administration's position prevails in court?
    Ms. Gluck. Well, it would end, and all those people who got 
insurance would be thrown off the rolls.
    Ms. Kelly. I am the chair of the congressional Black Caucus 
Health Brain Trust, and information we have been given, when 
you look at African-American men, the rate of prostate cancer 
has gone down significantly since many more have the ACA, and 
also breast cancer in women, in black women, has also gone down 
because of access and care because of the ACA.
    Ms. Gluck. Yes. I recently wrote an article about 
disparities in cancer care across races and geographic regions, 
and it has been found that the Affordable Care Act has done 
more to reduce disparities in cancer than anything else in 
recent memory. Part of that is because of the covered early 
screening and checkups. It is incredibly important for health 
justice in our society.
    Chairman Cummings. Would the gentlelady yield? Are you 
finished?
    Ms. Kelly. Yes.
    Chairman Cummings. Thank you. A little earlier, Mr. Hice 
from Georgia mentioned that some of his rural hospitals were 
closing, and I think Georgia is one of the states that didn't 
accept Medicaid under ACA. If they did, I think would be a 
little bit different, I think. Can you comment on that? And 
comment on uncompensated care. How has that been affected by 
the ACA.
    Mr. Isasi. Absolutely, and what we know, if you look at 
hospital closures in rural America across this country, almost 
all of them, and I mean almost all of them--I think it is north 
of 80 percent--are occurring in non-expansion states, states 
that choose not to expand Medicaid. They have that ability. 
They don't do it, and then the rural hospitals end up closing. 
I was part of a lot of negotiations with Governors trying to 
expand Medicaid. This was the No. 1 issue.
    It is the reason why hospitals show up and push for it 
because they know when you have a group of people and explore 
community who do not have health insurance, they cannot keep 
their doors open. Health insurance provides access, and it 
allows for the economics of that community to survive and that 
hospital to survive.
    Chairman Cummings. Okay. All right. Mr. Higgins.
    Mr. Higgins. Thank you, Mr. Chairman. I thank all our 
guests here today for your courage in being here, and your 
stories are touching. I'm going to tell a story, too. My wife 
has MS. It is a preexisting condition. I have four children, 
three living. I lost a daughter long ago to a condition that 
she was born with. I myself have many, many physical injuries 
from my years as a police officer, including a reconstructed 
eye socket. As a cop, cops earn in Louisiana $12, $13, $15, $16 
an hour. As a captain, when I resigned my commission to run for 
office, I was earning $20 an hour. My wife was a receptionist 
in parish government. She earned $12 an hour. Health insurance 
for many years before the ACA was always the same, $300, $400, 
$500 a month. The ACA came along, insurance premiums went up to 
unaffordable, $800, $900, $1,000 a month. Deductibles were 
always $500, $600, $1,000 for a deductible. It went up to 
$2,000, $3,000, $4,000, $5,000.
    Having a healthcare card from the ACA does not mean having 
healthcare. One of my colleagues mentioned that we want to 
destroy the ACA. We were told you can keep your plan. You can 
keep your doctor. Your premiums will go down by $2,500. You 
will have more access to care. Those with preexisting 
conditions will be protected. If the ACA had manifested well 
and Americans had not suffered the incredible increases in 
premiums and deductibles, we wouldn't be having this 
conversation. President Obama's crown jewel would be safe. But 
the fact is we must represent the interests of the American 
citizens that we serve.
    In business before the ACA, it was common for three, four, 
five, or six insurance companies to compete for the group 
policy of that business, or companies, large and small. That is 
gone. You don't have a competitive market anymore. Those 
companies have to search and beg. It used to be the other way 
around. Insurance companies would come to American businesses, 
large and small, and seek that business for the coverage they 
were providing their employees.
    My coverage expense after the ACA went up every year. It 
was quickly over a $1,000 a month. Couldn't afford it, man. Do 
the math. As a cop earning $15, $16 an hour, the wife of a cop 
earning $12. Very quickly you had to make a decision: are you 
going to buy groceries or health insurance? What do you think 
we did? We bought groceries. That was never an issue before the 
ACA.
    The ACA expense was not a distraction, as my colleague 
said. It was a disaster. Having an ACA policy card is not 
having healthcare. An unaffordable policy for a regular working 
American at $1,000 a month just to have the privilege of paying 
cash for your healthcare all year because you have a $5,000, 
$6,000, $7,000, $14,000 deductible that you never hit, that is 
not healthcare that we need to provide to our Nation. That is 
not real.
    My wife and I had to buy a non-ACA policy. That was 
reality, man. We had to buy a non-ACA policy, and we were 
subject to punitive fines from our own government whom we 
served, and I am a veteran as well, because the fines were down 
the line, the seizure of our property from the IRS, of all 
places, because we have the audacity to buy a non-ACA policy. 
That seizure of our property was down the line, but groceries 
were not.
    I am not opposed to the ACA because it was President 
Obama's crown jewel. I am opposed to the ACA because it has 
been an abysmal failure and a massive seizure of American 
property and American freedoms. Mr. Balat, you mentioned, and I 
thank you all for being here. You have mentioned reasonable 
postures, and you, my fellow children of God, my fellow 
Americans, have shared meaningful stories that touched our 
hearts. Help us fix this thing, man. That is what we seek. Mr. 
Chairman, I yield.
    Chairman Cummings. Mr. Isasi, his time has expired, but 
you----
    Mr. Isasi. Yes, just a brief statement, which is, you know, 
first of all, this is literally a mission of our organization. 
We want all Americans to have access to high-quality, 
affordable health insurance. We are with you 1,000 percent in 
that fight. An 18 percent increase in health insurance 
premiums, an 18 percent increase in one year, guess what year 
that was? That was 1987. A, let's see, 11 percent increase in 
health insurance, that was 2002, okay? What we know for sure is 
that after the ACA was enacted, the increase in premiums for 
employer-sponsored coverage where most Americans get coverage 
was lower. It was two - two percent. It was one percent. These 
are the CMS actuary's own facts and figures. That is what we 
are looking at right here.
    So there have been problems with health insurance premiums 
in this country for decades. We are with you. I think everybody 
on this panel is with you. We have to solve this problem. But 
to blame the Affordable Care Act because in 1987, 30 years 
before it was even conceived of, there was an 18 percent 
increase seems a little bit absurd.
    Voice. Mr. Chairman, could I----
    Chairman Cummings. You are going to ask a question in a few 
minutes, so if you don't mind. Ms. Pressley.
    Ms. Pressley. Thank you, Mr. Chairman, for convening 
today's hearing and for shining a light on what a critical 
lifeline the ACA has been for millions of families. I want to 
especially thank all of you for bringing the expertise of your 
lived experiences here, and I know just your advocacy alone 
will save lives. Ultimately, the ACA was saved the last time, 
not simply for the conviction of lawmakers, but for the courage 
of everyday people, who quite literally put their lives on the 
line, their bodies on the ground, and stood in the gap. And I 
believe that the same will be true again. So thank you for your 
courage and for being here today.
    Certainly in my district, the Massachusetts 7th, my 
congressional district, almost half of the residents are living 
with one or more preexisting conditions. I am grateful for the 
leadership of our Massachusetts attorney general, Maura Healey, 
who is an activist leader and a dear friend, who has been 
leading the fight on the front lines helping to protect the 
ACA, and affirming that healthcare is a fundamental right for 
all of us.
    Mr. Morley, I am paraphrasing, but it was very poignant and 
resonant when you said that instead of fighting to stave off 
bankruptcy, because of the ACA, you got to focus on staying 
well and staying alive. The fact is that we find ourselves at a 
time when people have to ask questions such as do I feed my 
family or pay my rent, or do I go start a Go Fund Me campaign, 
or do I risk forgoing the life-saving medicine my child needs 
to stay alive.
    I want to focus a line of questions on the persistent 
inequities and disparities a rollback to the ACA would cause 
for the 67 million women and girls who live with a preexisting 
condition. This law has saved countless lives, and undermining 
it and attacking it puts the health and well-being of our 
Nation's families at risk. Professor Gluck, could you explain 
for the committee what health insurance coverage was like for 
women before the ACA?
    Ms. Gluck. Women have benefited enormously--thank you for 
the question--from the ACA's protections. According to Kaiser, 
the uninsured rate on women dropped from 19 percent to 11 under 
the law. Before the ACA, only 12 percent of individual plans 
covered maternity care, which is a shocking statistic. Women 
could be charged 50 percent more than men for insurance because 
of the health risk that they pose because of conditions like 
pregnancy. The ACA ended that discrimination in pricing based 
on gender.
    It also significantly helped women's health because it now 
covers, without a co-pay significant, preventative services 
that are very important to women, and I mean much more than 
contraception. I mean breast cancer screening, colon cancer 
screening, HIV, HPV, and much, much more than that. The 
Medicaid expansion, it also worth noting, helps women have 
healthier pregnancies and keeps women healthier before they are 
pregnant, which in turn results in healthier pregnancies.
    Ms. Pressley. That is right. So women were paying out of 
pocket.
    Ms. Gluck. Yes.
    Ms. Pressley. Okay. All right. So is there anything else 
you would like to elaborate on, Professor, so far as to how the 
ACA put a stop to those kinds of discriminatory practices?
    Ms. Gluck. Well, you know, with this case that is pending 
in Texas right now, all of those protections would be gone. We 
would once again not have basic coverages that most people take 
for granted, like maternity care coverage for a huge swathe of 
the population.
    Ms. Pressley. Ms. Burton, as a woman with a chronic 
illness, you spoke of the stress of having to deal with being 
uninsured for so long. Before the ACA, women could be denied 
coverage for things like pregnancy, breast cancer, or treatment 
for sexual or domestic violence. We are also in the midst of, 
as Representative Kelly alluded to and has been leading on, a 
national maternal mortality crisis. Women are no safer giving 
birth today than they were 30 years ago. How important was it 
to you and your family that you were able to have coverage for 
maternity care during that time?
    Ms. Burton. It was definitely very important for me. I have 
had four C-sections. I did not have natural birth with any of 
my children. My pregnancies were all very high risk. My 
youngest child I gave birth to the first semester of my second 
year of law school. One of the biggest complications was my 
uterus had completely attached to my abdomen, and my C-section 
was a lot more extensive than it had been for the previous 
three. And had I not had coverage during that time, I wouldn't 
have had the followup care that I needed. Case in point, in 
2014, I suffered a miscarriage 10 weeks in, and I did not have 
insurance. I had my miscarriage in the emergency room, and I 
never got to followup to see why my baby died or what condition 
was in place at that time.
    Ms. Pressley. Thank you, Ms. Burton. And just really 
quickly, one in four residents of my district benefit from the 
ACA's requirement that allows them to remain on their parents' 
plan until the age of 26. Would anyone like to elaborate on why 
this is important?
    Chairman Cummings. The gentlelady's time has expired, but 
you may answer the question.
    Ms. Burton. It is important for me because I, as a mother 
of four children, my older two children are 19 and 18. They 
work jobs, but their jobs don't provide healthcare. So through 
the healthcare I have now through my employer, my kids are 
still covered. It is important that when we have kids, we 
expect them to continue their education and go to college, but 
we don't have a means for them to be insured during that time. 
And while we want to have these safety nets in place for them, 
we put impossible choices in their way. So by allowing that 
coverage until they are 26 years of age, that allows them to go 
through with the comfort and safety of pursuing an education 
without having to worry about if they get sick what is going to 
happen to them.
    Ms. Pressley. Thank you, Mr. Chairman. Thank you, Ms. 
Burton.
    Chairman Cummings. Thank you. Mr. Armstrong.
    Mr. Armstrong. So right now in North Dakota, we have the 
same number of people uninsured as we did 10 years ago or prior 
to the implementation of the Affordable Care Act. And we have 
passed Medicaid expansion at our state level. We have done all 
of those things. But considering that we are a lot of small 
businesses, a lot of small family farms, what we have done is 
shifted the burden up the economic food chain. If you are a 
small family farmer, you are not employed, so you can't get 
insurance through employment. You don't qualify for Medicaid, 
and you don't qualify for Medicaid expansion. So one of the 
major concerns with Obamacare, regardless of the outcome of any 
ongoing litigation, is the lack of insurance products to small 
business owners, sole proprietors, farmers, who have largely 
been priced out of the market.
    So I guess my first question would be to Mr. Balat. Can you 
elaborate on any proposals that actually could increase 
coverage in rural America?
    Mr. Balat. I had suggested earlier what is happening with 
rural America is many of the farm co-ops that exist have been 
taking advantage of the association health plans. I understand 
earlier that the witness to my right was saying that was an 
opportunity for insurance companies to play tricks. People are 
walking into these things with eyes wide open, and they are 
shopping responsibly and addressing their needs for themselves 
and for the groups that they represent. That has been a good 
solution, again, for those that are in transition. They are 
using short-term plans.
    But, more importantly--most importantly--is we are looking 
at addressing the HSAs and personal accounts that people can 
start to use their own money rather than having the government 
pay directly into the insurance companies' coffers, allow us to 
purchase our own insurance for ourselves, and that would be a 
big boon to the rural community. Also, I would also add the use 
of tele-medicine and the technical advances that we have had, 
that has really been a big help for very remote rural areas.
    Mr. Armstrong. Well, I think part of that is, I mean, 
outside of insurance or anything, it is how we deliver medical 
care. I mean, people drive 100 miles now, and as a state, we 
have done a great job over 50 years putting up picket fences 
for licensing and those types of issues. And now in the last 
several years, we have done a really or a pretty good job of 
reducing those picket fences, so things like tele-medicine and 
those options can actually be brought into rural America. But 
those are independent of Obamacare, any of those things. So I 
appreciate that.
    I would just also say we didn't have a lot of choice 
before. We have a state a 750,000 people. I mean, the markets 
adjust for that, but over 10 years, we have seen insurers flee 
our markets. I mean, to say that we have stabilized after 10 
years like that is some kind of accomplishment is really not 
the point because it was unsustainable to go any farther than 
actually stabilize at some point in time.
    Mr. Balat. I think it is also important to say that I have 
been part of a healthcare industry for 20 years. What we are 
talking about is not going back to pre-ACA. It is not a binary 
choice. It is not ACA today or pre-ACA. Those aren't our two 
choices. What we can do is create an environment that is better 
that will help address the real problems that people have for 
themselves and for their children. Let's give people choice.
    And I just want to add one more thing. One other issue that 
nobody has brought up about the Affordable Care Act is that the 
Kaiser Family Foundation has said that 20 percent of all in-
network claims in the ACA are denied by the insurance 
companies. That is not protecting people.
    Mr. Armstrong. I appreciate that, and I hope whatever we do 
moving forward gives states like North Dakota and our Governor 
and our insurance commissioner more ability to make decisions 
and the Federal Government less. With that, I would yield to my 
friend from Texas, Mr. Roy.
    Mr. Roy. I thank the gentleman for yielding. Mr. Balat, in 
2009, a CBO-JCT report said by 2016, the new law would cause 
premiums to increase in the individual market by 10 to 13 
percent. Does that sound right?
    Mr. Balat. I believe so. I don't recall.
    Mr. Roy. And the Obamacare regulations, though, in fact 
turned out to cause premiums to more than double from 2013 to 
2017. And, in fact, in the first four years of the ACA, every 
age group and household type experienced an increase of between 
56 and 63 percent. Does that meet with your understanding of 
what occurred?
    Mr. Balat. In the exchange, yes.
    Mr. Roy. And so in 2013 to 2017, premiums increased an 
average of 60 percent. Now go back. In the four years before 
the ACA, every age group and family type either experienced a 
premium decrease or an increase of 9.2 percent or less. The 
dollar amounts of the increase varied from, you know, $2,500 to 
a different dollar amount. But my point is if you look at this 
chart back here, the red lines are post-Obamacare. The blue 
lines are immediately preceding Obamacare. And here is the 
deal. We don't have witnesses here testifying for all the 
people who lost their insurance because of Obamacare. We don't 
have families here testifying who are paying the premiums 
reflected in those red bars. That is the reality. That is what 
we are dealing with throughout the country.
    We have 330 million Americans. We are talking about 20 
million, 10 or 11 million of whom are covered by Medicaid 
expansion, 10 or 11 million of whom are covered through the 
ACA, and I am glad that everyone who has that coverage does. I 
am just trying to figure out how we can make sure all of 
America is not getting stuck with insurance or an inability to 
get the healthcare of their choosing because we have created a 
system that is too expensive.
    Chairman Cummings. The gentleman's time has expired.
    Mr. Roy. Mr. Balat, any comments on that? Thank you.
    Chairman Cummings. The gentleman's time has expired, but 
you may answer that question.
    Mr. Balat. In spite of what happens with the ACA, my role 
is to help with research and educating lawmakers to find as 
many choices and find as many options and find as many 
solutions that work well regardless of the geography here in 
the United States. In Texas alone, my home state, South Texas 
is so different from North Texas and West, and East, and 
Central. It is culturally, geographically very diverse. And 
going back to my hospital days, my primary service area was one 
to three miles. That was my community. It is absurd to think 
that we can manage healthcare insurance coverage and the 
healthcare for people states away. It must be done at the state 
and local level.
    Chairman Cummings. Thank you very much. Ms. Tlaib.
    Ms. Tlaib. Thank you, Mr. Chairman, and thank you all so 
much for being here. Ms. Burton, I was very touched by your 
statement. I wasn't here, but I was able to get a written 
statement. But something that you said at the end was 
beautiful, that this is not a partisan issue, that it is about 
what happens to families without healthcare coverage. Why 
should a single mother of four be forced to choose between 
housing and healthcare? It is a "we are better as a Nation if 
we keep our people healthy" issue, and I really appreciate you 
emphasizing that.
    While the Affordable Care Act has helped millions of 
Americans obtain healthcare coverage nationwide, areas, such as 
Wayne County in my home state of Michigan, have some of the 
biggest impacts. According to a report from Georgetown 
University's Center for Children and Families, states that have 
expanded Medicaid under ACA have seen sharp declines in the 
rates of uninsured populations. For example, the percentage of 
those without insurance in Michigan decreased from 12.9 percent 
in 2013 to 6.1 percent in 2017. Mr. Isasi, why has Medicaid 
expansion been so effective?
    Mr. Isasi. Thank you so much for that question. Well, you 
know, one of the things is that before the ACA was passed, 
there was a misperception in the American public and a lot of 
lawmakers that if you were poor enough, you got Medicaid, and 
that wasn't the case. What Medicaid expansion did is it said 
that there is a group of people for whom nothing exists.
    I will give you an example. In the morning, I walk my dog 
in Logan Circle, and there is a gentleman with severe mental 
illness there. He lives. He is homeless. Before Medicaid 
expansion, there was nothing there for him. He could get 
nothing. There was a whole group of Americans who had access to 
nothing, no insurance whatsoever. Medicaid expansion said if 
you are poor enough, if you are struggling enough in your life, 
we are going to give you access to health insurance, and that 
is why it is been such a successful and important part of the 
Affordable Care.
    Ms. Tlaib. The ACA's Medicaid expansion is one of the many 
reforms that would disappear if the Trump Administration 
prevails in court. Is that correct, Professor Gluck?
    Ms. Gluck. Yes, it is.
    Ms. Tlaib. Our communities stand to lose if the Trump 
Administration wins, including 87,000 people alone in my 
district, in the 13th congressional District. It is not just 
Medicaid coverage that will be lost. Currently 79 million 
Americans live in what we call primary care health professional 
shortage areas, meaning there is less than one physician for 
every 3,500 people. Michigan has the third highest number of 
shortage areas for primary care, and the Metro Detroit area has 
over 20. This equals that individuals already have to travel 
further to receive healthcare coverage, and in many communities 
where hospitals have closed in recent years, they have to 
travel even further to receive emergency medical services. Mr. 
Isasi, under the ACA, patients do not have to pay a co-pay if 
they go to an out-of-network emergency room, correct? And would 
that change go if the Trump Administration prevails in court?
    Mr. Isasi. Under the ACA, there are protections for out-of-
network billings. They are incomplete, but they are there.
    Ms. Tlaib. If the Trump Administration succeeds in striking 
down the ACA, millions of Americans risk losing healthcare 
coverage, but this will not mean that the Americans will not 
stop needing emergency medical care. Instead hospitals will 
just be forced to provide more uncompensated care. Is that 
correct?
    Mr. Isasi. That is right.
    Ms. Tlaib. What is likely to happen, particularly to 
hospitals in shortage areas like Detroit, if the number of 
individuals requiring uncompensated care increases? Will this 
help or hurt their stability or ability to keep their doors 
open?
    Mr. Isasi. There is no question whatsoever in every state 
in the country, every hospital will show up and say without 
that coverage, we could risk closing our doors.
    Ms. Tlaib. And the ACA has also helped address provider 
shortages through something called the Community Health Center 
Fund. Professor Gluck or Mr. Isasi, can you explain what that 
fund does?
    Mr. Isasi. So could you ask the question again please?
    Ms. Tlaib. So the fund, it is called Community Health 
Center Fund. Is anybody on the panel familiar with that?
    Mr. Isasi. Yes.
    Ms. Tlaib. Yes. Can you explain that?
    Mr. Isasi. So it was a significant increase in the funding 
for what were called federally qualified health centers. All 
those community health centers operate in rural America, in 
inner cities. They are one of the most important source of 
primary care coverage in this country.
    Ms. Tlaib. Before my dad worked at Ford Motor Company and 
finally got access to healthcare, thanks to his union, I went 
to one of those clinics, a CHASS clinic, in Southwest Detroit. 
And I remember just going into it, and they poke you, you know, 
and do all those things. But it was required for us to be able 
to even get access to schools, right, to do the medical exams. 
I mean, think about those kinds of things.
    I really believe, you know, the Trump Administration's 
refusal to defend the ACA threatens to widen existing 
healthcare gaps and make it even harder for Americans to access 
care if they need it. On our road to Medicare for All--crossing 
my fingers--we must continue to work to close our healthcare 
gaps and expand vital care for all Americans, not dismantle it. 
I represent the third poorest congressional district in the 
country, and I can tell you at the frontline when I speak to so 
many of my residents, healthcare is always at the forefront of 
them choosing, like Ms. Burton talked about, between, you know, 
taking care of their children, groceries, and those everyday 
issues, to healthcare.
    So I thank you again for your panel. Thank you, Mr. 
Chairman.
    Chairman Cummings. Thank you. Mr. Jordan.
    Mr. Jordan. Thank you, Mr. Chairman. Mr. Isasi.
    Mr. Isasi. Isasi.
    Mr. Jordan. Isasi. It looks a lot like a former chairman's 
name that we had.
    Mr. Isasi. That is right.
    Mr. Jordan. So I think I have counted no less than four 
times you said, ``It is wrong to say that Obamacare is the 
cause of increased premiums.'' You have said that several 
times. But with all due respect, Mr. Isasi, I don't think that 
was the promise. The promise was Obamacare was going to lower 
premiums. When Democrats voted for this, when President Obama 
rolled it out, he didn't say pass the Affordable Care Act, pass 
Obamacare, and your premiums will go up, but don't worry, this 
bill won't be the cause. And I would dispute, even if we take 
your assessment as accurate, that it is not the cause. I think 
Mr. Roy just offered some numbers that show that it may, in 
fact, have been.
    Mr. Balat, in the past decade, what is the single biggest 
change to healthcare policy in this country?
    Mr. Balat. To healthcare policy?
    Mr. Jordan. Yes.
    Mr. Balat. That would be the ACA.
    Mr. Jordan. It would be Obamacare, right?
    Mr. Balat. Without question.
    Mr. Jordan. So let's go back to the basics. We have been 
through it a few times. But when Obamacare was passed, again, 
the single biggest change to healthcare policy in the last 
decade, projections were we were going to have 24 million 
people enrolled in it today. How many are enrolled in Obamacare 
today? Just in the exchange, not counting Medicaid expansion. 
Just Obamacare.
    Mr. Balat. Between 8 and 9 million.
    Mr. Jordan. So not even close, a third of what was 
projected. When Obamacare passed, again, the single biggest 
healthcare policy change in the last year, we were told that if 
you like your doctor, you keep your doctor. Has that 
materialized? Was that statement true, Mr. Balat?
    Mr. Balat. No, it is not true.
    Mr. Jordan. When Obamacare passed, again, the single 
biggest change in American healthcare in the last decade, we 
were told if you like your plan, you can keep your plan. Was 
that true?
    Mr. Balat. No, sir, it was not.
    Mr. Jordan. And, of course, as we started here, when 
Obamacare passed, we were told premiums were going to decline. 
Again, just nice and again for the record, did that happen, Mr. 
Balat?
    Mr. Balat. No, it did not.
    Mr. Jordan. For everyone, premiums in the exchange, out of 
the exchange, single, individual market, employer-sponsored 
plans, everybody's costs went up. Is that right?
    Mr. Balat. It did. The cost of the premiums went up. 
However, with the subsidy, it wasn't felt by those that were 
part of the exchange.
    Mr. Jordan. Do you think we were lied to when this bill 
passed back in 2010, Mr. Balat?
    Mr. Balat. Congressman, I don't want to speculate as to 
what the intent was.
    Mr. Jordan. Yes, you don't have to because the architect of 
it, Mr. Gruber, said this. Jonathan Gruber, MIT Professor, New 
York Times, said, the architect of Obamacare, going to the 
White House several times, meeting with all the key players who 
are putting this policy and this plan together said this. ``If 
any American really believes that Obamacare is going to control 
costs, I have got some real estate in Whitewater, Arkansas I 
would like to sell them.'' So the guy who put it all together 
told us it was going to drive up costs, and it certainly has. 
Have the co-ops worked that were part of Obamacare?
    Mr. Balat. The data shows that they have.
    Mr. Jordan. The ones that are still left have?
    Mr. Balat. Oh, wait, the co-ops.
    Mr. Jordan. The co-ops under Obamacare, the 23 co-ops that 
were created?
    Mr. Balat. Oh, no, I was referring to the others outside of 
the ACA.
    Mr. Jordan. Oh, exactly. The ones out in the private sector 
have. That is a lot different than the ones they set up. 
Twenty-three set up, only four are left. Nineteen bankrupt. Are 
there more healthcare choices today? Again, Obamacare, single 
biggest healthcare policy change in this country in the last 
decade. Are there more healthcare choices today than there were 
in 2010?
    Mr. Balat. There are not. Many of the carriers have left. 
Our individual market in Texas was----
    Mr. Jordan. Provider networks are smaller, larger, narrower 
networks?
    Mr. Balat. Much smaller.
    Mr. Jordan. Networks are much smaller.
    Mr. Balat. Much smaller, which is contributing to the 
surprise billing issue.
    Mr. Jordan. Exactly. What happens when you only got one 
insurance provider in a market? What happens to costs then?
    Mr. Balat. Premiums go up.
    Mr. Jordan. Well, frankly, you can go outside of 
healthcare. If you got one supplier of a product in any market, 
typically you don't have the kind of price consumers would 
prefer, do you? No, you typically don't. The last thing maybe 
I'd ask you is this. You said in your opening statement, Mr. 
Balat, that the ACA hurts families with preexisting conditions, 
and that stuck out in my mind. I actually wrote it down several 
hours ago when we started this hearing. Can you elaborate on 
that?
    Mr. Balat. Well, it really is a function of cost. Let's 
talk about insurance. The reason preexisting conditions is even 
a thing is because insurance is coupled with employment. The 
fact that we don't have more portable personal insurance plans 
causes us to jump from place to place, and that creates that 
preexisting condition issue.
    Now, in healthcare, we just call them conditions. 
Preexisting conditions is an insurance term, but how it has 
affected families is as these premiums have increased, as these 
deductibles have increased to high levels, they are just priced 
out of the market. And if they have a plan that they have had, 
and in some cases I have talked to people, you know, I have had 
my insurance for to 15 years and I just can't afford it 
anymore. And now that they have to look for some other product 
or go to another solution, they have a preexisting condition. 
That wasn't an issue so long as they had their plan that 
they've had for 15 years.
    Mr. Jordan. Thank you.
    Chairman Cummings. Thank you very much. Ms. Hill.
    Ms. Hill. Thank you, Mr. Chairman, and thank you all for 
being here today. When I speak to people in my district, 
whether they are community health centers and clinics, 
physicians and nurses, hospital associations, or patient 
groups, I hear by and large that we must focus on increasing 
access to critical services, like treatment centers, not 
decreasing those services and incentives. The Affordable Care 
Act massively expanded mental health and substance use disorder 
benefits and Federal parity protections for 62 million 
Americans. And the arguments we heard yesterday from the Trump 
Administration pose an imminent threat to the well-being of 
America.
    I would like to first focus on how the ACA is helping to 
address the drug overdose epidemic, which claimed over 70,000 
lives in 2017, with opioids accounting for nearly 48,000 of 
those deaths. In California, buprenorphine is growing in 
popularity due to regulatory changes, physician training, and 
other initiatives. The rate of Medi-Cal enrollees, California's 
Medicaid program, who received buprenorphine nearly quadrupled 
from the end of 2014 to the third quarter of 2018. The counties 
that make up my district are part of 40 California counties 
taking part in the Drug Medi-Cal ODS, organized delivery 
system, Pilot Program, and have joined California's effort to 
expand, improve, and reorganize treatment of SUDs in Medi-Cal 
under California's Medicaid Section 1115 waiver. In that vein, 
Mr. Isasi, what tools has the ACA provided to help us fight the 
opioid epidemic?
    Mr. Isasi. So this really cannot be stated strongly enough. 
The No. 1 tool in this country to combat the opioid epidemic is 
the Medicaid expansion, period. I have worked with Governors 
all over this country who are trying to stop this terrible 
plague in this country. Governor Beshear from Kentucky could 
speak so eloquently. Kentucky is one of the worst-hit states in 
this country, and it was the Medicaid expansion that helped him 
save lives. It provides the medication people need, and it 
provides the therapy that they need to be able to deal with the 
addiction.
    Ms. Hill. Anyone else want to add to that?
    Ms. Gluck. I would add to that. I think before the ACA, 45 
percent of individual plans did not cover substance use 
disorder treatment. With respect to the opioid crisis, you need 
treatment both before and after, so you need insurance access. 
You need to have coverage to cover you for your pain treatment. 
That is not necessarily a pill, but let's say as a behavioral 
therapy treatment, and you need that insurance coverage on the 
back end if you are addicted. There is nothing more important 
to combatting the opioid crisis like getting more Americans 
covered.
    Ms. Hill. Absolutely, and this is something that we hear. 
We need additional attention to and additional resources for, 
not the opposite. So let's focus on Medicaid for a moment. The 
ACA's Medicaid expansion has reduced the unmet need for 
substance abuse treatment by, according to some estimates, as 
much as 18 percent. Professor Gluck, you noted in your written 
statement that Medicaid is the largest payer for addiction 
treatment in this country, and, in fact, you both have said 
that. And according to the Kaiser Family Foundation, Medicaid 
provides comprehensive coverage to nearly four in 10 non-
elderly adults dealing with opioid addiction.
    So, Professor Gluck, if the ACA is overturned, what would 
happen to people who have gained access to treatment through 
the Medicaid expansion?
    Ms. Gluck. Well, they would lose it, and the crisis that we 
are dealing with now and trying to solve would get even worse.
    Ms. Hill. It is that simple. There is no plan to----
    Ms. Gluck. I have not been made aware of a plan, and I 
would say that the Administration's own plans to combat the 
crisis depend on that insurance coverage being in place.
    Ms. Hill. Right. There are other aspects of the ACA that 
have facilitated expanded access to treatment. In your written 
statement, you mentioned the importance of providing tax 
subsidies to help people purchase insurance through the 
marketplace. The ACA also expanded parity for mental health and 
substance use disorder coverage, meaning insurance plans are 
now required to cover these services just as they cover medical 
and surgical benefits. How would eliminating these provisions 
undermine the gains we have seen in connecting people with 
substance use treatment?
    Ms. Gluck. Well, these people who now have access to mental 
health and substance use disorder treatment would lose it, and 
we would go back to a time in which they were out there by 
themselves, maybe relying on pills, and not getting the kind of 
healthy treatment that we need to combat the crisis.
    Ms. Hill. Do you believe that insurance companies without 
the ACA would cover these kinds of things, these kinds of 
services?
    Ms. Gluck. Federal law requires mental health parity, but 
we know that mental health parity provisions have not been 
adequately enforced. In fact, there are different ways to get 
this kind of treatment. So you don't want insurers just 
covering a cheap pill. You want insurers covering the panoply 
of services that get people off pills and get the kind of pain 
and mental health treatment that they need. They need deeper 
insurance coverage to accomplish that.
    Ms. Hill. Right. We have received a statement for the 
record from Pennsylvania Insurance commissioner, Jessica 
Altman, crediting the Affordable Care Act's protection for 
preexisting conditions and expanded coverage of mental health 
and substance use disorders for helping the state fight the 
opioid epidemic. She wrote that overturning the ACA would, and 
I quote, ``effectively undo a decade of progress made toward 
ensuring those with mental health and substance use disorders 
have access to crucial, effective, evidence-based treatment 
services.'' I would like to enter Commissioner Altman's 
Statement into the record.
    Chairman Cummings. Without objection.
    Ms. Hill. We are truly facing the worst public health 
crisis in a generation, and yet this Administration is doing 
everything in its power to take health insurance coverage away 
from those who need it most. If the President truly wants to 
tackle the opioid epidemic, it starts with protecting and 
expanding, rather than taking away, healthcare for the millions 
of Americans battling substance use disorders. With that, I 
yield back my time. Thank you.
    Chairman Cummings. Thank you very much. Mr. Cloud.
    Mr. Cloud. Thank you, Chairman, and thank you, witnesses, 
for being here today. I appreciate the time that you are taking 
to be here and to share your stories, especially the witnesses 
who are with their personal stories. Mr. Balat, you are a 
fellow Texan. I appreciate you being here from the great state 
of Texas. I wanted to ask you if this sounds familiar: ``My 
insurance went from $345 a month to $1,200 a month.'' ``My 
premium increased drastically.'' ``Premiums increased from $247 
a month to $1,024 a month.'' ``The deductible went from $1,500 
to $6,000.'' ``My $225 a month catastrophic plan was declared 
illegal and premiums doubled.'' ``My insurance tripled in 
cost.'' ``It costs more and has fewer benefits.'' ``Premiums 
increased.'' ``Deductible increased $1,500 more a month.'' ``I 
was forced to go on Obamacare and lost all my doctors.'' ``My 
healthcare went from $125 a month for vision and full medical 
to $375. I couldn't afford it.'' ``My dad had to get Obamacare, 
and they denied him the meds he needed, denied him the surgery 
he needed, and his meds became beyond expensive, and his 
premiums and deductibles are ridiculous. He is limited on 
doctors, too.'' ``I have been without insurance for seven years 
because it is cheaper to pay the fee than have the medical 
insurance.'' Do these stories sound familiar?
    Mr. Balat. I hear those stories all the time, and many from 
the patients that would come into my own facility.
    Mr. Cloud. One of the reasons these sound familiar is we 
asked how has Obamacare affected you, and this is the response 
we have gotten. And while I appreciate the testimonies of the 
witnesses who are here, and I don't discount them at all, it 
would've been nice if the committee would have allowed us more 
than one witness so that we could have a more well-rounded 
understanding of how this is affecting American people, because 
the point is that a one-size-fits-all approach doesn't work for 
the American people.
    One thing that hasn't happened over the last decade, 
everybody keeps talking about healthcare, but we haven't had a 
real discussion about healthcare. Obamacare, as it was dubbed, 
should have been more dubbed Obama coverage. All the testimony 
we are hearing is about how many people are covered when I 
think the real question should be how do we get better access 
to care. The goal for all of us, regardless of what side of the 
aisle you are on, is care for the American people, not more 
coverage. So I think it would help us all if we could work our 
policymaking toward that objective and do so in a way that 
brings into light a well-rounded understanding of how this is 
truly affecting the American people.
    Can you tell me, there has been some talk about, you know, 
socialized medicine, whether or not Obamacare is or isn't that. 
One of the major concerns when the ACA was being debated is to 
whether it would be a first step to socialized medicine, 
universal healthcare. Could you explain the similarities? 
Indeed, I believe my understanding is over half the Democratic 
committee members have endorsed Medicare for All. So putting 
these two together, is there a similarity? Is there not?
    Mr. Balat. Well, the similarity is government-sponsored 
healthcare versus individual choice. That is what the 
distinction is at its most purest level. What we want is to 
have people have the freedom to use their own money the way 
that they wish, and to have some kind of coverage that protects 
them in a catastrophic fashion. But we are not in a place where 
we have that kind of relationship with our medical 
professionals anymore because insurance has been what we have 
pushed into.
    And you are right. Coverage is not what healthcare is. And 
I would say those folks that you read their stories, the 
increases in those premiums, many of them, the ones that I have 
talked to, are still uninsured today. They had good insurance. 
They were able to take care of their chronic disease. They were 
able to buy their medications. They were able to go to see 
their doctor. Today, they are uninsured, and they are having a 
challenge getting other kind of coverage because of a now 
preexisting condition, directly because of the ACA making 
things more expensive.
    Mr. Cloud. Do you believe market forces can work to help 
provide more access to care?
    Mr. Balat. I have seen it happen, without question.
    Mr. Cloud. I yield my remaining time to the current sitting 
ranking member, my friend from Texas, Mr. Roy.
    Mr. Roy. I thank my friend from Texas. I would ask my other 
friend from Texas, Mr. Balat, just expanding a little bit on 
what Mr. Cloud was talking about. I believe that the number is 
somewhere in the vicinity of 17 of my colleagues on the other 
side in this committee have, in fact, supported Medicare for 
All. I would be happy to correct that number if it is not 
right, but I think that is right. That is a sizable number. 
Could you explain to me why if Obamacare is working so well, so 
many of my colleagues are racing to go change it and offer a 
new approach in the form of Medicare for All, particularly 
after we were promised the ACA wasn't a path to a universal 
coverage kind of position? Thank you.
    Chairman Cummings. Your time has expired. You may briefly 
answer the question.
    Mr. Balat. I don't know that I could explain for them. 
However, it does seem as if they are abdicating their support 
of the ACA by going to this plan. It is a show that the current 
plan does not currently meet the needs of the people of this 
country.
    Chairman Cummings. Ms. Lawrence.
    Mrs. Lawrence. Thank you, Mr. Chair. I want to start by 
saying this meeting is not about Medicare for All, and as hard 
as others have tried, we are not going to dilute this debate. I 
want to thank my chair for holding this hearing.
    The ACA has increased access to care for every stage of 
children's lives, beginning with improved access to maternity 
care for better health outcomes for children. As the co-chair 
of the congressional Caucus on Women Issues and the 
congressional Caucus on Foster Youth, I firmly believe that the 
well-being of our country's children is of great importance. 
Thanks to the ACA, the insurers are no longer able to deny 
coverage for maternity care and treat pregnancy as a 
preexisting condition.
    I would like to ask unanimous consent to enter into the 
record a letter from the March of Dimes highlighting how 
important the ACA is to the health of children and women.
    Chairman Cummings. Without objection, so ordered.
    Mrs. Lawrence. Thank you, Mr. Chair. The letter notes that 
before the ACA, women with high-risk pregnancies could be 
unable to afford medical help for the rest of the year, and 
babies born pre-term ``exhaust a lifetime cap before the first 
birthday.'' Mr. Isasa, how did the ACA preexisting conditions 
protections on annual or lifetime limits change the health 
outcomes of such individuals?
    Mr. Isasi. Absolutely. It is one of the most critical 
protections in the Affordable Care Act, and really importantly, 
this is not just for people buying coverage in the marketplace. 
This is for all of us. For most Americans who are getting 
coverage through their employers, the ACA banned the ability of 
those insurers, the ones that your employers are enrolling 
with, from limiting, putting lifetime or annual caps [on]. In 
particular for moms who are giving birth to babies with complex 
healthcare needs, they could exhaust their entire benefit for 
their lifetime in a matter of just a few months.
    Mrs. Lawrence. And just for the record, America and 
everyone listening, the United States of America is leading in 
maternal mortality. That is women dying in childbirth. The fact 
that we are having a discussion, and if you want to say it is 
insurance, you can't discuss insurance if you are not talking 
about healthcare and healthcare lives. So, Professor, if the 
Trump Administration prevails in court, what would happen to 
these requirements?
    Ms. Gluck. Well, all of those caps would be put back in 
place, meaning lifetime caps, annual caps, no caps on out-of-
pocket maximums. You would also have a return to a time in 
which insurers could refuse to insure you for maternity care.
    Mrs. Lawrence. Before the ACA, only 13 percent of plans, 
when life was good before the ACA, covered maternity care, and 
women in 11 state capital cities couldn't purchase maternity 
coverage. Until something changes, the only way that we can 
continue as a human race is through birth and pregnancies, and 
it is an insult for us not to provide the care for women who 
are giving birth. Now Mr. Isasa, is that correct, that insurers 
are now required to cover preventive services, including 
maternal health visits, without cost savings? Is that correct?
    Mr. Isasi. That is exactly right.
    Mrs. Lawrence. Ms. Burton, you talked about being a mom, 
four beautiful children. Before ACA, you were uninsured for 
years, except for when you briefly qualified for Medicare 
during your pregnancy. How important was it for your health as 
a mother with a preexisting health condition and the health of 
your daughter to have insurance during that time?
    Ms. Burton. It was critical. As I mentioned previously, all 
of my children, all four of them, were born via Cesarean. So if 
I wouldn't have had the insurance to be able to cover that, I 
still wouldn't have come from under those bills. I have had 
very high-risk pregnancies that were very difficult, and it is 
utterly necessary that I am there to be able to take care of my 
children. It is not enough to just have them. I have got to 
raise them and take care of them.
    Mrs. Lawrence. Exactly. So my closing comment is that when 
we talk about ACA, we are talking about, for me, such a passion 
I have for children and women and pregnancy, that we not allow 
this shade of saying it is ineffective and it can't happen 
because of the women, protecting them. In this country to say 
that we are leading and women are dying in pregnancy, this is a 
way for us to address that and reverse those trends. I yield 
back. Thank you so much.
    Chairman Cummings. Thank you very much. Ms. Ocasio-Cortez.
    Ms. Ocasio-Cortez. Thank you, Mr. Chair. You know, there 
has been a lot of talk today about how improving healthcare 
opportunities for American families will lead to all sorts of 
dystopian outcomes, right? There is this idea that we are going 
to be rationing care. So I am curious for those of us here, to 
raise their hand if you have been uninsured in your life.
    [Hands raised.]
    Ms. Ocasio-Cortez. Keep your hand raised, and also raise 
your hand if you have been insured, but your deductible was 
exceedingly expensive.
    [Hands raised.]
    Ms. Ocasio-Cortez. So you rarely went to the doctor or got 
care that you needed. Thank you. I have been there, too. I was 
uninsured less than a year ago. I was uninsured seven months 
ago. So I want folks to raise their hand again, because I know 
what being uninsured is like. It is not just a financial issue. 
It is the stress and it is the anxiety when you wake up every 
morning and you don't know if you are going to slip on a curb, 
if you are going to find something on your body that you want 
to get checked out, if your knee starts to ache. Everything 
becomes a spiral of anxiety because you don't know how you are 
going to afford it.
    So when we talk about rationing care in a for-profit 
healthcare system with no guardrails, where it is the Wild 
West, where you are allowed to profiteer off of insulin, off of 
people's lives, how many of you in your time of being uninsured 
or having healthcare that was too expensive delayed getting a 
prescription or delayed going to the doctor?
    [Hands raised.]
    Ms. Ocasio-Cortez. So you rationed your own care. Is that 
correct, Ms. Burton?
    Ms. Burton. Yes, absolutely.
    Ms. Ocasio-Cortez. The cost of a for-profit insurance 
company forced you to ration your own care, correct?
    Ms. Burton. Absolutely.
    Ms. Ocasio-Cortez. I know exactly what that is like. I 
rationed my own healthcare for 10 years. I was on a self-
imposed wait list for 10 years, not going to an orthopedist 
when my knee hurt, not going to seek mental healthcare or 
counseling when my father died, all of those things. You know, 
what you shared with us, what you had the courage to share with 
us, Ms. Burton, about your miscarriage, about the fact that you 
had a miscarriage in the middle of an emergency room, and you 
said you were uninsured in that time, right?
    Ms. Burton. That is correct.
    Ms. Ocasio-Cortez. You were uninsured, so you miscarried in 
an emergency room, and you never were able to get the followup 
care that you needed. You never knew what happened to your 
baby, correct?
    Ms. Burton. That is correct.
    Ms. Ocasio-Cortez. Because insurance was too expensive, 
correct?
    Ms. Burton. That is correct.
    Ms. Ocasio-Cortez. Because CEOs needed to offer a profit 
margin, correct?
    Ms. Burton. Correct.
    Ms. Ocasio-Cortez. This right here is a complete, complete 
condemnation of the for-profit healthcare insurance industry 
because while they are talking about how socialized medicine, 
how a public guarantee to the right to healthcare will force us 
to ration care, we are rationing our own care. We are not 
talking about months-long waiting lists under the system we 
have now. We are talking about years-long waiting lists for the 
system that we have now.
    I will move on quickly. A key part of the ACA, Mr. Isasi, 
is Medicaid expansion, correct?
    Mr. Isasi. Yes.
    Ms. Ocasio-Cortez. Medicaid expansion allows people of 
lower incomes to essentially get covered by Medicaid, correct?
    Mr. Isasi. The very most vulnerable people in this country.
    Ms. Ocasio-Cortez. And that is a core part of the 
Affordable Care Act.
    Mr. Isasi. Correct.
    Ms. Ocasio-Cortez. Now there are some states that have not 
opted into this expansion.
    Mr. Isasi. That is right.
    Ms. Ocasio-Cortez. I have looked in some of these states. 
The states that have chosen to not cover, to not expand care to 
our lower-income Americans, Americans that are most vulnerable 
include Alabama. Is that correct, Mr. Isasi?
    Mr. Isasi. That is correct.
    Ms. Ocasio-Cortez. Florida?
    Mr. Isasi. That is correct.
    Ms. Ocasio-Cortez. Kansas?
    Mr. Isasi. That is correct.
    Ms. Ocasio-Cortez. Mississippi?
    Mr. Isasi. That is correct.
    Ms. Ocasio-Cortez. Missouri?
    Mr. Isasi. Correct.
    Ms. Ocasio-Cortez. North Carolina?
    Mr. Isasi. Correct.
    Ms. Ocasio-Cortez. South Carolina?
    Mr. Isasi. Correct.
    Ms. Ocasio-Cortez. Oklahoma?
    Mr. Isasi. Correct.
    Ms. Ocasio-Cortez. South Dakota?
    Mr. Isasi. Correct.
    Ms. Ocasio-Cortez. Tennessee?
    Mr. Isasi. Correct.
    Ms. Ocasio-Cortez. Texas?
    Mr. Isasi. Correct.
    Ms. Ocasio-Cortez. Wisconsin?
    Mr. Isasi. Correct.
    Ms. Ocasio-Cortez. Wyoming.
    Mr. Isasi. Correct.
    Ms. Ocasio-Cortez. These are the states that have chosen 
not to cover the most vulnerable Americans, correct?
    Mr. Isasi. That is right.
    Ms. Ocasio-Cortez. And these are the states that are also, 
we are seeing a lot of their representation trying to combat 
the ACA when they are not even buying into it to protect their 
own, correct?
    Mr. Isasi. We are talking about 2.5 million people who 
don't have coverage because they have not expanded Medicaid.
    Ms. Ocasio-Cortez. Why do you think they are doing that?
    Mr. Isasi. Well, you know, I used to work with the 
Governors on this very question. And the truth to that answer 
is because it was tainted as Obamacare, and it was a completely 
political decision.
    Ms. Ocasio-Cortez. So people are not getting insurance in 
these states for political reasons. That is your testimony?
    Mr. Isasi. Absolutely.
    Ms. Ocasio-Cortez. Thank you very much.
    Chairman Cummings. Thank you. And, Ms. Ocasio-Cortez, 
people are dying and getting sick. I will now go to Mr. Gosar.
    Mr. Gosar. Thank you, Mr. Chairman. Mr. Balat, you are from 
Texas, right?
    Mr. Balat. I am.
    Mr. Gosar. Are you familiar with federally qualified health 
centers?
    Mr. Balat. I am.
    Mr. Gosar. Now let me review. My understanding is it is 
first-come, first-served. You are seen on any basis, and your 
requirement for payment is a sliding-fee scale. Is that true?
    Mr. Balat. That is correct.
    Mr. Gosar. So technically, there is coverage for these 
populations.
    Mr. Balat. Yes, sir.
    Mr. Gosar. Hmm, interesting. So let me ask you another 
thing. You know, I have heard a number of things today in 
regards to the ACA. Who are the three groups that actually 
benefited from the ACA? Let me explain: big hospitals, the 
insurance industry, and pharmaceuticals. In fact, if you 
invested prior to the ACA in all those, you are a very wealthy 
individual, because one of the things we have overlooked is the 
lack of competition. We incentivized the insurance industry to 
gobble each other up, so you have regional monopolies. Then we 
had no competition in regards to the hospitals. Then what we 
had is a blow out in the pharmaceutical industry, so there are 
some common denominators here. Now I also know that we had a 
conversation about the VA.
    Mr. Balat. Mm-hmm.
    Mr. Gosar. And I am very astute about that. I am from 
Arizona, so the veterans that were dying were in my state. I 
also represent and have represented over 85 percent of the 
geography of Arizona, so a lot of rural areas, okay? And it was 
the implementation of the Choice Program that has actually 
saved us.
    Mr. Balat. Yes.
    Mr. Gosar. So that it actually helps those members that are 
out in the rural areas to pick and choose those providers, so 
it makes a big difference. Can you elaborate a little bit more 
in regards to the Veterans Administration as a single payer 
type apparatus, and why it is insufficient for the veterans?
    Mr. Balat. I can. I also serve as the chairman of a 
veterans charity. We build specially adapted housing for 
disabled veterans, and I have quite a few connections to the 
veteran community. I don't hear a lot of positive things about 
the VA. Talk about rationing. Talk about long wait lines. There 
was a time when I have seen veterans in their homes that have 
said my PTSD is so bad, I can't even come out the front door. 
It took him five minutes just to talk to me, but the only 
reason he came out to talk to me was to say we need to fix the 
VA.
    So they are a wonderful example of what a single payer 
would look like. You have got limited choices. You have got 
long wait lines. The care in many cases is good, but getting to 
it is often difficult. And what does it matter if you have the 
access if you don't have it until after something catastrophic 
happens, or until you have been living with pain for months and 
months and sometimes years? So, yes, it is problematic. It is 
very similar to how some of these other industrialized 
countries operate, and that is not what I would want for the 
people of this Nation.
    Mr. Gosar. Yes, sir. Now in getting back to pursuing how do 
we take care of people, one of the biggest problems, and just 
for clarity here, by the way, I was a dentist in a previous 
life, so I know a little bit about the healthcare industry. I 
was no fan of what was prior to Obamacare, and I am no fan of 
Obamacare.
    Mr. Balat. Nor was I.
    Mr. Gosar. I think there is something else. But my point is 
something has gone awry here, and the problem is that there are 
no real gatekeepers. We put them out of business. That would be 
primary care physicians. Isn't that true?
    Mr. Balat. Oh, yes.
    Mr. Gosar. So to stay in practice, you basically have to 
sell your soul to a hospital in order to stay in general 
practice.
    Mr. Balat. That is the unfortunate case. More than 50 
percent of all our primary care physicians are currently 
employed by hospital systems.
    Mr. Gosar. So now, I also heard today in the conversation 
that we are providing healthcare for all sorts of individuals 
coming here illegally. And at the same time what we are doing 
is we are actually stealing their well-educated people for 
medicine for their doctors, are we not? A lot of our physicians 
coming here are from overseas because nobody from the United 
States is really going into that discipline.
    Mr. Balat. It is becoming less and less, but we have also 
contributed to that problem as a government because even in 
this country, those that are coming out of medical school, we 
don't have the residency spots for them.
    Mr. Gosar. Yes, I want to yield the rest of my time to the 
gentleman from Texas.
    Chairman Cummings. He doesn't have any time.
    Mr. Gosar. Okay.
    Chairman Cummings. We are at the end of this hearing, but I 
have just a few questions. I have not asked questions. Before I 
conclude today's hearing, I would like to enter into the record 
six letters the committee has received in recent days, 
including submissions from the Little Lobbyists, the National 
Partnership for Women and Families, the National Women's Law 
Center, and the Veterans Health and Advocate Sergeant Edward 
Corcoran. All of these letters express concern about the grave 
impact that the Trump Administration's position in the Texas 
lawsuit could have on millions of Americans and the U.S. 
healthcare system. I ask unanimous consent.
    It is so ordered.
    Chairman Cummings. You know, as I sit here and I listen to 
all of this, I ask myself, Mr. Isasi, first of all, healthcare 
costs are going to go up no matter what. Am I right?
    Mr. Isasi. Absolutely.
    Chairman Cummings. I have for at least seven years been 
fighting with many of my colleagues to bring down the cost of 
prescription drugs. How much does that play in the cost of 
healthcare going up?
    Mr. Isasi. The cost that we see in premium increases are 
mostly because of the prices being paid for what the people 
get. So if prescription drugs go up in price, premiums go up. 
If hospital prices go up, premiums go up. That is what drives 
the vast majority of price increases in health insurance.
    Chairman Cummings. No doubt about it.
    Mr. Isasi. No doubt about it whatsoever.
    Chairman Cummings. Wow. So it is very difficult, as you 
probably know, to get the Congress to move in a direction of 
reducing the cost of drugs, prescription drugs. Matter of fact, 
my first and only meeting with the President was just about 
that subject. That was two years ago, and the price of 
prescription drugs has gone up, not come down.
    So, but, you know, the thing that I am sitting here 
thinking, I have listened to Mr. Balat. You will never convince 
me that the ACA is perfect, but nor can you convince me that it 
could not be fixed so that it is most effective and efficient 
and so that we are covering our people in this country. Would 
you agree with that?
    Mr. Isasi. A hundred percent.
    Chairman Cummings. We could do it.
    Mr. Isasi. Absolutely. We could make coverage more 
affordable. We could increase subsidies for people who are 
higher on the income scale who are suffering right now because 
there is not support for them. There are a lot of things we 
could do to really strengthen and make the ACA a much more 
effective program. No question.
    Chairman Cummings. There does seem to be a stream in some 
of the questioning that sort of blames the victim. I don't like 
that word, but the person who is going through some difficulty, 
as if to say, oh, it is your fault. Well, I can tell you I was 
fine. I could walk just like you could a-year-and-a-half ago. 
Now I can't walk without a walker. That was overnight, 
literally.
    And as I am sitting here and I am listening to our patient 
advocates, our patient folks, consumers, you know, I was 
thinking, I think, and, God forbid, if more people went through 
some of the stuff or had family members that went through what 
you have gone through, perhaps they would have a different 
perspective. There is nothing like suffering. There is nothing 
like being disabled. There is nothing like having your life 
change overnight. There is nothing like taking two hours to get 
dressed. Come on now. There is nothing like sharing your pain.
    The idea that you would come here, and the stories that you 
have told are so personal, but you are willing to share them 
with the world to make somebody else's life better. In some 
kind of way, there is something in here that I think we are 
missing, and I think President Obama said it best. He said we 
have in our country quite often an empathy deficit. An empathy 
deficit. So some kind of way, we got to get around to making 
sure that all people are taken care of. It almost feels like we 
are saying, well, I can't help you because I got to help this 
person. Well, I believe that we can help all of us if we have 
the will, and it can be an effective and efficient system, and 
one that will work for all Americans.
    Now we talk about the rising healthcare costs. We should be 
talking about ways to ensure that all Americans have access to 
affordable healthcare. But we need to remember how far we have 
come under the Affordable Care Act, especially in the 
individual market. Mr. Isasi, I would like to ask you about the 
individual market which you described in your written testimony 
as I quote, ``terrible,'' prior to the ACA, but now ``much, 
much better'' thanks to the Affordable Care Act. Before the 
ACA, you state that 60 percent of consumers in the individual 
market found it ``very difficult or impossible to find 
affordable insurance. Now the Affordable Care Act has cut that 
number down to 34 percent, and more consumers are finding the 
coverage they need, so more consumers are buying insurance.'' 
Sir, isn't it a measure of success that more people are able to 
afford the coverage they need under the Affordable Care Act?
    Mr. Isasi. Absolutely, and more people are spending their 
own money to buy health insurance under the ACA as well.
    Chairman Cummings. One of the things that has happened in 
my district and in our state of Maryland, when the Trump 
Administration pulled away the Navigator money, do you know who 
did the navigating? The Members of Congress. Do you know why? 
Because we didn't want people to have an opportunity that they 
did not know about. If you don't know about an opportunity, you 
might as well not have it. We spent hours upon hours trying to 
get the word out, the deadlines and all that kind of thing, so 
that people could be insured.
    Mr. Isasi. And, you know, Chairman, by the way, that is 
also one of the most effective ways to bring premiums down, to 
get everyone to participate. We have seen that in 
Massachusetts. We have seen that in California.
    Chairman Cummings. No doubt about it. Wow. So let me just 
say this. My Republican colleagues have claimed that the ACA 
has made insurance coverage unaffordable. As Mr. Isasi has 
pointed out, the opposite is true. Before today's hearing, the 
committee received a letter from the Pennsylvania Insurance 
Department commissioner, Jessica Altman. In this letter, 
Commissioner Altman describes how the Administration's position 
in the Texas lawsuit would create chaos in the market, 
resulting in higher premiums and out-of-pocket costs for 
consumers in Pennsylvania and across the country. I request 
that this be made a part of the record.
    Without objection, so ordered.
    Chairman Cummings. If my colleagues were serious about 
making coverage more affordable for the American people, they 
will condemn the Administration's actions.
    I am going to conclude the hearing, but I, again, want to 
thank you. I want to thank all of you for being here, and I 
especially want to thank our consumers. There is something 
about pain. There is something about it is a driving force. As 
I have said in other hearings, when bad things happen to you, 
do not ask the question of why did it happened to me, but why 
did it happen for me. And in this instance, why did it happen 
for the people of the United States? I want you to keep those 
words in mind, those three words: pain, passion, purpose. Do 
you have something to say, Mr. Roy?
    Mr. Roy. I thank the chairman. I just wanted to also thank 
the witnesses, all of you, for your time. It is has been a good 
length hearing, and thank you for taking the time. Those of you 
who have been battling illnesses, your testimony, I appreciate 
it. I am a cancer survivor. There are a lot of people on this 
committee who have been afflicted with illnesses and dealing 
with it. And the chairman is right, this is something about 
which we should be able to agree more. We do have different 
perspectives on how to address making sure that everybody can 
afford high-quality healthcare, but I appreciate all of you all 
coming here and testifying on behalf of the entire committee, 
and including those in the minority. Thanks to the chairman.
    Chairman Cummings. Thank you very much.
    [Whereupon, at 1:55 p.m., the committee was adjourned.]

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