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

                         PROPOSALS TO ACHIEVE UNIVERSAL
                              HEALTHCARE COVERAGE

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

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                               DECEMBER 10, 2019

                                   __________

                               Serial No. 116-84

          Printed for the use of the Committee on Energy and Commerce
                       govinfo.gov/committee/house-energy
                            energycommerce.house.gov

                                 __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    44-546 PDF                  WASHINGTON : 2023

    -----------------------------------------------------------------------------------

                        COMMITTEE ON ENERGY AND COMMERCE

                         FRANK PALLONE, Jr., New Jersey
                                     Chairman

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

                               Professional Staff

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

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

                                  ----------
                                                                       Page
    Hon. Anna G. Eshoo, a Representative in Congress from the State
      of California, opening statement...............................     1
        Prepared statement...........................................     2
    Hon. Michael C. Burgess, a Representative in Congress from the
      State of Texas, opening statement..............................     3
        Prepared statement...........................................     5
    Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, opening statement.........................     6
        Prepared statement...........................................     8
    Hon. Greg Walden, a Representative in Congress from the State of
      Oregon, opening statement......................................     9
        Prepared statement...........................................    11

                                   Witnesses

    Hon. Rosa L. DeLauro, a Representative in Congress from the State
      of Connecticut.................................................    12
        Prepared statement...........................................    15
    Hon. Pramila Jayapal, a Representative in Congress from the State
      of Washington..................................................    21
        Prepared statement...........................................    24
    Hon. Brian Higgins, a Representative in Congress from the State
      of New York....................................................    29
        Prepared statement...........................................    31
    Hon. Antonio Delgado, a Representative in Congress from the State
      of New York....................................................    33
        Prepared statement...........................................    35
    Hon. Tom Malinowski, a Representative in Congress from the State
      of New Jersey..................................................    37
        Prepared statement...........................................    39
    Sara Rosenbaum, Harold and Jane Hirsch Professor, Health Law and
      Policy, George Washington University Department of Health
      Policy and Management..........................................    42
        Prepared statement...........................................    44
        Answers to submitted questions...............................   280
    Peter Morley, Patient Advocate...................................    53
        Prepared statement...........................................    55
        Answers to submitted questions...............................   284
    Jean Ross, R.N., President, National Nurses United...............    67
        Prepared statement \1\
        Answers to submitted questions...............................   293
    Douglas Holtz-Eakin, Ph.D., President, American Action Forum.....    68
        Prepared statement...........................................    71
        Answers to submitted questions...............................   293

    ----------

    \1\ Ms. Ross' prepared statement has been retained in committee files
    and also is available at https://docs.house.gov/meetings/IF/IF14/
    20191210/110313/HHRG-116-IF14-Wstate-RossJ-20191210.pdf.
    Scott W. Atlas, M.D., David and Joan Traitel Senior Fellow,
      Hoover Institution, Stanford University........................    76
        Prepared statement \2\
        Answers to submitted questions \3\                              294

                               Submitted Material

    H.R. 584, the Incentivizing Medicaid Expansion Act of 2019,
      submitted by Ms. Eshoo\4\
    H.R. 1277, the State Public Option Act, submitted by Ms. Eshoo\4\
    H.R. 1346, the Medicare Buy-In and Health Care Stabilization Act
      of 2019, submitted by Ms. Eshoo\4\
    H.R. 1384, the Medicare for All Act of 2019, submitted by Ms.
      Eshoo\4\
    H.R. 2000, the Medicare-X Choice Act of 2019, submitted by Ms.
      Eshoo\4\
    H.R. 2085, the Consumer Health Options and Insurance Competition
      Enhancement (CHOICE)Act, submitted by Ms. Eshoo\4\
    H.R. 2452, the Medicare for America Act of 2019, submitted by Ms.
      Eshoo\4\
    H.R. 2463, the Choose Medicare Act, submitted by Ms. Eshoo\4\
    H.R. 4527, the Expanding Health Care Options for Early Retirees
      Act, submitted by Ms. Eshoo\4\
    Statement of Randy Albelda, Professor of Economics, University of
      Massachusetts Boston, et al., November 19, 2019, submitted by
      Mr. Engel......................................................   115
    Article of November 13, 2019, ``Health Reform's North Star: 10
      Guidelines to Reach Universal Health Care Coverage,'' by
      Jamilia Taylor and Jen Mishory, The Century Foundation,
      submitted by Ms. Eshoo.........................................   124
    Report of The Century Foundation, ``Road to Universal Coverage:
      Addressing the Premium Affordability Gap,'' by Jen Mishory and
      Katie Keith, September 18, 2019, submitted by Ms. Eshoo........   129
    Letter of December 10, 2019, from Advocates for Youth, et al., to
      House Committee on Energy and Commerce, submitted by Ms. Eshoo.   136
    Letter of July 10, 2019, from A. Philip Randolph Institute, et
      al., to Members of Congress, submitted by Ms. Eshoo............   139
    Letter of December 9, 2019, from Patrick Yoes, National
      President, National Fraternal Order of Police, to Ms. Eshoo and
      Mr. Burgess, submitted by Ms. Eshoo............................   142
    Letter of December 10, 2019, from Harold A. Schaitberger, General
      President, International Association of Fire Fighters, to Rep.
      Tom Malinowski, submitted by Ms. Eshoo.........................   144
    Letter of December 10, 2019, from Mary R. Grealy, President,
      Healthcare Leadership Council, to Mr. Pallone and Mr. Walden,
      submitted by Ms. Eshoo.........................................   145
    Letter of December 10, 2019, from Ingrida Lusis, Vice President,
      Policy and Government Affairs, American Nurses Association, to
      Ms. Eshoo and Mr. Burgess, submitted by Ms. Eshoo..............   148
    Statement of Representative Cedric L. Richmond, December 10,
      2019, submitted by Ms. Eshoo...................................   149
    Statement of the Texas Hospital Association by John Hawkins,
      Senior Vice President of Advocacy and Public Policy, December
      9, 2019, submitted by Mr. Burgess..............................   151
    Statement of the American Hospital Association, December 10,
      2019, submitted by Mr. Burgess.................................   152
    Letter of October 11, 2019, from Paul Hardin, President and Chief
      Executive Officer, Texas Food and Fuel Association, to Mr.
      Burgess, submitted by Mr. Burgess..............................   157
    Letter of April 29, 2019, from Carol Tobias, President, National
      Right to Life, to Representatives, submitted by Mr. Shimkus....   159
    Letter of April 29, 2019, from Thomas McClusky, President, March
      for Life Action, to Representatives, submitted by Mr. Shimkus..   162

    ----------

    \2\ Dr. Atlas' prepared statement has been retained in committee files
    and also is available at https://docs.house.gov/meetings/IF/IF14/
    20191210/110313/HHRG-116-IF14-Wstate-AtlasS-20191210.pdf.
    \3\ Dr. Atlas did not answer submitted questions for the record by the
    time of printing.
    \4\ The proposed legislation has been retained in committee files and
    also is available at https://docs.house.gov/Committee/Calendar/
    ByEvent.aspx?EventID=110313.
    Letter of October 28, 2019, from Leanne Gassaway, Senior Vice
      President, State Affairs and Policy, America's Health Insurance
      Plans, to Executive Director Kim Bimestefer, Colorado
      Department of Health Care Policy and Financing, and
      Commissioner of Insurance Michael Conway, Colorado Division of
      Insurance, submitted by Mr. Griffith...........................   164
    Letter of March 7, 2019, from America's Health Insurance Plans to
      Senate Chairman Matt Lesser and House Chairman Sean Scanlon,
      Connecticut Insurance and Real Estate Committee, submitted by
      Mr. Griffith...................................................   171
    Letter of May 1, 2019, from Leanne Gassaway, Senior Vice
      President, State Affairs, America's Health Insurance Plans, to
      Jay Inslee, Governor of Washington, submitted by Mr. Griffith..   175
    Letter of March 13, 2019, from Stephanie Berry, Regional
      Director, State Affairs, America's Health Insurance Plans, to
      Representative Andrea Salinas, State of Oregon , submitted by
      Mr. Griffith...................................................   177
    Letter of January 30, 2019, from Stephanie Berry, Regional
      Director, State Affairs, America's Health Insurance Plans, to
      Representative Eileen Cody and Senator David Frockt, State of
      Washington, submitted by Mr. Griffith..........................   181
    Letter of September 26, 2018, from Sara Orrange, Regional
      Director, State Affairs, America's Health Insurance Plans, to
      Legislative Health & Human Services Committee, New Mexico State
      Legislature, submitted by Mr. Griffith.........................   186
    Summary, WA SB 5526: Cascade Care, America's Health Insurance
      Plans, submitted by Mr. Griffith...............................   190
    Statement of the Blue Cross Blue Shield Association, December 10,
      2019, submitted by Mr. Griffith................................   192
    Letter of March 18, 2019, from Neil L. Bradley, Executive Vice
      President and Chief Policy Officer, Chamber of Commerce of the
      United States of America, to Members of the House of
      Representatives, submitted by Mr. Griffith.....................   198
    Report, Partnership for America's Health Care Future, submitted
      by Mr. Griffith................................................   199
    Memo of May 20, 2019, from Lauren Crawford Shaver, Partnership
      for America's Health Care Future, submitted by Mr. Griffith....   211
    Letter of December 9, 2019, from Lauren Crawford Shaver,
      Executive Director, Partnership for America's Health Care
      Future, to Ms. Eshoo and Mr. Burgess, submitted by Mr. Griffith   215
    Fact sheet, ``Explaining The Facts on Medicare For All,''
      Partnership for America's Health Care Future, submitted by Mr.
      Griffith.......................................................   217
    Statement, ``Medicare Buy-In, Public Option Proposals Would Harm
      Our Health Care System,'' Partnership for America's Health Care
      Future, submitted by Mr. Griffith..............................   221
    Statement, ``Medicare For All Means Layoffs,'' Partnership for
      America's Health Care Future, submitted by Mr. Griffith........   225
    Statement, ``Medicare For All Was `Spectacular Failure' &
      `Financial Train Wreck' In Vermont,'' Partnership for America's
      Health Care Future, submitted by Mr. Griffith..................   229
    Membership list, Partnership for America's Health Care Future,
      submitted by Mr. Griffith......................................   232
    Statement, ``Public Option `Could Be Plenty Disruptive,'''
      Partnership for America's Health Care Future, submitted by Mr.
      Griffith.......................................................   237
    Statement, ``Public Option Limits Patient Choice,'' Partnership
      for America's Health Care Future, submitted by Mr. Griffith....   240
    Memo of July 30, 2019, ``Under Sanders's Medicare For All,
      Americans Would Pay More To Wait Longer For Worse Care,''
      Partnership for America's Health Care Future, submitted by Mr.
      Griffith.......................................................   242
    Statement of the Partnership for Employer-Sponsored Coverage,
      December 10, 2019, submitted by Mr. Griffith...................   246
    Statement, ``The Medicare for All Act of 2019 Presents Grave
      Life, Conscience Protection, and Religious Liberty Concerns,''
      The Ethics & Religious Liberty Commission of the Southern
      Baptist Convention, submitted by Mr. Griffith..................   247
    Letter of December 9, 2019, from Marjorie Dannenfelser,
      President, Susan B. Anthony List, to Representatives, submitted
      by Mr. Griffith................................................   248
    Statement of the American Action Forum, ``Is a Medicare Buy-In
      Plan Viable?,'' by Christopher Holt, November 15, 2019,
      submitted by Mr. Griffith......................................   249
    Report prepared for the American Hospital Association and the
      Federation of American Hospitals, ``The Impact of Medicare-X
      Choice on Coverage, Healthcare Use, and Hospitals,'' by KNG
      Health Consulting LLC, March 12, 2019, submitted by Mr.
      Griffith \5\
    Report of the Committee for a Responsible Federal Budget,
      ``Choices for Financing Medicare for All: A Preliminary
      Analysis,'' October 28, 2019, submitted by Mr. Griffith........   251
    Report of The Heritage Foundation, ``How `Medicare for All' Harms
      Working Americans,'' by Edmund F. Haislmaier and Jamie Bryan
      Hall, November 19, 2019, submitted by Mr. Griffith \6\
    Report of the Mercatus Center at George Mason University, ``The
      Costs of a National Single-Payer Healthcare System,'' by
      Charles Blahous, July 2018, submitted by Mr. Griffith \7\
    Memo from Lauren Crawford Shaver, Partnership for America's
      Health Care Future, December 9, 2019, submitted by Mr. Griffith   261
    Statement, ``New Poll: Vast Majority Satisfied With Current
      Health Care Coverage,'' Partnership for America's Health Care
      Future, submitted by Mr. Griffith..............................   263
    Article, ``Pelosi: ObamaCare could `be path to Medicare for
      All,''' by Rachel Frazin, The Hill, December 6, 2019, submitted
      by Mr. Griffith................................................   265
    Article, ``Biden and Buttigieg say you can keep your health-care
      plan. They're lying--just like Obama,'' by Marc A. Thiessen,
      The Washington Post, December 3, 2019, submitted by Mr.
      Griffith.......................................................   266
    Statement, ``By The Numbers: The Devastating Costs of the
      Democrats' Proposed Government Takeover of Your Healthcare,''
      Blue Cross Blue Shield Association, submitted by Mr. Griffith..   268
    Statement, ``The Medicare for All Act of 2019: HR 1384,''
      Congressional Pro-Life Caucus, submitted by Mr. Griffith.......   270
    Statement, ``House Dem Campaign Chief On Medicare For All: `Hard
      To Conceive How That Would Work' & Price Tag `A Little
      Scary,''' Partnership for America's Health Care Future,
      submitted by Mr. Griffith......................................   272
    Mission statement, Partnership for America's Health Care Future,
      submitted by Mr. Griffith......................................   273
    Statement, ``CRFB: Medicare For All `Would Mean ... Tripling
      Payroll Taxes Or More Than Doubling All Other Taxes,'''
      Partnership for America's Health Care Future, submitted by Mr.
      Griffith.......................................................   274
    Statement, ``Exploring The Effects Of The Public Option On
      America's Health Care System,'' Partnership for America's
      Health Care Future, submitted by Mr. Griffith..................   275
    Statement, ``Examining The Impact Of The Public Option On Rural
      Health Care,'' Partnership for America's Health Care Future,
      submitted by Mr. Griffith......................................   276
    Statement, ``Assessing Medicare for America,'' Partnership for
      America's Health Care Future, submitted by Mr. Griffith........   277
    Statement, ``Understanding Medicare-X Choice,'' Partnership for
      America's Health Care Future, submitted by Mr. Griffith........   278
    Statement, Partnership for Employer-Sponsored Coverage, submitted
      by Mr. Griffith................................................   279

    ----------

    \5\ The report has been retained in committee files and also is
    available at https://docs.house.gov/meetings/IF/IF14/20191210/110313/
    HHRG-116-IF14-20191210-SD013.pdf.
    \6\ The report has been retained in committee files and also is
    available at https://docs.house.gov/meetings/IF/IF14/20191210/110313/
    HHRG-116-IF14-20191210-SD014.pdf.
    \7\ The report has been retained in committee files and also is
    available at https://docs.house.gov/meetings/IF/IF14/20191210/110313/
    HHRG-116-IF14-20191210-SD015-U5.pdf.

               PROPOSALS TO ACHIEVE UNIVERSAL HEALTHCARE COVERAGE

                                  ----------

                           TUESDAY, DECEMBER 10, 2019

                      House of Representatives,
                                Subcommittee on Health,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 10:31 a.m., in
    room 2322, Rayburn House Office Building, Hon. Anna G. Eshoo
    (chairwoman of the subcommittee) presiding.
        Members present: Representatives Eshoo, Engel, Butterfield,
    Matsui, Castor, Sarbanes, Lujan, Schrader, Kennedy, Cardenas,
    Welch, Ruiz, Dingell, Kuster, Kelly, Barragan, Blunt Rochester,
    Pallone (ex officio), Burgess (subcommittee ranking member),
    Shimkus, Guthrie, Griffith, Bilirakis, Long, Brooks, Hudson,
    Carter, Gianforte, and Walden (ex officio).
        Staff present: Jeffrey C. Carroll, Staff Director; Tiffany
    Guarascio, Deputy Staff Director; Zach Kahan, Outreach and
    Member Service Coordinator; Saha Khaterzai, Professional Staff
    Member; Josh Krantz, Policy Analyst; Una Lee, Chief Health
    Counsel; Aisling McDonough, Policy Coordinator; Meghan Mullon,
    Staff Assistant; Kaitlyn Peel, Digital Director; Alivia
    Roberts, Press Assistant; Samantha Satchell, Professional Staff
    Member; Rebecca Tomilchik, Staff Assistant; Rick Van Buren,
    Health Counsel; C.J. Young, Press Secretary; Nolan Ahern,
    Minority Professional Staff Member, Health; Margaret Tucker
    Fogarty, Minority Legislative Clerk/Press Assistant; Theresa
    Gambo, Minority Financial and Office Administrator; Tyler
    Greenberg, Minority Staff Assistant; Peter Kielty, Minority
    General Counsel; Ryan Long, Minority Deputy Staff Director;
    Kate O'Connor, Minority Chief Counsel, Communications and
    Technology; J.P. Paluskiewicz, Minority Chief Counsel, Health;
    Kristin Seum, Minority Counsel, Health; and Kristen Shatynski,
    Minority Professional Staff Member, Health.
        Ms. Eshoo. Good morning, everyone. The Subcommittee on
    Health will now come to order. The Chair now recognizes herself
    for 5 minutes for an opening statement.

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

        And welcome to our colleagues that are at the table and
    everyone that is here in the hearing room.
        Today's hearing features House colleagues who will present
    their legislative proposals to advance what I have always
    called the North Star of the Democratic Party, and that is to
    achieve universal healthcare for the American people. Five
    members are or will be at the witness table. Two
    representatives, Mr. Lujan and Ms. Schakowsky, will speak from
    the committee seats and two others, Representative Cedric
    Richmond and Representative Veasey, are submitting written
    statements.
        Every American should feel secure that, if they get sick or
    if they are hurt, they will receive the care they need without
    going bankrupt. That principle is why President Johnson signed
    Medicare and Medicaid into law, despite the protests at that
    time that it was ``socialized medicine'' and the ``Moscow party
    line.'' Today, Medicare covers 44 million Americans and
    Medicaid covers 75 million Americans.
        Our goal to achieve universal coverage motivated Congress
    to pass the Children's Health Insurance Program in 1997. It is
    why President Obama signed the Affordable Care Act into law in
    2010, which today provides health coverage to more than 20
    million Americans. But we know there is more work to be done to
    achieve universality. During our second panel today, we will
    hear the stories of fellow Americans who live in daily fear
    that they will lose their healthcare because of a decision by
    their employer, their insurer, or this President.
        My hope rises as I see the talented colleagues before us
    who will present their proposals and broaden our thinking. That
    is why I specifically asked each to be here today. My hope
    rises as I look out at doctors, nurses, and patients in the
    audience who have dedicated their lives to achieving quality
    healthcare for every American. Advent is a season of hope and
    an appropriate time for colleagues on both sides of the aisle
    to approach this hearing with open minds and hearts, knowing
    that the goal is to have healthcare for every American.
        Shortly before his death, Senator Ted Kennedy wrote a
    letter to President Obama about health reform and what he
    called ``that great unfinished business of our society.'' He
    wrote, ``What we face is, above all, a moral issue; that at
    stake are not just the details of policy, but fundamental
    principles of social justice and the character of our
    country.'' I think we all need to reflect on that moral issue
    today.
        [The prepared statement of Ms. Eshoo follows:]

                    Prepared Statement of Hon. Anna G. Eshoo

        Today's hearing is historic and hopeful. It continues our
    near century-long work to achieve universal healthcare for the
    American people.
        Every American should feel secure that if they get sick or
    hurt, they will receive the care they need without going
    bankrupt.
        That principle is why President Johnson signed Medicare and
    Medicaid into law despite protests that it was ``socialized
    medicine'' and the ``Moscow party line.''
        Today, Medicare covers 44 million Americans and Medicaid
    covers 75 million Americans.
        Our goal to achieve universal coverage motivated Congress
    to pass the Children's Health Insurance Program in 1997.
        It's why President Obama signed the Affordable Care Act
    into law in 2010, which has provided health coverage to more
    than 20 million Americans.
        But there's more work to be done.
        During our second panel today we will hear stories from
    fellow Americans who live in daily fear that they'll lose their
    healthcare because of a decision by their employer, their
    insurer, or this President.
        It shouldn't be this way. The question is: How to fix it?
        Today, we'll hear nine plans to do just that.
        Those nine plans are why this hearing isn't only historic,
    but hopeful.
        I feel hope looking at my talented colleagues before me who
    will present their proposals.
        It's why I specifically asked you to be here today.
        I feel hope looking at the doctors, nurses, and patients in
    the audience who've dedicated their lives to achieving quality
    healthcare for every American.
        And I feel hope during this Advent season, that my
    colleagues on both sides of the aisle can approach this hearing
    with open minds and hearts knowing that the goal is to ensure
    universal healthcare, including for the most vulnerable among
    us.
        Shortly before his death, Senator Ted Kennedy wrote a
    letter to President Obama about health reform and what he
    called ``that great unfinished business of our society.''
        He wrote, ``What we face is above all a moral issue; that
    at stake are not just the details of policy, but fundamental
    principles of social justice and the character of our
    country.''
        Let us all reflect on that moral issue today.
        I yield the rest of my time to Representative Dingell.

        Ms. Eshoo. I now would like to yield the remainder of my
    time to Congresswoman Dingell.
        Is she here? Not here? Pardon me? She is on her way. Well,
    we are going to move on, because the Chair is now going to
    recognize Dr. Burgess, the ranking member of the subcommittee,
    for his 5 minutes for an opening statement.
        Mr. Burgess. Actually, before I start that, may I ask a
    unanimous consent request, unanimous consent to insert into the
    record the two letters that Mr. Walden and I sent asking for
    this hearing earlier in the year?
        Ms. Eshoo. So ordered.
        [The information appears at the conclusion of the hearing.]
        Mr. Burgess. And also, I am OK with you yielding your final
    minute and a half to Mrs. Dingell when she gets here.
        Ms. Eshoo. Thank you.

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

        Mr. Burgess. So, thank you for leading the hearing.
    Certainly, Mr. Walden and I have requested this, and we
    requested it very early in the year and I appreciate that you
    took our request seriously.
        So, Chairman Pallone and Chairwoman Eshoo stated in
    noticing this hearing that universal healthcare coverage has
    long been the North Star of the Democratic Party. Every bill
    before us today is paving the road to the North Star, if that
    is even possible. The idea is we accomplish one-size-fits-all
    healthcare.
        Another Advent analogy: The Three Wise Men--not quite the
    same, but I am not sure they would appreciate your comparison,
    as this North Star journey would lead our healthcare system as
    we currently know it to disintegrate. If, in fact, we are
    listening to the great philosopher Joni Mitchell, then the
    Northern Star is not very reliable, as it is constantly in the
    dark.
        Medicare for All would eliminate private insurance,
    employer-sponsored health insurance, Medicaid, the Children's
    Health Insurance Program upon which many Americans depend. I am
    concerned about the consequences for existing Medicare
    beneficiaries. The policy would raid the Medicare Trust Fund,
    which is already slated to go bankrupt in 2026. This will not
    help. Our Nation's seniors have been paying into and depending
    upon the existence of Medicare for their healthcare needs in
    retirement for, literally, their entire lives.
        More than 70 percent of Americans are satisfied with their
    employer-sponsored insurance, which does provide robust
    protections. We should focus on strengthening the parts of our
    health insurance markets that are working. However, instead of
    building upon the success of our existing health insurance
    framework, a one-size-fits-all policy would tear it down.
        I also feel obligated to mention, having been in the
    healthcare provider business, the doctor business, coverage
    does not equal care. It never has and never will. Single-payer
    healthcare would be another failed attempt. As a one-size-fits-
    all approach to healthcare, single-payer is in reality not one-
    size-fits-all, it is one-size-fits-no one. Single-payer
    healthcare would cost over $33 trillion for the first 10 years.
    This high price tag would require new tax increases. In fact,
    it would double the currently projected Federal individual and
    corporate income tax collections in order to pay for it,
    according to the Mercatus Center.
        So each and every one of these bills before us today is
    about Medicare for All and the pathway to socialized medicine.
    We have all seen the reports of increased wait times for
    patients in countries like Canada of up to almost 9 weeks for a
    specialist consultation. Hospitals stand to lose billions under
    a Medicare for All plan. The New York Times reported rural
    hospitals saying that they would virtually close overnight,
    while others said that they would try to offset the steep cuts
    by laying off hundreds of thousands of workers and abandoning
    the lower-paying services such as mental health services.
        We simply cannot afford the financial or human suffering
    that would accompany such a misguided policy. It is clear that
    this takeover of even one sector of the healthcare industry we
    are going to be talking about later this week, prescription
    drugs in Speaker Pelosi's H.R. 3 bill--and it would reduce the
    number of new drugs coming to the market--the Congressional
    Budget Office estimated between 8 to 15 new drugs would fail to
    come to the market over the course of the next 10 years. The
    Council of Economic Advisors anticipated as many as a hundred
    drugs. It doesn't matter which figure you use, everyone is in
    agreement that it would reduce new drugs coming that we have
    all wanted through innovation.
        I support commonsense, market-driven improvements to our
    healthcare system. The goal should be to increase access to
    healthcare services and drive down the costs for our patients.
    These universal healthcare coverage bills are all going in the
    wrong direction. In fact, I introduced H.R. 1510, the Premium
    Relief Act of 2019, which does include reinsurance that is
    coupled with a structural reform of the Affordable Care Act.
    This would give States more choice on how to repair their
    markets that have been damaged by previous legislative
    attempts. Even better, this legislation is fully paid for by
    stopping bad actors from gaming the system.
        There are policies that we could work on to get Americans--
    to reduce their cost and complexity of healthcare, but we have
    before us today nine bills that fail to have a single
    Republican cosponsor among them. I am glad we finally are
    having this hearing, Madam Chair. It has been a long time
    coming and certainly something we should have done as we
    started this year. But at the end of the day, I would really
    hope the Energy and Commerce Committee can open the blinds and
    reveal what the North Star really looks like, completely in the
    dark. I yield back.
        [The prepared statement of Mr. Burgess follows:]

                 Prepared Statement of Hon. Michael C. Burgess

        Thank you, Madam Chair. Thank you for holding this hearing
    on various universal heath care coverage proposals, including
    Medicare for All. Ranking Member Walden and I requested a
    hearing on Medicare for All numerous times this year, and I
    appreciate that you took our request seriously enough to hold
    today's hearing. I would like to ask unanimous consent that our
    two letters be included in the record. Coverage does not equal
    care.
        Chairman Pallone and Chairwoman Eshoo stated in noticing
    this hearing that ``universal healthcare coverage has long been
    the North Star of the Democratic Party.'' Every bill before us
    today is paving that road to the North Star--to accomplishing
    one-size-fits-all healthcare coverage.
        I'm not sure the Three Wise Men would appreciate your
    comparison, as this North Star journey would lead our
    healthcare system as we currently know it to disintegrate into
    ashes. If we're listening to Joni Mitchell, then the Northern
    Star is not very reliable as it is constantly in the dark.
        Medicare for All would eliminate private insurance,
    employer-sponsored health insurance, Medicaid, and the
    Children's Health Insurance Plan, upon which many Americans
    depend. I am concerned about the consequences for existing
    Medicare beneficiaries, as this policy would raid the Medicare
    Trust Fund, which is already slated to go bankrupt in 2026. Our
    Nation's seniors have been depending on the existence of
    Medicare for their healthcare needs in retirement for their
    entire lives.
        More than 70 percent of Americans are satisfied with their
    employer-sponsored health insurance, which provides robust
    protections for all individuals. We should be focused on
    strengthening the parts of our health insurance markets that
    are working. However, instead of building upon the successes of
    our existing health insurance framework, a one-size-fits-all
    policy would tear it down.
        Single-payer healthcare would be another failed attempt at
    a one-size-fits-all approach to healthcare. Single-payer is not
    one-size-fits-all, it is really one-size-fits-no-one. Single-
    payer healthcare would cost $32.6 trillion for the first 10
    years of full implementation. This high price tag would require
    new tax increases. In fact, doubling all currently projected
    Federal individual and corporate income tax collections would
    be insufficient to finance Medicare for All, according to the
    Mercatus Center.
        Let me be clear, each and every one of these bills before
    us today is about Medicare for All and the pathway to
    socialized medicine. We have seen reports of increased wait
    times for patients in countries like Canada of up to almost 9
    weeks for a specialist consultation. Hospitals stand to lose
    billions under a Medicare for All plan. The New York Times
    reported rural hospitals saying they would virtually close
    overnight, while others said they would try to offset the steep
    cuts by laying off hundreds of thousands of workers and
    abandoning lower-paying services like mental health. We simply
    cannot afford the financial or human suffering that would
    accompany such misguided policy. To further lay out that
    argument, I would like to request unanimous consent to insert
    statements from the Texas Hospital Association and American
    Hospital Association into the record.
        It is clear that a socialist takeover of even one sector of
    the healthcare industry--prescription drugs--in Speaker
    Pelosi's HR 3, there would be a reduced number of new drugs
    coming to market. The Congressional Budget Office estimated
    between 8-15 new drugs would fail to come to market over the
    course of 10 years.
        Whereas the Council of Economic Advisors anticipated as
    many as 100 drugs would not reach Americans. This is the effect
    of a socialist policy, the ramifications of which would be even
    greater under Medicare for All.
        Evidently, the House Democrats are looking to socialize all
    of medicine and our whole healthcare system.
        While I support commonsense, market-driven improvements to
    our healthcare system that would increase access to healthcare
    services and drive down costs for patients, these universal
    healthcare coverage bills are steps in the wrong direction.
        I introduced HR 1510, the Premium Relief Act of 2019, which
    includes reinsurance that is coupled with a structural reform
    of the Affordable Care Act. This would give states more choice
    on how to repair their markets that have been damaged by
    Obamacare.
        Even better, this legislation is fully paid for by stopping
    bad actors from gaming the system.
        There are many policies that we could work on that would
    get to providing more Americans healthcare coverage; however,
    nine bills that fail to have a single Republican cosponsor
    among them, is not the answer. I am glad we finally had a
    hearing on Medicare for All so the Energy and Commerce
    Committee can open the blinds and reveal what this ``North
    Star'' really looks like to the American people--completely in
    the dark. I yield back.

        Ms. Eshoo. The gentleman yields back. I now would like to
    yield the minute and a half that I want to yield to
    Congresswoman Dingell so that you can make use of the time that
    you asked for.
        Mrs. Dingell. Thank you.
        Today, we have the opportunity to discuss legislation that
    would, once and for all, address the cost and access issues
    that continue to deny millions of Americans the right to
    quality, affordable healthcare. Every member of this committee
    has heard from--and every Member of this Congress--has heard
    from constituents who are fearful and frustrated by our current
    health system. We have received letters and calls from
    individuals who face devastating financial hardship as a result
    of predatory health insurance companies enabled by the current
    system.
        And as I have always said, when I would take John to the
    doctor, it was like holding a town hall. Person after person
    would come up and share their stories that were just--they were
    people that were desperate and scared and needed help. We can
    and must do better. This is the promise of Medicare for All, a
    comprehensive system of coverage that empowers all Americans.
        The Medicare for All of 2019 would provide coverage for all
    Americans, improve traditional Medicare for seniors by offering
    additional benefits at lower cost, and utilizing administrative
    efficiencies and negotiations to bring down prices. This is a
    historic day. I thank you, Madam Chair, for scheduling this
    hearing. We have never had a Medicare for All hearing in this
    committee, and I look forward to discussing this legislation
    further with our distinguished experts today and to keep
    answering questions and giving people the facts as we go
    forward. Thank you, Madam Chair.
        Ms. Eshoo. The Chair now recognizes the chairman of the
    full committee, Mr. Pallone, for his 5 minutes for an opening
    statement.

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

        Mr. Pallone. Thank you, Madam Chair.
        Since the passage of the Affordable Care Act, more than 20
    million Americans have gained the peace of mind that comes from
    knowing that they and their loved ones have health insurance.
    This landmark law resulted in the highest insured rate in our
    Nation's history. It also expanded consumer protections so
    that, no matter where you live or work in the U.S., your family
    would have access to affordable, comprehensive healthcare.
        The ACA ended decades of insurance companies price gouging
    older Americans, charging women more than men, and
    discriminating against people with preexisting conditions. It
    not only prevented health insurance companies from
    discriminating against people with preexisting conditions, it
    also required insurance companies to cover a set of essential
    health benefits like hospitalization, emergency services,
    maternity care, and substance use disorder services. It also
    eliminated annual and lifetime limits on coverage that for
    years had forced people with preexisting conditions into
    bankruptcy. Thanks to the ACA, young Americans can stay on
    their parents' plan until they turn 26.
        The law also expanded Medicaid, which made health insurance
    available to millions of low-income Americans, including many
    with serious and chronic preexisting conditions and unmet
    medical needs. Yet, millions more would be covered today if it
    were not for the continued resistance of Republican Governors
    to the law's Medicaid expansion and the repeated attempts by
    congressional Republicans and the Trump administration to
    undermine and dismantle the law.
        House Republicans voted 69 times to repeal the ACA.
    Luckily, they failed to do so, but they did repeal the law's
    individual mandate, increasing prices for everyone. Meanwhile,
    20 Republican attorneys general and Governors sued the Federal
    Government, challenging the constitutionality of the law. The
    Trump administration has taken the extraordinary position of
    refusing to defend the law in the courts. If the Republicans
    are successful in court, it would cause millions of people to
    lose their health insurance, eliminate protections for people
    with preexisting conditions, and immediately spike healthcare
    costs for all Americans.
        I firmly believe that today we would be very close to
    universal coverage had it not been for the sabotage and for the
    refusal of Republican Governors to expand Medicaid. I also
    believe that, had the final law included the public option as
    supported by the majority of this committee and the House at
    the time, that we would be even closer to universal coverage.
    Now, unfortunately, that is not the case, and millions of
    Americans remain uninsured, particularly in States that have
    refused to expand Medicaid.
        Also, among the uninsured are undocumented immigrants and
    their families. When we drafted the ACA, I worked to include
    the undocumented, but I couldn't get the votes, and I would
    like to know how the various bills before us today would
    address the undocumented. When people get sick, they get other
    people sick, so it makes no sense to exclude any group of
    people regardless of their legal status. And, under the Trump
    administration, the uninsured rate has gone up and American
    families have lost coverage, including hundreds of thousands of
    children. We need to enact policies that include all the
    uninsured, and that is why we are here today.
        The bills we are considering reflect Democrats' continued
    commitment to achieving universal coverage and making
    healthcare more affordable and accessible for all Americans. I
    believe that we must continue to build on the success of the
    ACA until healthcare is truly a right for all Americans, which
    it should be.
        [The prepared statement of Mr. Pallone follows:]

                 Prepared Statement of Hon. Frank Pallone, Jr.

        Since the passage of the Affordable Care Act, more than 20
    million Americans have gained the peace of mind that comes from
    knowing that they and their loved ones have health insurance.
    This landmark law resulted in the highest insured rate in our
    Nation's history. It also expanded consumer protections so
    that, no matter where you live or work in the United States,
    your family would have access to affordable, comprehensive
    healthcare.
        The ACA ended decades of insurance companies price gouging
    older Americans, charging women more than men, and
    discriminating against people with preexisting conditions. It
    not only prevented health insurance companies from
    discriminating against people with preexisting conditions, it
    also required insurance companies to cover a set of essential
    health benefits, like hospitalization, emergency services,
    maternity care, and substance use disorder services. It also
    eliminated annual and lifetime limits on coverage that for
    years had forced people with preexisting conditions into
    bankruptcy.
        Thanks to the ACA, young Americans can stay on their
    parents' plans until they turn 26 years old.
        The law also expanded Medicaid, which made health insurance
    available to millions of low-income Americans, including many
    with serious and chronic preexisting conditions and unmet
    medical needs.
        Yet millions more would be covered today if it were not for
    the continued resistance of Republican Governors to the law's
    Medicaid expansion and the repeated attempts by congressional
    Republicans and the Trump administration to undermine and
    dismantle the law.
        House Republicans voted 69 times to repeal the ACA.
    Luckily, they failed to do so, but they did repeal the law's
    individual mandate, increasing prices for everyone.
        Meanwhile, 20 Republican attorneys general and Governors
    sued the Federal Government, challenging the constitutionality
    of the law. The Trump administration has taken the
    extraordinary position of refusing to defend the law in the
    courts. If the Republicans are successful in court, it would
    cause millions of people to lose their health insurance,
    eliminate protections for people with preexisting conditions,
    and immediately spike healthcare costs for all Americans.
        I firmly believe that today we would be very close to
    universal coverage had it not been for the sabotage and for the
    refusal of Republican Governors to expand Medicaid. I also
    believe that had the final law included the public option, as
    supported by the majority of this committee and the House at
    the time, that we would be even closer to universal coverage.
        Unfortunately, that's not the case and millions of
    Americans remain uninsured, particularly in States that have
    refused to expand Medicaid. Also, among the uninsured are
    undocumented immigrants and their families. When you have more
    uninsured people, costs go up for everyone. And, under the
    Trump administration, the uninsured rate has gone up and
    American families have lost coverage, including hundreds of
    thousands of children. We need to enact policies that include
    all the uninsured.
        And that's why we are here today. The bills we are
    considering reflect Democrats' continued commitment to
    achieving universal coverage and making healthcare more
    affordable and accessible for all Americans. I believe that we
    must continue to build on the success of the ACA until
    healthcare is truly a right for all Americans.
        I look forward to the discussion today and I yield back.

        Mr. Pallone. I look forward to the discussion and yield the
    balance of my time to the gentlewoman from Illinois, Ms.
    Schakowsky.
        Ms. Schakowsky. Thank you so much. Today really does mark a
    landmark day to discuss ways that the United States of America
    can join the rest of the industrialized world in saying that
    healthcare is a right and not a privilege for all of our
    people. You know, we spend more than any other country on
    healthcare right now, yet millions of people don't have access
    to care. We have the highest rates of infant--or maternal
    mortality, we have a shorter life span, and we can do better.
        So I have been a cosponsor and a supporter of single-payer
    healthcare since a lot of you in this room were even born, but
    I also want to say that I am a cosponsor of every single bill
    that is going to improve healthcare in this country because we
    have to move forward. I am a cosponsor of a bicameral public
    option bill ever since the Affordable Care Act didn't include
    it. I am a cosponsor--and you will hear from Representative
    DeLauro--on Medicare for America. I am a Medicare for All--I am
    a cosponsor of that and was there at its inception.
        So we don't know exactly what path we are going to take,
    but over the last 50 years we have seen some dramatic changes.
    We have seen Medicare and Medicaid get passed, we have seen the
    ACA, and these are examples of the dynamic changes that we can
    make and that we should be making. We need to work together.
    Americans are asking us, begging us to improve our healthcare
    system. They all want to be covered. We can do this, and we are
    going to hear about how we can do this today. I thank the
    panel, and I yield back.
        Ms. Eshoo. Does the gentleman yield back? Mr. Pallone?
        Mr. Pallone. I am sorry. Yes, I yield back, Madam Chair.
        Ms. Eshoo. What are you dreaming about there, over there?
        Mr. Pallone. Dreaming about a better world.
        Ms. Eshoo. Lovely.
        I now would like to recognize the ranking member of the
    full committee, my friend Mr. Walden, for his 5 minutes for an
    opening statement.

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

        Mr. Walden. Thank you. I want to join the chairman in
    dreaming about a better world. It is that spirit we should have
    here this holiday season.
        Ms. Eshoo. Well, I believe it is. I believe it is.
        Mr. Walden. Madam Chair, yes. Thanks for holding this
    hearing. I think it really is important to flesh out these
    issues and learn a lot about them.
        As you know, our committee has moved forward on maternal
    mortality legislation. Ms. Schakowsky referenced that as a huge
    issue, and it is, and I am glad we have moved forward on some
    of those specific issues. This is the committee that created
    Medicare Part D to help seniors get access to affordable
    prescription drugs that had never been a part of Medicare
    before. We did that. The House passed it. I helped write it and
    support it all along.
        This is the committee that led the effort in a bipartisan
    way on 21st Century Cures. I know there is an effort beginning
    to look at a Cures 2.0 so we can find these magic miracles that
    are saving people's lives and invest in American innovation and
    research. This is the committee that is on the cusp of
    reauthorizing fully funding our community health centers for
    the next 5 years. I am a big fan of our community health
    centers. When I chaired the committee, I helped lead the effort
    to fully fund them.
        And Chairman Pallone and I are working together on
    legislation to stop surprise billing so consumers aren't ripped
    off when they go to the emergency room. One in five are getting
    a surprise bill today. That is wrong. We are on the cusp of
    dealing with that. And we fully funded Children's Health
    Insurance Program in the last Congress, when I chaired the
    committee, for 10 years. It had never been fully funded for
    more than 5.
        So I think we all share a commitment to trying to find
    answers to the cost of healthcare, to access issues when it
    comes for healthcare. Some of us, however, think that Medicare
    for All is not the right approach; that it would actually take
    away the health insurance that 180 million Americans have
    today, many of whom have bargained for that health insurance as
    part of very aggressive union-employer bargaining agreements.
    They have traded away wages in order to have better healthcare
    or lower-cost deductibles and all. Medicare for All would strip
    that away from them, as it would take away Medicare Advantage
    Plans and put it all under one system. And I will just tell
    you, when Washington politicians promise you something for
    free, you better hold on to your wallets.
        As you know, 84 percent of Americans actually like the
    health insurance they have today. We all think it is probably
    too expensive. We all wish it were a little better. We can work
    to make changes to fix some of those issues, but a one-size-
    fits-all system that rations care and restricts access and
    blows a hole in the budget is not where many of us are at.
        At the presidential debate in October, a top Democrat said,
    and I quote, ``If you eliminated the entire Pentagon, every
    single thing, it would pay for about a total of 4 months'' of
    this Medicare for All plan. These plans are so complex and
    confusing and costly that even the Congressional Budget Office
    could not figure out the price tag. However, two think tanks,
    one on the left and one on the right, came up with a range of
    between 28 trillion and 32 trillion dollars over the next 10
    years. Other versions we have heard about would cost upwards of
    $52 trillion.
        Even doubling the current--doubling the current--personal
    and corporate taxes would not cover the costs. Doubling.
    Doctors and hospitals could see payment cuts of 40 percent.
    Forty percent. How would they keep their doors open? What
    happens to our access to care? We can look north to Canada. The
    Fraser Institute did some research on this and found that a
    doctor's referral for specialty care, the medium wait time was
    20 weeks, double what it was 25 years ago. That is a
    government-run system.
        Canada is facing a shortage of medical providers, and in
    some provinces some hospitals have responded by actually
    closing their emergency rooms 2 days a week. In British
    Columbia, 300 patients died waiting for surgery between 2015
    and 2016 because of a lack of anesthesiologists. And, according
    to the British Columbia Anesthesiologists' Society, they say
    that is a huge problem.
        Canada has 16 CT scans for every million people. In
    America, we have 45 for every million people. That means that
    you can get access to care quicker here, get those scans. Delay
    and denial of care is how government-run healthcare systems
    control costs. You see what is going on in England right now
    with a young boy that was being treated, I think, in a hallway.
    They ration care. They delay care. If the government decides a
    treatment or drug you need is not cost effective, you are
    denied access. We had that debate in this committee. The data
    are clear about how long you wait to get access to miracle
    drugs in other countries. Upwards of 40 percent of the new
    drugs are not available. These are cancer drugs. These are new
    drugs on the market that would save lives, and do, in America.
        We have got to deal with the issue of costs, certainly, but
    there is a way to do that. And by the way, most of these
    government-run systems prevent you from going around the
    government-run system. Some people do flee a country, come to
    another one, mainly America, to get access to care when their
    own government system fails them. It is not just a theory. It
    is what happens in some of these countries.
        So I am not a fan of that complete government takeover. I
    am a fan of reform and of making sure we have the network in
    place. So, Madam Chair, thanks for having this hearing. I yield
    back.
        [The prepared statement of Mr. Walden follows:]

                     Prepared Statement of Hon. Greg Walden

        Today we're here to talk about the greatest government
    takeover of private business, and the greatest denial of
    individual choice, in modern history. Medicare for All would
    not only take away your health insurance, but also end Medicare
    as we know it. It would ban private insurance and rob consumers
    of any choice they have in making healthcare decisions that
    work for them.
        We hear all the time, ``don't worry, Medicare for All will
    give you free healthcare from Washington, D.C. that's better
    than what you get today.'' When Washington politicians promise
    you something for free, you better hold onto your wallet.
        Let's look at what Medicare for All would do. More than 180
    million Americans lose the health insurance plan they've chosen
    or bargained for. Even Medicare Advantage plans for seniors are
    wiped out.
        A recent poll found that 84% of Americans are satisfied
    with the healthcare plans they're on. These are union members
    and workers who have negotiated their healthcare benefits for
    decades--under the Democrats' plan, they would lose the
    coverage they've chosen for their families and are shoved into
    a one-size-fits-all system that rations care, restricts access
    and blows a hole in the budget.
        At the presidential debate in October, a top Democrat said,
    `If you eliminated the entire Pentagon, every single thing. it
    would pay for a total of four months.'
        These plans are so complex, confusing and costly that even
    the Congressional Budget Office could not figure out the price
    tag. However, independent studies from think tanks on the left
    and the right arrived at similar conclusions: Medicare for All
    would cost between $28 trillion and $32 trillion over 10 years.
    Other versions could cost up to $52 trillion. Leading Democrats
    are forced to admit this would require massive tax increases on
    working families and American companies.
        But even doubling current personal and corporate taxes
    would NOT cover the costs. DOUBLING--still not enough. Doctors
    and hospitals could see payment cuts of 40%! How would they
    keep their doors open? What would happen to our ability to
    access care?
        We can look north to Canada to see what Canadians deal with
    every day. The Fraser Institute found that after a doctor's
    referral for specialty care, the median wait time is 20 weeks,
    double what it was 25 years ago.
        Canada is facing a shortage of medical providers and in
    some provinces, some hospitals have responded by closing their
    emergency rooms on certain days of the week. In British
    Columbia, 300 patients died waiting for surgery between 2015
    and 2016 because of a lack of anesthesiologists, according to
    the British Columbia Anesthesiologists' Society. Canada has 16
    CT scanners for every million people. Here in the U.S. we have
    nearly three times as many CT scanners.
        Delay and denial of care is how government-run healthcare
    systems control costs. They ration care. If the government
    decides the treatment or drug you need are not ``cost
    effective,'' you are denied access. And the law prevents you
    from going around the government to get care.
        This is not just a theory, this is what happens in other
    countries with government-run healthcare administered by
    bureaucrats--care is rationed, access is restricted, and
    patients have worse outcomes. That's not what Republicans want
    for Americans.
        Mr. Chairman, I do want to thank you for having this
    hearing. The American people deserve to hear the facts about
    what a government takeover of their health insurance will mean
    for access to care in a timely manner. These plans ration care
    and deny life-saving treatments. Importing foreign healthcare
    systems to the U.S. runs counter to our shared goal of
    expanding access to the latest cures and improving access to
    lifesaving therapies.

        Ms. Eshoo. The gentleman yields back.
        The Chair wants to remind Members that, pursuant to
    committee rules, all Members' written opening statements shall
    be made part of the record, and certainly the written
    statements of the two Members that are part of the nine
    proposals that we are going to hear about today.
        So they don't really need any introduction, but I think
    that it is appropriate to still do so. It is an honor to
    welcome our colleagues here today for this hearing. Each of
    them is going to speak for 5 minutes to present their specific
    proposal. Each one differs, and I think that, as I said in my
    opening statement, that it is important for everyone to listen
    because we have varying sets of ideas, and I think that we need
    to have an open mind about them.
        So, beginning with Congresswoman Rosa DeLauro from my home
    State where I was born and raised, Connecticut, welcome to you;
    to Representative Jayapal from the State of Washington, welcome
    to you; to Representative Higgins from New York, thank you for
    making yourself available today; to Representative Delgado from
    the State of New York; and Representative Malinowski from New
    Jersey. Welcome to each one of you. Thank you for the work that
    you have put into the product that--the legislation that you
    are going to explain to us today.
        So we will start with Congresswoman DeLauro. You are
    recognized for 5 minutes to speak to your legislation, 1384,
    the Medicare for--no, 2452, I am sorry, the Medicare for
    America Act. You all know the light system, so I don't need to
    explain that to anyone.
        Welcome. Thank you, Rosa.

     STATEMENT OF HON. ROSA DeLAURO, A REPRESENTATIVE IN CONGRESS
                     FROM THE STATE OF CONNECTICUT

        Ms. DeLauro. Thank you so much, Madam Chair. Congressman
    Pallone, Congresswoman Eshoo, Ranking Members Walden and
    Burgess, I am delighted to be here this morning. It is an honor
    for me join with the members of this committee and also to be
    with all of my colleagues here this morning on what is a
    critical, critical discussion on what are the pathways that we
    can move forward to universal care.
        I am here this morning to advocate for Medicare for
    America, which I first introduced with my dear friend and my
    colleague, Congresswoman Jan Schakowsky. We did this in
    December 2018, and we reintroduced it this May. Medicare for
    America achieves universal, affordable, high-quality health
    coverage by creating a program based on Medicare and Medicaid
    that covers all Americans through auto enrollment starting at
    birth while maintaining high-quality, affordable employer
    coverage.
        Medicare for America moves every individual currently
    enrolled on the individual exchanges and Medicare beneficiaries
    on to the program. Individuals and children enrolled in
    Medicaid and CHIP are transitioned on to Medicare for America,
    over time, to ensure that their care is not disrupted as we
    transform our healthcare system. We made this deliberate choice
    after working with members of the disabilities community who
    know all too well about disruptions in the face of budget cuts
    and other complications.
        For those with employer-sponsored coverage, two things can
    be true, and are true: employers have shifted many Americans to
    high-deductible plans with less generous coverage, and many are
    very satisfied, including those union members that negotiated
    very good coverage in lieu of wages in lean budget years. So
    Medicare for America allows high-quality, affordable, private
    employer-sponsored coverage to remain, or employers can enroll
    their employees in Medicare for America and continue to pay a
    contribution, or those employees who work for these employers
    that continue to offer private coverage can choose Medicare for
    America and their employer contributes toward the premium. This
    way, no one is locked into employer-sponsored coverage.
        Let me touch on something that I hear from most of my
    constituents and that is cost. For individuals, seniors,
    families living below 200 percent of the Federal poverty level,
    they will have no premiums and no cost sharing. There are never
    out-of-pocket costs for children under 21 and for maternity
    services, for preventive and chronic services, for long-term
    services and supports, and for prescription drugs. There are
    also zero deductibles. Zero. Annual out-of-pocket costs are no
    more than $3,500 for individuals, $5,000 for families on a
    sliding scale, and premiums are capped no more than 8 percent
    of income for enrollees and are determined on a sliding scale.
         And, additionally, on the topic of the cost of the
    program, our bill included pay-fors. I ask you to read it. I
    won't enumerate all of them, but the pay-fors are there.
         Let me discuss what is innovative about Medicare for
    America. Today, healthcare benefits are too dependent on your
    ZIP Code. Universal coverage must be universal, so Medicare for
    America is explicit in the benefits covered, especially with
    respect to long-term services and supports.
        We are in a crisis. Families spend themselves into poverty
    to get the care their aging loved ones need, hundreds of
    thousands of individuals with developmental and intellectual
    disabilities that wait years for services that may never come,
    so Medicare for America establishes the gold standard for long-
    term services and support. We partnered with members of the
    disability community on the entire bill in order to ensure
    their needs. The resulting coverage: home health aides,
    personal attendant care services, hospice, care coordination,
    respite services, to name a few.
        We prioritized those supports and services for workforce
    development, raising the reimbursement rates for direct-care
    workers and ensuring a career pipeline, credentialing, and
    worker rights. Then, in the interim, the bill recognizes the
    central role that family caregivers play by compensating them
    for their work, because it is work. Beyond the LTSS workforce,
    Medicare for America preemptively raises reimbursement rates
    for primary care and mental and behavioral health and cognitive
    services.
        Far too many individuals face roadblocks because
    reimbursement rates are too low. Far too many providers are
    weighed down or scared off because of mounting debt and choose
    only private insurance. So Medicare for America establishes
    all-payer rate setting. Private insurance pays the Medicare for
    America rate. It all comes back to getting patients the care
    they need. That is why we ban private contracting. Current law
    allows providers to cover individuals and private coverage.
    They also talk about paying out-of-pocket for care even if
    their insurance covers the benefit. It is a two-tiered system
    that must not continue. Patients deserve to be treated fairly
    to get the care they need.
        We acknowledge the crippling of the student loan debts that
    many healthcare workers face that often leads to private
    contracting, so we say to providers: Pay our rates, see our
    patients, and we forgive 10 percent of your student loan. By
    making smart investments upfront, the American people save a
    great deal of money in the long run. At its core----
        Ms. Eshoo. Rosa.
        Ms. DeLauro. One second. At its core, Medicare for America
    is about ensuring that every American has healthcare, and as we
    debate into the future on universal healthcare coverage, my
    view: Medicare for America is the best way forward in providing
    historic change.
        Ms. Eshoo. Amen.
        Ms. DeLauro. Thank you. And thank you for inviting me.
        [The prepared statement of Ms. DeLauro follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you, Congresswoman DeLauro. With all the
    energy she always brings to everything that she does, thank
    you.
        Next, we welcome and thank Congresswoman Jayapal. She is
    the sponsor of H.R. 1384, the Medicare for All Act. So you have
    your 5 minutes to present your proposal.
        Ms. Jayapal. Thank you.
        Ms. Eshoo. And thank you again for being here today. I know
    that you have Judiciary as well, so away we go.

    STATEMENT OF HON. PRAMILA JAYAPAL, A REPRESENTATIVE IN CONGRESS
                      FROM THE STATE OF WASHINGTON

        Ms. Jayapal. Thank you so much, Chairwoman Eshoo, Ranking
    Member Burgess, and Chairman Pallone and Ranking Member Walden,
    and distinguished members of the Subcommittee on Health. Thank
    you for holding this historic hearing. This is a great day.
        And let me start by saying that the Affordable Care Act was
    critically important in expanding healthcare for tens of
    millions of Americans across the country and providing
    insurance for those who had preexisting conditions, but equally
    important, the Affordable Care Act allowed Americans to dream
    of a future where everybody had the right to healthcare. And
    for us, we need to ensure that we don't stop with the
    Affordable Care Act and that we get to the place where we have
    universal care for all people in our country.
        And that is why I am so proud to have introduced, along
    with my esteemed colleague, Representative Debbie Dingell, H.R.
    1384, the Medicare for All Act of 2019. Our 119 cosponsors,
    over half of the Democratic Caucus, many of you on this
    committee, thank you for your input and your support as we
    developed this bill. This is now the fourth historic hearing we
    have had on Medicare for All in the House of Representatives,
    and that would not be possible without an enormous movement for
    Medicare for All.
        And I want to particularly recognize, quickly, a few
    groups: Physicians for a National Health Program; National
    Nurses United, who you will hear from today; Public Citizen;
    the labor coalition; the Disability Rights Coalition; and a
    racial justice coalition and a women's coalition that worked
    with us for over 6 months to develop this piece of legislation,
    I would submit, the most comprehensive and bold solution to fix
    our broken healthcare system. We simply wouldn't be here
    without their leadership.
        Our Nation's healthcare system is the most expensive in the
    world. Contemplate that. This year, we will spend almost $3.9
    trillion, or 18 percent of our GDP, on healthcare expenditures,
    and that is almost double what every other industrialized
    country in the world spends. Over the next decade, our current
    healthcare system will cost America about $55 trillion. What
    does that astronomical spending get us? The highest maternal
    and child mortality rates among our peer countries and the
    lowest life expectancy. It gets us 500,000 Americans who every
    year are forced into bankruptcy because of medical costs. It
    gets us 70 million people who still remain uninsured or
    underinsured, and that is just a bad deal.
        Why is America so far behind our peer countries? You might
    ask that. Because profit-making motives are baked into our
    system and our healthcare system incentivizes putting profits
    over patients. For-profit insurance companies with extremely
    high administrative waste stand between Americans and good
    quality, affordable healthcare. Every American knows someone, a
    loved one, a friend, a child, or a parent, who has suffered a
    healthcare crisis, and they know that the system we have
    doesn't work.
        So how do we respond to this? I think, if we really want to
    fix this, we have to do three things. First, any plan that
    proposes to fix our healthcare crisis has to cover everyone.
    Not just expand coverage for some, but cover everyone,
    guaranteed. Second, it has to provide comprehensive benefits
    and high-quality healthcare when you need it. And, finally, it
    has to take on the out-of-control costs, administrative waste,
    and for-profit motive of the current system and bring down
    costs for American families.
        Our bill, H.R. 1384, is a 125-plus-page bill, a
    comprehensive plan to lay out exactly how we get there, and it
    is the only plan that does all three of those things. Our bill
    improves the successful Medicare program that we have, but it
    expands it to cover everyone with a guaranteed government
    insurance plan, including comprehensive benefits, vision,
    hearing, dental, mental health, and of particular importance,
    long-term care for people with disabilities and older
    Americans.
        All of this with no copays, no private insurance premiums,
    and no deductibles. And because all doctors and hospitals will
    be in network, Medicare for All gives the American people more
    choice than ever before. No more worrying about a massive
    surprise bill that you might get. No more worrying about what
    happens if you have to quit your job because you are too sick
    to work. No more worrying if you want to go start a small
    business but you can't afford the cost of healthcare.
        H.R. 1384 also includes important cost-containment measures
    to ensure that we rein in health spending. It bolsters rural
    hospitals and safety-net hospitals with special provisions to
    help these hospitals stay open and thrive and have patients who
    are all insured. I want to be clear that every study, including
    the Koch Brothers' conservative study, says that we will save
    money with a Medicare for All plan.
        American families will pay 14 percent less than they
    currently pay in healthcare costs, and that is why over 250
    economists sent a letter to Congress saying that Medicare for
    All is the right plan for our economy. It is why former CMS
    Administrator under President Obama, Don Berwick, said that,
    after being the Director of Medicare for some, he now believes
    it is time for Medicare for All, and it is why 30 unions for
    the first time--don't listen to the arguments that unions don't
    want this. For the first time, 30 unions, including the major
    unions in our country, have supported this bill.
        Ms. Eshoo. Pramila?
        Ms. Jayapal. Now it is up to us.
        Ms. Eshoo. Pramila?
        Ms. Jayapal. And it is time for us----
        Ms. Eshoo. Wind up.
        Ms. Jayapal [continuing]. To pass Medicare for All.
        I am just listening to my mentor, Rosa DeLauro, who took a
    minute more--
        Mr. Shimkus. Regular order. Regular order.
        Ms. Eshoo. Yes. Yes.
        Ms. Jayapal [continuing]. To continue to say----
        Ms. Eshoo. Just wrap up.
        Ms. Jayapal [continuing]. That it is time for us to pass
    Medicare for All. Thank you, Madam Chair.
        [The prepared statement of Ms. Jayapal follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you. Thank you very much for being here
    today and testifying.
        We will now call on Congressman Brian Higgins. Welcome,
    Brian. It is wonderful to see you here, and you have 5 minutes
    to present your proposal.

     STATEMENT OF HON. BRIAN HIGGINS, A REPRESENTATIVE IN CONGRESS
                       FROM THE STATE OF NEW YORK

        Mr. Higgins. Yes, thank you very much, Chairwoman Eshoo and
    Chairman Pallone and Ranking Member Burgess. I just want to say
    that I was a proud supporter of the Affordable Care Act, which
    will be 10 years old this March. But even the President, the
    Speaker, recognized that the passage of the Affordable Care Act
    represented a start, not a finish, and that it was highly
    imperfect in many ways, including the lack of a public option,
    to be a real countervailing force to private insurance, because
    I think by and large private insurance screws people. They jack
    up premiums. They jack up deductibles. They jack up copays. And
    then, when you go to use the insurance that you already paid
    too much for, there is very little underlying insurance.
        You know, before the Affordable Care Act, if you had a kid
    that was stuck with childhood cancer, an insurance company
    could deny you coverage because of a preexisting condition. You
    can't do that anymore. It is against the law. And the only
    Federal law that protects people with preexisting conditions is
    the Affordable Care Act. In 2010, Democrats lost control of the
    House because of healthcare; 2018, Republicans lost control of
    the House because of healthcare. We are even. Let's move
    forward.
        I want to talk about three things: complexity, cost, and
    leverage. The human body has 11 organ systems. There are 70,000
    ways that those organ systems can fail. There are 4,000 medical
    procedures. There are 6,200 FDA-approved prescription drugs.
    There are 206 bones in the human body. There are 30 trillion
    cells in 200 cell types. The human body and healthcare are
    fascinating but complicated.
        The United States Government pays $1.3 trillion for
    healthcare this year under Medicare, Medicaid, and the Veterans
    Administration, then another $360 billion in prescription
    drugs. That is a lot of money. The Federal Government pays
    about a third of the Nation's entire healthcare bill. But it is
    also a lot of leverage, and that is what I want to talk about
    today.
        All of these bills are outstanding. We need to make
    progress by using the best public option that already exists,
    and that is Medicare. Medicare has been around for 54 years. It
    is wildly popular with those who have it and those who provide
    services for those who have that as their health insurance.
    Ninety-six percent of Medicare beneficiaries have access to
    both a primary care doctor and a physician specialist, and all
    of the hospital institutions take Medicare as well.
        I have a bill that would allow people 50 to 65 to buy
    Medicare as a medical option. The Henry J. Kaiser Family
    Foundation that has done extraordinary work in this regard says
    that 77 percent of the American people support a Medicare buy-
    in 50 to 65. Why that age demographic? Because this age
    demographic, 50 to 65, is to this century what the traditional
    Medicare population was to the previous century, and that is
    that private insurance had every opportunity to write policies
    for people that were older and sicker but chose not to do it.
    And a good and generous nation responded by establishing the
    Medicare program, and then all the privates wanted in on it
    when it was deemed to be profitable and successful under the
    Medicare Advantage program.
        This age demographic experiences very high preexisting
    conditions, about 50 percent. Their premiums are very high,
    their deductibles are very high, and their copays are very,
    very high. I will give you an example. A 60-year-old able to
    buy into Medicare at their own cost that will not adversely
    affect the Medicare Hospital Insurance Trust Fund, according to
    the Rand Corporation and the Henry J. Kaiser Family Foundation,
    would save 48 percent when compared to a Gold Plan on the
    individual market.
        Now Rand also said that 6 million Americans would take
    advantage of that plan. That is almost 14,000 people per
    congressional district. And I would remind you that that age
    demographic also votes, so it is good on the politics. It is
    good on the substance. I think we have an obligation to, much
    like we said 10 years ago, we need the next iteration, the next
    exciting iteration of Medicare expansion, and I believe that my
    bill should be in that conversation relative to that goal.
    Thank you very much.
        [The prepared statement of Mr. Higgins follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you very much. And thank you for being on
    time as well, on time with your conclusion using your 5
    minutes.
        It is a pleasure to welcome and thank Representative
    Delgado from New York to present his idea, his proposal, which
    is H.R. 2000, the Medicare-X Choice Act. So welcome and----

    STATEMENT OF HON. ANTONIO DELGADO, A REPRESENTATIVE IN CONGRESS
                       FROM THE STATE OF NEW YORK

        Mr. Delgado. Thank you. Thank you, Chairwoman Eshoo. Thank
    you, Ranking Member Burgess. Chairman Pallone. It is really
    nice to be with you all this afternoon, or this morning. I am
    pleased to see the committee considering my bill, the Medicare-
    X Choice Act, and I am honored to have the opportunity to
    explain why it is a priority of mine.
        The title of today's hearing, ``Proposals to Achieve
    Universal Healthcare Coverage,'' an urgent need, indeed. We are
    the richest nation in the world and yet the only developed one
    without some form of universal coverage. If unable to qualify
    for Medicare, TRICARE, or Medicaid, Americans are left to fend
    with a system that is entirely beholden to the profit motives
    of the private insurance marketplace. As a result, millions of
    Americans are priced out of the market and left uninsured or
    have insurance but simply can't afford to take advantage of it.
    It is unacceptable.
        We have got to achieve universal healthcare coverage, and I
    believe we can get there with a public option. I promised my
    constituents I would pursue this path, and with that promise in
    mind, this spring introduced the Medicare-X Choice Act along
    with my colleagues including Representative Higgins and Larsen.
    Medicare-X establishes a public option, a government-run
    insurance plan available in the marketplace for anyone to buy
    if they are uninsured or unhappy with their current plan. The
    effect of a public competitor in the private insurance
    marketplace will undoubtedly bring down the skyrocketing costs
    of premiums and deductibles.
        The plan starts in rural areas, where coverage options can
    be scarce, and it automatically enrolls every child in the CHIP
    program. Critically, Americans who like their current plans,
    like many union members who have spent years bargaining for
    what they have now or seniors on Medicare Advantage, can keep
    them. This plan covers every American in just 3 years, but also
    attacks the underlying affordability crisis that plagues
    families across the country, an issue not discussed nearly
    enough.
        We start by, one, requiring Medicare to negotiate drug
    prices; two, increasing Federal support for those who need it
    by eliminating the subsidy cliff for Americans above the 400
    percent of the Federal poverty line and increase in the tax
    credit for those individuals below it; and three, authorizing
    30 billion over 3 years for a national reinsurance program.
    Under this bill, a family of four with an income of $101,000
    would see their premiums cut in half. We do all that without
    costing the Federal Government a dime.
        The Congressional Budget Office recently found that
    Medicare-X would actually add money to the Treasury over time.
    Medicare-X fulfills the promise of the Affordable Care Act that
    healthcare coverage will be simpler, more accessible, and more
    affordable when families can choose the plan that works best
    for them.
        Every time I have held a town hall--and I have held quite a
    few--I hear from folks about the cost of healthcare. Congress
    needs to get this done so families don't have to choose between
    paying medical bills or buying groceries. As this committee
    considers the healthcare legislative options, I hope you will
    find two main takeaways from my testimony today: more choice,
    lower costs. Two concepts I hope everyone on this panel can get
    behind.
        I thank the committee again for your time and the
    opportunity to share my priorities with all of you.
        [The prepared statement of Mr. Delgado follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. We thank the gentleman. It is a great source of
    pride to all of us that of the five that are speaking at the
    witness table this morning that Mr. Delgado and Malinowski are
    new Members of Congress. This is their first term. And you are
    a source of pride to us, and you more than hit the ground
    running with ideas. You are fresh off the campaign trail, and
    it is always refreshing to see what new people bring to the
    Congress, so thank you as a combination with the others.
        Mr. Delgado. Thank you.
        Ms. Eshoo. Now it is a pleasure to both welcome and
    recognize Mr. Malinowski for your 5 minutes to talk about your
    proposal, which is H.R. 4527, the Expanding Healthcare Options
    for Early Retirees Act.

    STATEMENT OF HON. TOM MALINOWSKI, A REPRESENTATIVE IN CONGRESS
                      FROM THE STATE OF NEW JERSEY

        Mr. Malinowski. Thank you so much for those kind words,
    Chairman Eshoo, Mr. Ranking Member Burgess. Thank you for the
    opportunity to testify today alongside my colleagues, each of
    whom have put together thoughtful proposals to get us closer to
    that North Star of universal coverage. And speaking of North
    Stars, Mr. Burgess, Joni Mitchell is Canadian, which means she
    comes from a country with lower healthcare costs and higher
    life expectancy. So I am hoping you might have her for the next
    panel to answer some of Mr. Walden's concerns. All right.
        Chairman Pallone, I also want to thank you for your
    leadership and your work with Mr. Walden, especially on the
    surprise-medical-billing issue. Let's please get that passed
    before we go home for the holidays. That would be a huge win, I
    think, for all of our constituents. I am here to talk about a
    bill that I also hope that we can find common ground on.
        My bill, the Expanding Healthcare Options for Early
    Retirees Act, would allow retired first responders--
    firefighters, police officers, EMTs--to buy into Medicare
    beginning at age 50. Due in part to the physically demanding
    nature of their work, first responders often retire earlier
    than other workers and can experience gaps in coverage until
    they become eligible for Medicare. This legislation would close
    that gap. Coverage under this bill would be identical to the
    coverage provided under the existing Medicare program. Retirees
    would be eligible for tax credits, subsidies, and tax advantage
    contributions from their former employers or pension plan.
    Further, the bill specifically requires that it be implemented
    in a way that will not harm the existing Medicare program
    beneficiaries or trust fund.
        We are grateful to have the support of the International
    Association of Fire Fighters, the Fraternal Order of Police,
    the National Association of Police Organizations, the National
    Sheriffs' Association, the National Troopers Coalition, the
    International Union of Police Associations, the National
    Conference on Public Employee Retirement Systems, AFSCME, among
    other organizations. Many of their representatives are with us
    today.
        And since introducing the bill in September, my office has
    received dozens of phone calls and letters and messages from
    people all across the United States describing how it would
    help them or a family member. A person from Wilson County,
    Tennessee, wrote to us, ``This is a such a needed law. More and
    more agencies are washing their hands of insuring first
    responders when they retire. It is not a young person's job.
    And when we retire, we are damaged physically and emotionally
    and need the healthcare that eats up most of our pension.''
        A paramedic from Florida wrote, ``I am 53 and can retire in
    2 years. Healthcare has been my major concern after my
    retirement. I pray for all of you working on this proposed
    bill.''
        A paramedic firefighter from Oregon wrote, ``I was born to
    be a firefighter in the community I was born and raised in. You
    naturally never think about your body wearing out. I have had
    several Toradol and steroid shots in both my elbows, shoulders,
    and neck over my career so that I can be at work answering my
    community's calls. It would be so helpful being eligible for
    Medicare benefits when I retire.''
        A newspaper in Texas quoted the head of the Abilene Police
    Officers Association saying, ``The bill would allow us to
    retire at a good age and be able to afford healthcare. This
    affords us the opportunity to retire earlier, spend more time
    with our families, and enjoy life.''
        This is why we are here today examining how to improve our
    healthcare system so that every American can spend more time
    with our families and enjoy our lives so that we can choose a
    profession we love and to change it when we please without the
    crushing existential anxiety that comes from being uninsured or
    underinsured, without the fear that an accident or an illness
    could lead to bankruptcy.
        Now, I believe that everybody who wants Medicare--teachers,
    caregivers, coal miners, farmers, service workers, everyone--
    should be able to live with the dignity and security that the
    program provides. But, as we debate how to free every American
    of the anxiety of dealing with the current healthcare system,
    let us at least do something to free the few, the dedicated and
    brave few, who risk their health and their lives to protect us.
        Thank you so very much, and I yield back.
        [The prepared statement of Mr. Malinowski follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. The gentleman yields back. And let me express on
    behalf of all of the members of the committee, both sides of
    the aisle, for not only accepting our invitation to be here
    today to describe your idea, your legislative proposal, but the
    clarity in which you have done so. We are legislators. We are
    lawmakers, and it is incumbent upon us to respect the thinking
    that goes into each person's proposal, and your thoughtfulness
    is on display this morning.
        I know that two of our colleagues have left, but my kudos
    to each of you, all five of you. So thank you for spending time
    with us here this morning, and now you can go on with the rest
    of your full schedule for the day, and the staff will prepare
    the table for the second panel of witnesses.
        And you can come--let's see. We need to change the name
    tags at the table so that they know where they are sitting. But
    can we do that with some sense of timeliness? Who is going to
    do that on the staff?
        All right, let's get to it. Maybe everyone can check their
    phones while we are waiting.
        Mr. Burgess. Are you expecting a call?
        Ms. Eshoo. No, I am not expecting a call, but people like
    to see what messages they have received.
        [Pause.]
        Ms. Eshoo. 0K. We are now going to hear from our second
    panel of witnesses on this all-important issue, and we welcome
    you. We thank you for making yourselves available to us today.
        First, Ms. Sara Rosenbaum. She is a health law and policy
    professor at the Milken Institute of Public Health at George
    Washington University. Welcome and thank you to you.
        Mr. Peter Morley, patient advocate, thank you to you, and
    welcome.
        Ms. Jean Ross, the president of the National Nurses United,
    welcome to you.
        Dr. Douglas Holtz-Eakin, president of the American Action
    Forum. It is nice to see you again, and thank you for being
    here today.
        Dr. Scott Atlas, a senior fellow at the Hoover Institution
    at Stanford University, which I have the privilege of
    representing, thank you, and it is wonderful to see you again.
        So I will now recognize Ms. Rosenbaum for your 5 minutes of
    testimony, and you can begin. I think you all know what the
    lighting system--green. When you see the yellow light speed up,
    because on the heels of the yellow light comes the red light.
    Welcome, and you may proceed.

    STATEMENTS OF SARA ROSENBAUM, HAROLD AND JANE HIRSCH PROFESSOR,
    HEALTH LAW AND POLICY, GEORGE WASHINGTON UNIVERSITY DEPARTMENT
        OF HEALTH POLICY AND MANAGEMENT; PETER MORLEY, PATIENT
     ADVOCATE; JEAN ROSS, R.N., PRESIDENT, NATIONAL NURSES UNITED;
     DOUGLAS HOLTZ-EAKIN, Ph.D., PRESIDENT, AMERICAN ACTION FORUM;
    AND SCOTT W. ATLAS, M.D., DAVID AND JOAN TRAITEL SENIOR FELLOW,
                HOOVER INSTITUTION, STANFORD UNIVERSITY

                      STATEMENT OF SARA ROSENBAUM

        Ms. Rosenbaum. Thank you, Madam Chair and Ranking Member
    Burgess and members of the subcommittee for this opportunity.
        Over the past half century, Congress has pursued various
    solutions in its effort to insure all Americans, as the limits
    of what could be achieved through a voluntary employer
    insurance system became evident, especially for the elderly,
    the poor and low-income people, and people with disabilities.
    We have embraced over many years a range of solutions ranging
    from a single-payer solution in the case of Medicare to efforts
    to strengthen public and private insurance and expand our
    largest public health program, Medicaid. Much work remains to
    be done, and, of course, this work takes place against a
    backdrop of the highest-cost health system among wealthy
    nations.
        After years of progress, the number of uninsured is growing
    again, and millions more are underinsured because costs are too
    high and coverage is too limited. Using an incremental payer
    approach, the Affordable Care Act accomplished a great deal.
    Immediately before the law took effect, 44 million people were
    uninsured. By 2016, the number had dropped 26.7 million.
    Progress occurred at all income levels and in all States, but
    especially among lower-income people and, of course, in the
    ACA's Medicaid expansion States.
        Preventive coverage has improved markedly, and coverage has
    improved for children and adults with disabilities. People with
    serious health conditions have benefited from the law's
    essential health benefit rules that broadened coverage and
    limited out-of-pocket exposure while promoting actuarial value.
    Fifty-four million Americans have benefited from the protection
    against preexisting condition exclusions and discriminatory
    coverage practices. Medicare prescription drug coverage has
    improved, 2.3 million young adults have coverage through their
    parents' plans, and community health centers have doubled their
    capacity.
        But now the latest census data show that we are moving
    backwards. The percentage of uninsured Americans is growing,
    from 7.9 percent in 2017 to 8.5 percent in 2018. We are up to
    27.5 million uninsured children and adults. The Trump
    administration is championing a lawsuit that could disinsure
    over 20 million people overnight. Fourteen States remain
    without the Medicaid expansion, and over 2 million people are
    caught in this coverage gap, ineligible for Medicaid but too
    poor for tax subsidies.
        Other administration initiatives are aiming to push
    Medicaid enrollment still lower through block grants, work
    experiments, and other administration strategies. The
    administration has targeted the private insurance reforms under
    the ACA in order to erode access to higher-value policies in
    favor of what experts call ``junk insurance,'' while taking
    constant aim at the law's essential health benefit and
    affordability provisions.
        I think that we face two major challenges, one set in the
    near term and one set for longer-term discussion, and they are
    reflected in the amazing range of bills you have before you
    today and the deeper thinking that has gone on behind those
    bills. The first is to what I would call ``stanch the flow.''
    We need steps to redouble the effort to incentivize the
    Medicaid expansion where it has not happened and people who
    depend on subsidized private insurance need more help. The ACA
    insurance market needs to be stabilized in order to promote
    affordable coverage. That is an immediate set of needs.
        In the longer term, you face bigger decisions, as you well
    know. What is the best mix of public and private insurance
    coverage? Do we preserve employer coverage? Do we maintain
    multiple programs or consolidate various public programs into
    one major alternative? If we move in this direction, should
    this program be open to employers and individuals, or just
    individuals? And should it remain--instead, should we retain
    multiple public programs with various targeting built in?
        How broad should public coverage be? Should it subsume
    long-term care? Should we use auto-enrollment to cut down on
    churn? What is the best approach to financing reform? And in
    order to achieve true health equity, do we need to think beyond
    coverage itself and also focus on community-level investments
    in order to ensure accessible healthcare and a broad continuum
    of health-promoting policies?
        Thank you very much for this opportunity.
        [The prepared statement of Ms. Rosenbaum follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you. It is so wonderful to have people
    widen the lens.
        Welcome again and thank you, Mr. Morley. You have 5 minutes
    to offer your testimony.

                       STATEMENT OF PETER MORLEY

        Mr. Morley. Sorry, OK. Sorry.
        Thank you, Chairwoman Eshoo, Ranking Member Burgess, and
    members of the subcommittee. I am honored to speak with you
    today on my 28th trip to DC since July 2017 to fight for
    healthcare.
        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 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 is 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 as well as
    millions of others. 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
    from us because an insurance company decides it is in their
    best interest not to cover something, or if Congress decides to
    repeal our insurance, or if the Trump administration sabotages
    and refuses to defend the Affordable Care Act.
        As someone who spends the majority of my waking hours in
    doctors' offices, the ACA has meant focusing on healing, not
    bankruptcy. I did not ask to be chronically ill. I used to be
    very private about my health, but once President Trump was
    elected and set 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. In the last 2\1/
    2\ years, I have traveled to DC 27 times. I have collected the
    healthcare stories of thousands of people who shared their
    personal stories and concerns with me. I have held over 350
    meetings with Democratic and Republican Members of Congress
    alike. Many of you actually sit here in front of me today.
        My message is simple. If you think people don't get hurt
    when this administration doesn't defend the ACA, think again.
    We do. I do. Millions do. And if you think preexisting
    condition protections are not 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.
        This past July, I testified for the late Congressman Elijah
    Cummings. He thanked me for taking my pain, turning it into a
    passion to do my purpose. I will never forget those words. So,
    today, in the spirit of our beloved Congressman, I have an ask
    of this entire subcommittee. Please work together to make
    healthcare of all Americans your passion.
        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 DC. But I am here today to ask you to
    protect the ACA so we can enhance it and move towards universal
    health insurance for all Americans. Thank you for allowing me
    the opportunity to testify, and I am happy to answer your
    questions.
        [The prepared statement of Mr. Morley follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. What an honor to have you here. Thank you for
    your courage and your tenacity. It really is an honor to have
    you here, and we are going to do everything to help keep you
    healthy. And I will never forget your testimony and your words,
    just as you will never forget our late Elijah Cummings.
        And now it is a pleasure to recognize Ms. Jean Ross, the
    president of the National Nurses United, for your 5 minutes of
    testimony. Thank you again for being here and for what you will
    say, so you are recognized.

                         STATEMENT OF JEAN ROSS

        Ms. Ross. Good morning and thank you, Chairwoman Eshoo,
    Ranking Member Burgess, and members of the subcommittee for
    inviting me to testify today. My name is Jean Ross. I have been
    a registered nurse in Arizona for 45 years, and I am president
    of National Nurses United, the largest union representing
    bedside nurses in the United States, with over 150,000 members.
        In my testimony today, I want to illustrate two main
    points. First, our current patchwork system of public programs
    and private for-profit insurers is ineffective, inefficient,
    and financially unsustainable. Second, the only way we can
    guarantee every person living in this country receives the care
    they need is by adopting a single-payer Medicare for All
    system. Every day, nurses witness the failure of our current
    health system. I have watched as patients don't seek the care
    they need because they can't afford their copays or deductibles
    or don't have insurance. I have watched as insurers refused to
    cover the care that my patients need.
        Over many years, I cared for countless patients who showed
    up in the ER with severe illnesses only because they could not
    afford preventive care. One patient always stands out to me. He
    arrived in the ER in a hypertensive crisis. We treated him for
    an imminent stroke. I learned he was rationing his blood
    pressure medication. Instead of taking it every day as
    prescribed, he was taking it every 2 days. He knew he needed to
    take those pills daily, but he could not afford the medication
    even with his private insurance plan.
        As a nurse I have so many stories like this, but I am also
    a mother and a grandmother, and this broken system has affected
    my family too. My son, Tony, suffers from a leaky heart valve.
    For the past 15 years he has been consistently unable to afford
    the cardiology care he needs, so he just doesn't see his
    cardiologist. As a nurse, I know that this valve could lead to
    heart failure. As his mother, I live with the constant fear
    this could happen to my son because the health system I work in
    is failing him.
        My daughter is a single parent, and she struggled to pay
    the copays for my grandchildren's care. When my grandson, Evan,
    was an infant, my daughter called me because he was sick, she
    wanted my advice as a nurse. She didn't have the money to take
    him to the doctor. I told her I would pay the copay because I
    knew that Evan needed immediate attention, medical attention,
    now. Indeed, he was suffering from encephalitis, which is an
    inflammation of the brain, which can cause permanent brain
    damage and even death. I am so grateful that I had the economic
    resources to help, because if I hadn't, like so many other
    patients who don't have the means, Evan would have been in
    severe trouble.
        As a grandmother, I want to leave my grandchildren with a
    country where healthcare is a right, where they know when they
    or their children get sick, they will only have to worry about
    their health and not the cost. As a nurse for 45 years, I know
    these stories are not unique. Thirty million people have no
    health insurance, an additional forty-four million people are
    underinsured, yet the U.S. spends more money on healthcare per
    capita than any other nation in the world.
        But despite paying top dollar for our healthcare, we get
    poor results. Our country ranks poorly on many international
    health indicators, including average life expectancy, infant
    and maternal mortality, and death from preventable diseases.
    High cost and poor health outcomes persist because access to
    insurance is not the same as guaranteed healthcare for all.
        This brings me to my second point. Single-payer Medicare
    for All is the only way we can guarantee healthcare while also
    reducing the amount of money we spend on healthcare overall.
    Under Medicare for All, we will transform our profit-driven
    health system--insurance system--into a healthcare system, one
    that prioritizes patient care. Everyone will receive quality,
    comprehensive, therapeutic care without any financial barriers.
    With Medicare for All, doctors and nurses will be able to
    provide care based on our professional judgment without
    insurance company interference. We will have better patient
    outcomes, and we will save money too.
        As you consider different options to improve our health
    system, I encourage you to consider the following questions.
    Will this proposal guarantee safe, therapeutic healthcare to
    every person in the country regardless of their ability to pay?
    Will it allow people to get healthcare independent of where
    they work or if they have a job? Will it reduce administrative
    complexity and waste in the system and control costs?
        There is only one bill before the subcommittee today that
    will achieve all of these things, H.R. 1384, the Medicare for
    All Act of 2019, authored by Congresswomen Jayapal and Dingell.
    The primary responsibility of a registered nurse is to protect
    the health and well-being of her patients. In my professional
    judgment, the only way we can put our patients first, as we are
    ethically and morally bound to do, is through Medicare for All.
    I urge every Member of Congress to support H.R. 1384. Thank
    you. 1A\1\
    ---------------------------------------------------------------------------
        \1\ Ms. Ross' statement has been retained in committee files and
    also is available at https://docs.house.gov/meetings/IF/IF14/20191210/
    110313/HHRG-116-IF14-Wstate-RossJ-20191210.pdf.
    ---------------------------------------------------------------------------
        Ms. Eshoo. Thank you, Ms. Ross.
        It is now a pleasure to recognize Dr. Holtz-Eakin, who is--
    you are recognized for your 5 minutes of testimony, and thank
    you again for joining us today.

                STATEMENT OF DOUGLAS HOLTZ-EAKIN, Ph.D.

        Mr. Holtz-Eakin. Chairwoman Eshoo, Ranking Member Burgess,
    and members of the committee, thank you for the privilege of
    being here today to discuss these proposals for progress
    towards universal coverage, which is, indeed, a very important
    goal for the United States. The proposals fall into two broad
    categories, as you have heard. Some are like Medicare for All,
    sweeping single-payer reforms which would cover everybody in
    the United States, and then a series of more targeted reforms
    that take the character of Medicare buy-ins, Medicaid buy-ins,
    and then public options, and I want to discuss them in turn.
        The proposal for Medicare for All is a truly sweeping
    reform unlike any single-payer elsewhere on the globe. Other
    single-payers do not ban private insurance, indeed, often
    supplement it; do not eliminate a role for regions and States,
    but often rely on them to deliver their healthcare and their
    insurance. They don't eliminate copays and other incentives for
    individuals to utilize care effectively. And in one case,
    Britain, they actually own and operate the hospitals. In this
    case, that no such thing goes on.
        So this is not something where you can say we are going to
    get something that looks like something elsewhere in the world.
    This is like nothing else that has ever been proposed, and it
    has embodied in it, inevitably, some serious tradeoffs. Among
    them will be the tradeoff between covering folks in this manner
    and access to care and the quality of that care.
        In the data, it is quite clear that, as hospitals try to
    reach higher-quality goals, they can be more successful the
    larger the fraction of commercial payers they have in their
    patient base. That relationship between the rate of
    reimbursement and the quality of the care is quite strong and
    important in the research. These proposals would diminish the
    rate of reimbursement for hospitals and thus would inevitably
    degrade the quality of that care.
        In the extreme, one would worry that the reimbursements
    would be so low that hospitals could not actually be able to
    remain open and thus diminish access to care entirely, which is
    obviously counter to the basic intention, but it is something
    that needs to be dealt with in these proposals. The easiest way
    to deal with it, of course, is to reimburse at higher rates,
    but that is going to be extraordinarily expensive. As proposed,
    the Medicare for All is on the order of 30 trillion expense, or
    32, 35, get in that ballpark. To give you a flavor for what
    that means as a matter of public finances, if you were to
    finance that in the traditional fashion of Medicare with a
    payroll tax, you would need to have a 21-percentage point
    increase in the payroll tax, according to a Heritage Foundation
    study.
        And in doing that, the additional payroll taxes would
    outweigh the savings and health premiums for two-thirds of
    American households, so they would financially be worse off by
    the imposition of this proposal. And to what end? The goal,
    obviously, is universal coverage, but if you look at the 30
    million-odd uninsured individuals in America, half of them are
    already eligible for an important public program, the ACA,
    Medicaid, or CHIP. Others are turning down an offer for
    employer-sponsored insurance. They have been offered that.
        Indeed, if you can identify the group that, really, you
    might be able to get, it is about two and a half million
    individuals who are relatively low income and did not reside in
    a Medicaid expansion State. Is it worth overturning the
    enormous heterogeneity and rich complexity of the U.S.
    healthcare system for two and a half million individuals? There
    has got to be a better way to do that.
        Some of the other approaches are more targeted. So, for
    example, there is a Medicare buy-in proposal that you heard
    Congressman Higgins describe. We have taken a look at that at
    the American Action Forum, the think tank that I run, and in
    our estimate that bill would get about 293,000 Americans to buy
    a Medicare buy-in the first year. By the end of 10 years, it
    will be down to about 170, 187,000 individuals.
        To the extent that there are increases in coverage from
    that bill, it comes from adding additional funding to the
    existing ACA channels. But even with $180 billion in additional
    Federal money, total coverage only rises by about 500,000
    individuals. So we have these two approaches, a sweeping
    turnover of the American healthcare system to little gain, and
    some approaches that are targeted but probably not very
    effective.
        And so, I would encourage the committee to continue to
    search for ways to get to universal coverage, but these don't
    appear to be the way to go. I thank you and look for the chance
    to answer your questions.
        [The prepared statement of Mr. Holtz-Eakin follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you for your testimony.
        It is a pleasure to welcome Dr. Atlas, and you have 5
    minutes to present your testimony.

                     STATEMENT OF SCOTT ATLAS, M.D.

        Dr. Atlas. Thank you, Chairwoman.
        Ms. Eshoo. Thank you again for accepting our invitation to
    be here.
        Dr. Atlas. OK. Thank you, Chairwoman Eshoo, Ranking Member
    Burgess, and members of the committee for the opportunity to
    speak today. The overall goal of U.S. healthcare reform should
    be to broaden access for all Americans to high-quality medical
    care and not simply to label them as insured. The notion that
    single-payer healthcare represents a goal for health system
    reform is mainly driven by the attractiveness of a simple
    concept: the government explicitly ``guarantees'' medical care.
        In England, the NHS constitution explicitly states ``you
    have the right to receive NHS services free of charge,''
    despite taxing citizens $160 billion per year. The opposition
    to single-payer care, though, should not focus only on massive
    new taxes that will be required, but instead on the well-
    documented half century of its failure in the medical
    literature to provide timely, quality medical care. The truth
    is that single-payer systems--including in the U.K., Canada,
    Sweden, and other European and Nordic countries--impose
    shockingly long waiting times for doctor appointments,
    diagnostic procedures, drugs, and surgery that are virtually
    never found in the United States specifically as a means of
    rationing care.
        Indeed, the Supreme Court of Canada in the 2005 Chaoulli
    decision, famously stated ``access to a waiting list is not
    access to healthcare.'' Barua calculated that over a 16-year
    period, over 44,000 additional Canadian women died due to
    Canada's imposed wait times for medically necessary care. In
    England alone, a record 4.2 million patients are on NHS waiting
    lists, a hundred thousand of whom have been waiting for more
    than 6 months for treatment after receiving their diagnosis.
        The average Canadian woman--maybe not Joni Mitchell--waits
    5 months for her GP visit to her treatment by her gynecologist.
    In the U.K.'s single-payer system, more than 19 percent of
    those referred for ``urgent treatment for cancer'' wait more
    than 2 months for their first treatment. In Canada, almost 8
    months for brain surgery after seeing the doctor. These long
    waits are the defining feature of all single-payer systems, and
    they stand in stark contrast to U.S. healthcare.
        Waiting lists are not a feature in the United States, as
    stated by the OECD and verified by numerous studies. Even for
    low-priority checkups, U.S. wait times are far shorter than for
    seriously ill patients in countries with single-payer care.
    Single-payer systems also restrict the availability of new
    drugs, including cancer drugs, sometimes for years. Of the
    world's 54 new cancer drugs from 2013 to 2017, by 2018, 94
    percent were available for Americans, for Brits 70 percent, in
    Canada 53 percent, in France 43 percent, in Australia 28
    percent.
        These long waits have major consequences. In the medical
    literature--not anecdote--worse health outcomes than the U.S.
    system from cancer, heart disease, stroke, hypertension,
    diabetes. Why would Americans voluntarily move toward a system
    proven worse than current U.S. healthcare? Americans should
    also ask why the U.S. would move towards single-payer care when
    every other country with decades of that experience now use
    private care to solve their failures.
        Governments in Finland, Ireland, Italy, the U.K., The
    Netherlands, Norway, Spain, Sweden, Denmark--all with single-
    payer care--spend taxpayer money now, sometimes even outside
    their own country, on private care to solve their
    unconscionable failures. Americans should also wonder why those
    with financial means spend even more money than their already
    high taxes for something that is ``guaranteed and free.'' Half
    of all Brits earning more than 50,000 pounds now buy or plan to
    buy private insurance. Here is the reality: Only the poor and
    lower middle class are stuck with nationalized single-payer
    healthcare because only they cannot afford to circumvent the
    system.
        Those who advocate a conversion to Medicare for All fail to
    acknowledge this widely published evidence in the world's top
    medical journals, and they fail to acknowledge that continued
    access to care is already at risk according to the Actuary of
    CMS who calculated that most hospitals, nursing facilities, and
    in-home healthcare providers already lose money per patient
    with Medicare. And they fail to acknowledge this, that about 70
    percent of seniors choose to rely on private insurance
    supplementing or replacing traditional Medicare coverage. Why
    would beneficiaries need that if pure government insurance was
    so satisfactory?
        What is wrong with offering government insurance as an
    option? Because government insurance expansions only erode or
    crowd out private insurance. The public option is not a
    moderate or compromised proposal. It is simply a more insidious
    pathway to single-payer healthcare where only the affluent
    could afford to circumvent that.
        Contrary to the false guarantees, the only valid guarantees
    from single-payer healthcare is worse healthcare for Americans
    and higher taxes. Rather than compelling Americans to accept an
    inferior government-run system that literally restricts medical
    care to regulate cost, why not focus on creating conditions
    long proven to bring down prices while simultaneously improving
    quality in every other good or service in the United States?
        Incentivizing empowered consumers to seek value for their
    money with cheaper, broadly available, higher-deductible care
    less burdened by regulations; markedly more valuable expanded
    health savings accounts; tax reforms to eliminate
    counterproductive incentives; and then coupling that with
    strategic increases by deregulation and breaking down anti-
    consumer barriers to competition in the supply of doctors and
    hospitals.
        These reforms would permit all Americans, rich or poor, to
    access the same excellence of medical care that the affluent--
    including some of the most strident advocates for single-payer
    care for the rest of us--all use for their own personal
    healthcare. Thank you. 1A\1\
    ---------------------------------------------------------------------------
        \1\ Dr. Atlas' prepared statement has been retained in committee
    files and also is available at https://docs.house.gov/meetings/IF/IF14/
    20191210/110313/HHRG-116-IF14-Wstate-AtlasS-20191210.pdf.
    ---------------------------------------------------------------------------
        Ms. Eshoo. Thank you.
        Now we will--we have concluded the witnesses' opening
    statements, and we will move to Member questions, so I am going
    to recognize myself for 5 minutes for questions.
        Now we have, obviously, the whole span of what, thinking,
    on public and private health insurance and that has been
    expressed rather eloquently by each witness. I am taken with
    the following, and that is that the percentage of people that
    still are not insured in our country. I don't understand why
    people that are eligible are not enrolled. It is such a loss
    because they are subjected to all of the things that we know--
    Mr. Morley, you spoke to them and that they are not enrolled,
    that is a whole other issue--but at 6.8 million people in our
    country.
        Now, in terms of the ACA, we have brought the percentage of
    uninsured down, so--but we need to always remember that there
    were 14 States where Governors denied their own constituents
    the coverage that they were entitled to where the Federal
    Government for 5 years was picking up the full tab.
        I would like to hear from each one of you--and I am sorry
    to say this, Dr. Atlas, but I think that you don't agree with
    anybody on the panel, but you can try to answer the question.
    You may have----
        Dr. Atlas. I will give it a shot.
        Ms. Eshoo [continuing]. Something that you like somewhere.
    But for each one of you, in terms of the thoughtful proposals
    that have been put forward by the nine Members of Congress,
    what do you think will best help to achieve universal
    healthcare in our country? So I will start with Ms. Rosenbaum.
        Ms. Rosenbaum. Thank you very much.
        Ms. Eshoo. And everyone be brief. You have 3 minutes to
    answer that, and that will be my only question. But I am
    curious to hear from each one of you what fits with your
    thinking.
        Ms. Rosenbaum. Thank you. So, if you look at the number of
    people in the United States who are not enrolled but who are
    eligible for something, the overwhelming majority will tell you
    that they can't afford it. And getting to affordable quality
    coverage, of course, is a very complicated thing to do. I think
    the reality for this country over the past half century has
    been an employer system that was limited in its reach to begin
    with. It worked very well and continues to work well for people
    who are in a position----
        Ms. Eshoo. But what do you think? I mean, my question is
    very specific.
        Ms. Rosenbaum. Right.
        Ms. Eshoo. Of the nine proposals, is there anything--given
    your background, research, all that you know--that you think
    would best help us achieve universal healthcare in the country?
        Ms. Rosenbaum. Yes. I think, because of the backdrop, there
    has got to be some combination, and it may change over time, of
    a strong public insurance option coupled with potentially
    private insurance option for people who have good comprehensive
    coverage.
        Whether you ever take the next step----
        Ms. Eshoo. Thank you. Thank you. But we need to get to the
    others, all right. And you are going to have the opportunity to
    tell me more with written questions that will be submitted to
    all the witnesses.
        Mr. Morley?
        Mr. Morley. Thank you for asking this question. I just have
    to say I have, you know, the majority of my advocacy has been
    defending the Affordable Care Act, so----
        Ms. Eshoo. Thank you for that.
        Mr. Morley. You are so welcome. But I have very limited
    opportunity to think proactively, but I take my cues from
    Congresswoman Schakowsky, all of them. I support all of them.
    Anything that is going to get us access, to increased access, I
    believe in all of them.
        Ms. Eshoo. You are so beautiful.
        Ms. Ross, we already know where you are, right? But if you
    want to restate it.
        Ms. Ross. I would like to start by saying that we have
    always been very appreciative of the ACA, very appreciative.
        Ms. Eshoo. Oh, and we appreciate what the United Nurses did
    in that effort, certainly.
        Ms. Ross. Because it moved us so much closer to making sure
    that everyone got care. Now we need to take the next step. It
    won't do it anymore, not as long as private insurers are
    involved.
        Ms. Eshoo. OK.
        Ms. Ross. We have to eliminate barriers to care and,
    really, Medicare for All is the only one that will do that.
        Ms. Eshoo. Thank you.
        Dr. Holtz-Eakin?
        Mr. Holtz-Eakin. Yes, I would say two things. First, I want
    to echo the importance of genuine delivery system reforms to
    make whatever gains in coverage you achieve sustainable,
    because they just won't stay unless we do that. It is why I am
    very worried with the Medicare for All. That is going backwards
    to fee-for-service medicine, which this committee with MACRA
    recognized was not the way to go.
        In terms of the low-hanging fruit, there is a report out
    today that there are 4.7 million people who could sign up for a
    zero-premium Bronze Plan today, so it can't be cost. There is
    something else going on. Cover those people.
        Ms. Eshoo. Thank you very much.
        Dr. Atlas. Yes, I mean the disconnect, in my view and with
    my proposal, is that the goal is not to label someone as
    insured. The goal should be to bring the cost of medical care
    down. And when you bring the cost of medical care down,
    insurance premiums come down because 80 percent of insurance
    premiums are due to cost of care, and all government outlays
    for programs for healthcare are much less, and by that way you
    broaden access to care.
        So the way to do that is to empower patients by putting
    them in the driver's seat in controlling the money, to getting
    rid of the regulation that has falsely stopped competition----
        Ms. Eshoo. Yes, I appreciate it, and it reflects your
    original testimony.
        And I should just announce that December 15th is the
    deadline for enrollment, so whomever is listening in--if it is
    C-SPAN and everyone else--we are talking about insurance,
    affordable coverage, everyone understand, December 15th.
        And now I would like to recognize--thank you, witnesses,
    for answering my question. Now it is a pleasure to recognize
    the ranking member, the gentleman from Texas, Mr. Burgess, for
    his 5 minutes of questions.
        Mr. Burgess. Thank you.
        And, Dr. Atlas, let me just give you a few minutes to wrap
    up what you were saying, or a few seconds to wrap up what you
    were saying.
        Dr. Atlas. Yes. Well, the basic plan should be to get
    people to be incentivized to save money on healthcare by higher
    deductibles, paying more directly, cheaper insurance, and
    therefore care about the cost of care to increase the supply of
    competitors for that money, and to get rid of the, really,
    incorrect incentives in the current tax code that make people,
    incentivize people to spend more on healthcare.
        That is the way everything in the United States gets
    reduced price with higher quality. That is exactly how it
    works, and it can work with healthcare, as we have evidence
    that it does.
        Mr. Burgess. Well, and I thank you for your observations. I
    thank you for your testimony. It was some of the most
    interesting I have read in a while.
        Dr. Holtz-Eakin, can you talk somewhat about the--well, I
    guess the phenomenon is cross-subsidization. Currently, the
    current Medicare system does not reimburse for the cost of the
    care so that cost, that delta, is covered by generally
    employer-sponsored insurance or individual insurance. Can you
    speak to that? What would happen in a world where there was no
    longer the ability for that cross-subsidization?
        Mr. Holtz-Eakin. I am deeply concerned about that in these
    proposals, (A) because there is evidence that many institutions
    have negative Medicare margins. They lose money seeing a
    Medicare beneficiary. Proposals that would move everyone to
    Medicare levels of reimbursement or something close to that run
    the risk of turning everyone into that position, and that risks
    cutting off access to care entirely, particularly if you have a
    single rural hospital. It can't pay the bills. That is a
    concern to me.
        The importance of that level of reimbursement for things is
    brought home by some of the work the administration did on
    international drug prices where the attention was that drugs
    are cheaper elsewhere. But what was not caught in that proposal
    was that, of the 27 most expensive drugs that Medicare patients
    in the United States get and use, only 11 were available in all
    of the other 16 countries that were studied.
        If you don't reimburse at adequate levels, people do not
    get access to modern care. That is what I am concerned about.
    Getting rid of the commercial subsidy runs that risk.
        Mr. Burgess. And, of course, as you know, I spent years of
    my life trying to get rid of a Medicare formula called the
    sustainable growth rate formula and----
        Mr. Holtz-Eakin. Congratulations.
        Mr. Burgess [continuing]. The effect of that, of course,
    was to limit the number of providers who would--I mean, one of
    the questions I got at town halls when I first became a Member
    of Congress was, How come you turn 65 and you have got to
    change your doctor? And the answer was because their doctor was
    no longer taking Medicare, was not a participating physician
    because of the ratcheting down of reimbursement rates that
    happened automatically every year, year in and year out.
        Dr. Atlas, if you could--and you didn't mention it in your
    oral testimony--but in your written testimony you talked a
    little bit about the difference in infant mortality rates--
    United States, other parts of the world--and I think the
    statement that you have is about how in the United States the
    effort to save some of the most premature infants is different
    from other parts of the world.
        Some people would argue, well, maybe that is not a
    worthwhile activity. But I will just tell you, in 1976, I am in
    medical school and a neonatal intensive care unit was unheard
    of, and today every good-sized hospital has one, so our ability
    to take care of those infants has increased because of that. I
    just wonder if you had any thoughts on that.
        Dr. Atlas. Yes, I do. I think this is very important vis-a-
    vis what has been said about both life expectancy and infant
    mortality. These statistics are very coarse and poorly
    calculated numbers, and I will give you the specific reason
    why. Infant mortality, for instance, is not a valid indicator
    at all because, when you look at the way it is calculated, the
    European countries--the United States counts every live birth
    as a live birth with one heart rate, one heartbeat, one
    respiration. That is WHO criteria. When you look at countries
    in Western Europe who are so-called pure nations, some of them
    don't count infants as having been born unless they are a
    certain gestational age or unless they survive 24 to 48 hours.
    They don't count the babies who died as having been born if
    they don't live that long.
        So you can imagine, in a fraction, if you change the
    denominator you have a totally invalid statistic. This is
    documented in the peer-reviewed medical literature. This is not
    my assertion.
        Same thing with life expectancy, although a little bit
    different. Most of the deaths in young people in the United
    States are not even due to illness. Immediate gunshot wound to
    the head in murder is not a reflection of healthcare quality,
    OK. And when you look at, for instance, lifestyle behavior is
    very different in the U.S. than other countries. Forty percent
    of the difference in life expectancy between the U.S. and other
    countries is due to one lifestyle behavior: obesity.
        If you standardize for these things, you see these
    statistics are not meaningful. That is why, to me, the best way
    to sort of compare health systems is to look at outcomes in
    diseases.
        Ms. Eshoo. It is hard for me to cut people off, but you
    are----
        Dr. Atlas. I am sorry there are too many facts, but----
        Mr. Burgess. A lot of facts.
        Ms. Eshoo. Yes.
        Mr. Burgess. But, just before I yield back, I would like to
    ask unanimous consent to add to the record a letter from the
    Texas Hospital Association and the American Hospital
    Association.
        Ms. Eshoo. So ordered, happy to place it in the record.
    Thank you. The gentleman yields back.
        Now it is a pleasure to recognize the chairman of the full
    committee, Mr. Pallone.
        Mr. Pallone. Thank you, Chairwoman. I should thank you for
    having this hearing. I was one of the drafters of the ACA and
    obviously very proud of that fact, and I do believe that the
    ACA could have and still can achieve almost universal coverage.
    I mean, the idea was that, you know, 65-some percent of the
    people get their insurance through the employer, and then we
    had this large group of people who buy insurance individually
    on the marketplace but can't afford it, so the idea was to try
    to make it affordable, and that is where the subsidies came in.
        And the mandate, you know, the idea of the mandate was
    that, you know, we will give them enough of a subsidy so they
    will buy insurance rather than paying a penalty to not buy it.
    But there were still two groups that were still out there even
    with that scenario, one where those who wouldn't be able to pay
    a premium--and that is why we wanted to expand Medicaid--and
    then the last group were the uninsured--I mean, I am sorry, not
    the uninsured, the undocumented, which as far as I am
    concerned, you know, we should have addressed and we had a
    debate, but we couldn't get the votes.
        So I wanted to ask Ms. Rosenbaum, you know, with regard to
    the Medicaid expansion, you know, it was not supposed to be
    optional under the ACA, but the Supreme Court holding in NFIB
    v. Sebelius said they had a choice whether to expand or not,
    and if all of the States were willing to put aside this
    partisanship and act in the best interest of their residents, I
    think we would be much closer to the goal of universal
    coverage.
        So let me quickly, because I want to get to the
    undocumented, can you tell us as of today how many States have
    expanded Medicaid?
         Ms. Rosenbaum. Everybody but 14. A couple are still on the
    verge of phasing in, but there are 14 left.
        Mr. Pallone. OK. And for those States that expanded
    Medicaid, you know, they got a pretty generous deal in terms of
    how much of that cost is paid for by the Federal Government,
    correct?
        Ms. Rosenbaum. Yes.
        Mr. Pallone. And Congressman Veasey's bill that we are
    considering today, the Incentivizing Medicaid Expansion Act,
    would make that offer even more generous, correct?
        Ms. Rosenbaum. Yes.
        Mr. Pallone. So, if all States were to expand Medicaid as
    originally intended by the ACA, how many people do you think
    would gain coverage that don't have it now?
        Ms. Rosenbaum. We are at about 15 million now. It is
    roughly another 2 million people, a little more than 2 million
    people.
        Mr. Pallone. OK. Now do you want to--and not open-ended,
    because I want to get to the undocumented--but would you give
    me any sense of why you think these States are still rejecting
    the Medicaid expansion? Is it strictly ideology? What is it, do
    you think?
        Ms. Rosenbaum. This has been looked at a lot. I would say
    it is a deep philosophical opposition to the expansion. Cost
    certainly doesn't explain it. The Federal financing doesn't
    explain it, even at the current rate. So I would say we are
    dealing with something deeper.
        Mr. Pallone. Ideological, all right.
        Now let me get to the undocumented. You know, we know that
    a large portion of this country's uninsured rate comes from
    undocumented individuals. What would you--like, if we covered
    all the undocumented, what, you know, what do you think
    percentage-wise that would mean?
        Ms. Rosenbaum. Well, I mean, that would be universal
    coverage, their proposals that are universal up to legally
    present immigrants and also that address the short-term, the
    people who have been here for less than 5 years.
        Mr. Pallone. Well, let me put it to you this way.
        Ms. Rosenbaum. But undocumented----
        Mr. Pallone. Let's assume that everybody who was----
        Ms. Rosenbaum. Yes.
        Mr. Pallone [continuing]. Legally here, documented, had
    insurance coverage. I think we--would it be accurate to say we
    would still maybe be only at 95 percent because there would be
    another 5 percent that are undocumented? I mean, I know that is
    a huge----
        Ms. Rosenbaum. Right. No, and it is not a good thing for
    any healthcare system to leave anybody out, in my opinion.
        Mr. Pallone. OK. But would you agree, you know, even if
    everyone was covered who is legal, you would probably still
    have another 5 percent of the total population that is not
    covered because they are undocumented.
        Ms. Rosenbaum. Yes. Yes.
        Mr. Pallone. OK. So, I mean, I agree with you. It doesn't
    make any sense. You get sick, you spread disease. I mean, what
    are we talking about here? It is, you know, you can't operate
    in isolation, so, I mean, those undocumented people obviously
    have healthcare needs. How do they get that care, and what cost
    does that add to our system? How is this--does this make any
    sense--I don't think so--to not cover the undocumented in terms
    of the cost to our system and how we operate?
        Ms. Rosenbaum. Those who are willing to come forward use
    isolated public health services. In extreme situations they
    would turn to an emergency department, but the care is uneven,
    too late, and too many people live in the shadows, really,
    without any healthcare at all. There are no waiting lists for
    people who are uninsured.
        Mr. Pallone. But also doesn't it just not make sense from a
    cost point of view, because if those people got preventive care
    and were able to see a doctor, they wouldn't end up in the
    hospital emergency room because they wouldn't get as sick. I
    mean, do you want to comment on that?
        Ms. Rosenbaum. Absolutely. And it is very difficult to
    begin to quantify these kinds of shifts, but very important to
    bring everybody in to deal with health problems before they
    become serious enough to be high cost.
        Mr. Pallone. All right, thank you so much. Thank you, Madam
    Chair.
        Ms. Eshoo. The gentleman yields back. It is a pleasure to
    recognize the gentleman from Illinois, Mr. Shimkus, for his 5
    minutes of questions.
        Mr. Shimkus. Thank you, Madam Chairman, and I appreciate
    the hearing and I appreciate the people in the healthcare
    sector because this compassionate, trying to do the right
    thing, even those who are trying to make sure we can pay for it
    adequately, we are on it for the right reasons.
        You know, I was here when we passed Medicare Part D. It was
    helpful. I was here when we did expansion of Medicare
    Advantage, very helpful. So--but numbers and budgets and
    dollars matter. So, Dr. Holtz-Eakin, what happens with the
    hospital insurance, HI Trust Fund in 2026?
        Mr. Holtz-Eakin. At that point it will be exhausted and----
        Mr. Shimkus. What does that mean, ``exhausted''?
        Mr. Holtz-Eakin. It means that the payments out to
    hospitals will have cumulatively exceeded the payroll taxes
    that go in, and at that point there will not be the legal
    authority to reimburse for care.
        Mr. Shimkus. Can you say that again?
        Mr. Holtz-Eakin. At that point it will be illegal for you
    to reimburse hospitals for their care to Medicare
    beneficiaries. They will have to do it, but----
        Mr. Shimkus. So how do--by adding more people to Medicare,
    how does it help solve this 2026 funding problem?
        Mr. Holtz-Eakin. It would not help solve. That would
    increase the outflow without raising the inflow.
        Mr. Shimkus. So it actually would create an insolvency much
    sooner.
        Mr. Holtz-Eakin. Yes.
        Mr. Shimkus. And, Dr. Atlas, you identify this in your
    testimony, kind of, on your Figure 3 here in your statement.
    And this is no different than our problems with Social
    Security: Workers today pay for Medicare for our retirees. That
    more people are retiring and living longer, it is financially
    unsustainable. Is that what you are trying to say here on this
    Figure 3?
        Dr. Atlas. Yes. What figure you are alluding to shows that
    the number of workers funding per Medicare beneficiary started
    out when the program started at 4.6, and now it is about 2-
    point-something. And so, when you have not enough people
    working to fund the program at the same time as this explosion
    of an aging population and actually a positive of people living
    longer, living longer also means incurring more medical
    expenditures because older people have these----
        Mr. Shimkus. Well, let me reclaim my time, and I appreciate
    that. So I want our friends here to understand that there is a
    funding crisis. I have said it for 20 years. Someday, someone
    is going to believe us, that there is a funding problem on
    Social Security, there is funding problem with Medicare.
        And we are part of the problem on Medicare, because who in
    this room--who doesn't get visited by people saying the coding
    for fee-for-service is screwed up, pay us more, right? Who
    doesn't get visited by folks here in the audience who say we
    are not compensated enough, right? And that is going to
    continue.
        Let me ask a question to both of you, Dr. Holtz-Eakin and
    Dr. Atlas, what happens when a new product comes to market
    under Medicare for All?
        Mr. Holtz-Eakin. It is not clear.
        Mr. Shimkus. OK. And we are talking about this too. We have
    this big H.R. 3 drug debate about, well, maybe 10 new
    blockbuster drugs won't get to market, some estimates are a
    hundred. If you are the patient who is looking for that
    lifesaving new drug, you want to be able to get it. And it is,
    I think, the countries that we have talked about who have
    single-payer systems, their actuary--not actuary, but their
    listing--it takes a long time for new products to come on the
    market, is that correct?
        Mr. Holtz-Eakin. That is absolutely correct. In the U.S. of
    new brand-name drugs, new therapies becoming available, 95
    percent are available in 3 or 4 months. That number is about
    half that size elsewhere.
        Mr. Shimkus. Right. And Medicare Advantage under Medicare
    for All, what happens to that?
        Mr. Holtz-Eakin. It is gone.
        Mr. Shimkus. It is gone.
        Let me finish with this. I am from rural America. A lot of
    our hospitals are not-for-profit, faith-based institutions and
    who do their best to cover folks.
        Madam Chairman, I would like to submit two letters for the
    record from the National Right to Life Committee, April 29,
    2019, and the March for Life Action, and whenever you are
    willing to do that, and I know you may want to look at it.
        But I want to read a statement: ``There are certain key
    details of this legislation that would mean dramatic and
    radical departure from longstanding abortion-related policy.
    The legislation would require government funding of abortion
    without limitation and also likely would require unwilling
    hospitals and doctors to perform abortion procedures.''
        When you go into a government system and you don't have
    choice, you have to play by the rules.
        And, Madam Chairman, I would like to submit those two, and
    I yield back my time.
        Ms. Eshoo. I will review them and advise the gentleman as
    to whether they will be placed in the record.
        Mr. Shimkus. Thank you.
        Ms. Eshoo. OK, it is a pleasure to--the gentleman yields
    back. It is a pleasure to recognize our colleague, Mr. Engel
    from New York, for his 5 minutes of questions.
        Mr. Engel. Thank you, Madam Chair, and I have a lot to get
    in. I am going to see if I can do it all, but let me first say
    healthcare continues to eat a growing share of every American
    family's income. We know that from years of watching this and
    also from the testimony today.
        The trend is reflected by the healthcare sector consuming
    an increasing portion of our Nation's GDP. In 2016 it has
    accounted for 18 percent of our GDP, but in 2026 it will jump
    to 20 percent, and that trend is unaffordable and
    unsustainable. And every day, like my colleagues, I hear
    heartbreaking stories from my constituents about how families
    are having to choose between paying for lifesaving healthcare
    and other necessities such as groceries.
        So I am pleased to be an original cosponsor of the Medicare
    for All Act and a founding member of the Medicare for All
    Caucus. This legislation will improve and expand Medicare for
    all Americans and will provide new benefits, including dental,
    vision, and hearing, all without copays, premiums, and
    deductibles. As I have said many times before, healthcare is a
    human right, and I believe that H.R. 1384 will help every
    American access high-quality healthcare.
        Ms. Ross, let me ask you, could you please describe how
    Medicare for All will save money and put our Nation's
    healthcare expenditures on a sustainable financial footing?
        Ms. Ross. I think the biggest savings in Medicare for All
    will come from administrative costs, because right now there
    are so many different plans to administer. Nurses and doctors
    just want to care for their patients. That is their main goal,
    so without the interference of those insurance companies we can
    actually do that. So you have got the lowering of the
    administrative costs. You have got accurate budgeting which we
    have not had before that is actually sustainable.
        Mr. Engel. Thank you.
        Madam Chairwoman, I would like unanimous consent to submit
    into the record a letter in support of H.R. 1384 from 253
    leading economists discussing how this bill will reduce
    healthcare costs while guaranteeing every American access to
    comprehensive care.
        Ms. Eshoo. So ordered.
        [The information appears at the conclusion of the hearing.]
        Mr. Engel. Thank you. Let me also say again, Madam Chair, I
    want to thank you and Mr. Pallone for holding today's important
    hearing.
        The ACA, the Affordable Care Act, which I helped author, I
    was on this committee when we tried so hard, first to get
    everyone covered and then--for a public option--we didn't have
    the votes. But the ACA has enabled over 20 million Americans to
    become covered, including a hundred thousand of my
    constituents, and yet despite this remarkable progress, the
    Trump administration is taking actions to gut the ACA,
    including promoting junk plans and curtailing outreach
    programs. This committee has led the charge to reverse this
    sabotage through legislation such as the Strengthening
    Healthcare and Lowering Prescription Drug Costs Act, and I want
    to thank Chairwoman Eshoo for her hard work with that.
        With that said, we must continue to build on the ACA's
    success, and two of the bills before us today introduced by New
    York, my colleagues in New York, Brian Higgins and Antonio
    Delgado, would create public options to help improve access to
    coverage. Let me ask Ms. Rosenbaum, how would a public option
    as envisioned by the bill as drafted by Congressmen Higgins and
    Delgado help strengthen the ACA marketplaces?
        Ms. Rosenbaum. What they would do is introduce a
    competitive alternative to private plans for especially
    vulnerable older Americans, whose healthcare costs are quite
    expensive, relatively speaking. This would give them a more
    affordable way to buy care.
        Mr. Engel. Thank you.
        And, finally, Mr. Morley, I have a question for you because
    I want to thank you for coming from my hometown, New York City,
    to testify. One of the hallmark features of the ACA is that it
    prohibits health insurance companies from discriminating
    against Americans living with preexisting conditions such as
    diabetes. The Center for American Progress estimates that
    nearly 311,000 of my constituents below the age of 65 have a
    preexisting condition, and the Trump administration's efforts
    to weaken these protections through regulatory actions
    jeopardize the health coverage of my constituents.
        So I want to thank the leadership of Members like
    Congresswoman Kuster who authored the Protecting Americans with
    Preexisting Conditions Act. The House is fighting back against
    these policies. So, Mr. Morley, could you describe the impact
    that eliminating the ACA's protections for preexisting
    conditions would have on your ability to access healthcare
    services?
        Mr. Morley. It wouldn't just obviously be mine, it would be
    for 130 million Americans so I can't really speak for myself on
    that. I think the stress of all the sabotage that has been done
    by the Trump administration has been really overwhelming at
    times. I have lost a lot of sleep, as I am sure a lot of people
    have. That is the number one concern I hear from people.
        But limiting my access to care, insurance companies can go
    back to discriminating against me. And, as I stated in my oral
    testimony, you know, I have experienced that already, and it
    has cost me tens of thousands of dollars. And I had the ability
    to work at that point in my life, and I don't have the ability
    to work anymore, so there is no way that I could pay for that.
    I have monthly infusions. Each one of my infusions for my lupus
    costs $10,000, and there is no way I could pay for that.
        Mr. Engel. Thank you. Thank you, Madam Chair.
        Ms. Eshoo. The gentleman yields back.
        I just want to add something to what the gentleman from New
    York said relative to the ACA and the public option. The House
    passed that. It was the Senate that fell short on--we all feel
    strongly about it because we fought so hard and we achieved
    what we wanted to achieve in the House, but I think it is
    important to have that as part of the record.
        It is a pleasure to recognize the gentleman from Missouri,
    Mr. Long, for his 5 minutes of questions.
        Mr. Long. It is a pleasure to be recognized by my buddy,
    the Madam Chairwoman, and thank you. And thank you all for
    being here today on this extremely important topic. Every day
    we hear of someone. In fact, when I go home, I usually give
    them the health report, and it just seems like every day
    someone is coming down with a disease, someone we know, someone
    we are close to, near and dear to.
        My daughter--she is 30 now--25 years old she was diagnosed
    with Hodgkin's lymphoma. She went through all of the treatments
    and lost her hair, got her hair back, and is doing very good
    now. In fact, going to get married next October. And I am
    wearing today my St. Jude's Children's Research Center tie that
    I am very passionate about and have been for over, well, close
    to 40 years now, I guess, but over 30 years.
        When I was an auctioneer before this life, for 30 years I
    was on the National Auctioneers Board of Directors, and we
    picked one national charity to support, and that was St. Jude,
    so I always try and showcase my St. Jude tie at any
    opportunity.
        Sunday night, we were at the Kennedy Center Honors. Two of
    the honorees, one that founded Earth, Wind and Fire, suffered
    from Parkinson's disease before his demise, and Linda Ronstadt,
    who had to give up singing--one of the most beautiful voices
    ever--was honored Sunday, and she had to give it up due to
    Parkinson's disease. So, again, it is a very, very important
    topic, and thank you all for being here.
        Dr. Atlas: First name Charles, middle name Charles, any?
        Dr. Atlas. Not many people know who that was anymore, I
    don't think.
        Mr. Long. I am showing my age, but I have never met an
    Atlas that wasn't named Charles, so I am just----
        Dr. Atlas. OK.
        Mr. Long [continuing]. Curious, but inquiring minds want to
    know.
        But if you think back to 2013, with the rollout of
    healthcare.gov and all the issues that they had getting the
    website opening up, and I think six people actually were able
    to sign up that first day. It took months and months to get it
    where it was fully functional and more than $1\1/2\ billion
    over budget to get it up and going. In the end, healthcare.gov
    website finally launched about 3\1/2\ years after the passage
    of the Affordable Care Act.
        The Medicare for All bill is estimated to cost over $30
    trillion and would fully transition from our current healthcare
    system to a single-payer system in 2 years. So if the United
    States Government couldn't build a functioning website in 3\1/
    2\ years and went massively over budget trying, how can we
    possibly expect the Government to successfully transition to a
    single-payer system in just 2 years and stay on budget? Any
    comment?
        Dr. Atlas. Yes. I don't think there is an answer to the
    question, except I would say to the point about why single-
    payer, why Medicare for All will save money, it is because the
    same reason that every other single-payer system is less than
    the United States. They restrict the use of healthcare and they
    have worse results for that. So, if that is what people, voters
    are interested in doing, having worse healthcare and having
    more people die like Canada and England and everywhere else and
    no access to these drugs that we enjoy as Americans, you know,
    that would be a reform that would be appropriate.
        I think the best way to get access is to reduce the cost
    for everyone just like it is done--that is why the cellphone in
    your pocket, it is a supercomputer, doesn't cost $20,000, from
    competition and empowering consumers who care about the price
    of what they are actually directly buying.
        Mr. Long. OK. The Harvard School of Business determined
    that the lack of relevant experience, lack of leadership, and
    time constraints were the primary factors leading to
    healthcare.gov's initial failure. Do you believe the United
    States Government currently has the manpower, resources,
    management talent, and expertise to fundamentally take over our
    healthcare system?
        Dr. Atlas. Not in the Government, no. The private sector
    would.
        Mr. Long. OK. In your testimony, the opposition to single-
    payer should not--you said the opposition to single-payer
    should not focus only on requirement for massive new taxes, but
    instead on the well-documented half century of its failure to
    provide timely, quality medical care. This failure is not just
    about low=priority checkups or routine appointments, it is
    about people that are seriously ill. You note that the U.K.'s
    NHS system has set a standard and declared it would be
    acceptable for 15 percent of cancer patients.
        And I have spoken of cancer patients, including my
    daughter, here this morning to wait 2 full months. And when I
    think of the day that I took her to the emergency room here in
    Washington and first was told her there was nothing wrong and
    go home, but they had an IV in her arm and she couldn't get
    dressed and go home. They decided to do an x ray and they came
    back and they said ``You have a large mass in your chest, and
    it is malignant.'' Waiting 2 full months for treatment would
    definitely have not been acceptable in her case, or it should
    not be in anyone's case, and one out of five patients has to
    wait over 2 months for their first treatment of cancer.
        And I am beyond my time by 20 seconds, and I yield back to
    my friend.
        Ms. Eshoo. The gentleman yields back. I am a kind
    chairwoman. I have a hard time cutting people off. It is only
    at the urging of others that I do this. So it is a----
        Mr. Long. That is an auctioneer's gavel. I can do that.
        Ms. Eshoo. Yes. He is a real live auctioneer. You can hear
    it in his voice, can't you?
        Now all the--let's see, we have all of our women to ask
    questions. The gentlewoman from California, Ms. Matsui, is
    recognized for 5 minutes for her questions.
        Ms. Matsui. Thank you very much. And I want to thank the
    witnesses for all being here today and thank Chairwoman Eshoo
    for having this hearing here today.
        You know, for the past decade, our healthcare system has
    been constantly under attack. Republicans in Congress and the
    statehouses across the country have made it their mission to
    repeal or systematically undermine the Affordable Care Act. The
    goal of universal coverage has long been, as we always say, a
    North Star for the Democratic Party. We believe everyone should
    have access to care, and I was disappointed when more
    progressive policies to expand coverage were ultimately left
    out of the Affordable Care Act.
        But that is why this moment presents a unique opportunity.
    The ACA improved the quality of basic care everyone receives.
    It unlocked access to care for Americans who have been
    historically shut out of or priced out of the system. It has
    expanded coverage to over 20 million Americans since it was
    signed into law. While acknowledging our successes, we must
    also recognize the need for improvement, the need to look up
    again at the North Star of universal coverage and ask ourselves
    what comes next.
        It is my hope that today we can have a productive
    conversation about how to obtain universal coverage, increase
    the role of Federal Government in lowering the cost of care,
    and maintain our role as the global leader in cutting-edge
    treatments and health technology. Our path forward will say a
    lot about who we are as a nation.
        Healthcare touches all of our lives in some way. That is
    why I am excited by the proposals before us today, all of which
    are united by the common goal of improving the access and
    affordability of healthcare. California is the first State in
    the Nation to improve coverage affordability for low- and
    middle-income consumers by expanding subsidies available
    through our ACA marketplace, Covered California. California has
    also reinstated the individual mandate tax penalty. As a result
    of both policies, plans sold through our health insurance
    marketplace saw A record-low statewide average rate change of
    less than 1 percent for 2020, bringing savings and stability to
    the entire individual market.
        Many of the bills we will discuss here today would enhance
    ACA premium tax credits and cost-sharing subsidies to
    marketplace enrollees. Ms. Rosenbaum, can you briefly explain
    how the ACA subsidy cliff works and what groups face the
    biggest affordability challenges as a result of this phenomena?
        Ms. Rosenbaum. Yes. There are two kinds of subsidies under
    the ACA: There is a premium subsidy, and then there is a cost
    sharing subsidy. The premium subsidy begins at the Federal
    poverty level and it ends at 400 percent of poverty, and it
    essentially works by keeping down your cost of coverage to a
    certain percentage of your income. Currently, the subsidy has
    sort of a steep cliff and ends completely at 400 percent of
    poverty.
        The cost-sharing assistance is similar in that it
    essentially discounts the cost of care at the point of service,
    but its cliff is steeper. It ends at 250 percent of poverty.
        Ms. Matsui. Right. So you would agree that improving
    subsidies is key to increasing coverage for both low- and
    middle-income individuals?
        Ms. Rosenbaum. Absolutely. It is the number-one reason why
    people----
        Ms. Matsui. So if we were to scale these solutions
    nationwide, how would you expect enhanced subsidies coupled
    with return of the individual mandate to impact overall
    uninsured rates and the stability individual marketplace?
        Ms. Rosenbaum. Estimates suggest that just those two
    changes alone, probably along with, of course, something for
    the Medicaid expansion States that have not expanded, would
    probably raise the insured levels by at least 10 million
    people, even more with autoenrollment.
        Ms. Matsui. Sure. Now, in the Medicaid expansion States,
    the ACA is working as we envisioned, filling historical
    coverage gaps tied to income level by expanding Medicaid
    eligibility and providing subsidies for purchasing coverage. In
    nonexpansion States, many adults whose incomes are above
    Medicaid eligibility but below the threshold for subsidies are
    trapped in a coverage gap.
        Ms. Rosenbaum, how many people nationwide would be eligible
    for Medicaid if their States expanded?
        Ms. Rosenbaum. It is slightly more than 2 million people.
        Ms. Matsui. So are larger populations of people caught in
    the coverage gap concentrated in certain States or parts of the
    country?
        Ms. Rosenbaum. Yes. They are disproportionately people of
    color. They are disproportionately residents of southern
    States.
        Ms. Matsui. Mr. Morley, I just want to make a comment.
    Thank you for your testimony. We really do understand what you
    have been going through, and we really want to work on behalf
    of you and many other patients such as yourself. And thank you
    for sharing your unique perspective with us. I am equally
    concerned about the actions taken by the administration to
    undermine Medicaid and the ACA protections and that have
    increasingly exposed, you know, consumers to coverage gaps.
    And, believe me, that is what we are trying to do today, to
    ensure that we level the playing field and understand how
    important it is. Thank you very much, appreciate it.
        Mr. Morley. Thank you very much for saying that. I
    appreciate that.
        Ms. Eshoo. The gentlewoman yields back. It is a pleasure to
    recognize the gentleman from Kentucky, Mr. Guthrie, for his 5
    minutes of questions.
         Mr. Guthrie. Thank you very much. Sorry. There is another
    hearing of this full committee, a subcommittee that was meeting
    earlier, and it was on foreign drug inspections, so I wasn't
    able to hear your stories, Mr. Morley. But God bless you and
    thanks for being here to share.
        What I kind of want to talk about with Dr. Atlas and Dr.
    Holtz-Eakin is, I think all of us here are wanting people to be
    covered with--the question is that we get to when you look at
    Medicare for All, how does it change the healthcare system we
    have today?
        We are currently in discussion this week about H.R. 3,
    which is setting a price for pharmaceuticals. We all want lower
    drug prices, and there is a bipartisan bill to do that, but now
    we are going to where we are setting drug prices to the point
    where CBO says we will get less, 8 to 15 less drugs over the
    next 10 years. And people on this committee in that hearing
    said, if we are going to lose miracle cures or--they didn't say
    that, I won't put the words--if we are going to lose some cures
    because we are going to have lower drug prices, that is a
    tradeoff we are willing to pay.
        I like to take people when they come to my district to
    Owensboro, a fantastic medical center; Bowling Green, two
    medical hospitals; Elizabethtown, a medical hospital; Danville,
    Ephraim McDowell, father of modern gynecology, hospital, and
    just say, if we were in a European state or Canada, a city this
    size would not have a hospital of this quality, in my opinion.
    I mean, and I tell them, take me to a city of less than a
    hundred thousand people that have world-class--we can do heart
    surgery. We do a lot of different things.
        So the concern as we go down this path is--and we have to--
    it is not just a slogan that we can put on a bumper sticker or
    a T-shirt, it is, How is this going to affect the healthcare
    system that Americans have? We can cure sickle cell anemia.
    We--cystic fibrosis is going to be a disease that people can
    live with further. It is going to be a maintenance disease.
    Artificial pancreases, available now. Just the things that are
    coming out of this country, and we are subsidizing the rest of
    the world. And that is an issue that we try to address in H.R.
    19 on drugs, is that we have a U.S. trade negotiating or
    negotiate with other drugs.
        But just ramping down payments and giving, in order to get
    a hundred percent universal coverage in one plan, Medicare for
    All, at the expense of that which I don't see how you take that
    much money out of the system and not lose hospitals. For
    example, under the Affordable Care Act we did Medicaid
    expansion and within--and my State expanded, Kentucky--and with
    Medicaid expansion, it was paid for by decreasing the DSH
    payments, disproportionate share payments, because if everybody
    is covered, we are not going to have to have these subsidies.
        Well, I will tell you, every rural hospital in Kentucky
    today, an expanded State, would say if--and we are making it
    up, we are doing Medicaid expansion and DSH payments because it
    just doesn't work--they would all say they would close or have
    difficult--particularly the smaller ones. I won't say Owensboro
    or Bowling Green, but the smaller hospitals would close, they
    tell me, if we didn't make up the DSH payments when the policy
    was everybody be covered, but the problem is the payments are
    so low, even the people covered, the hospitals can't make it
    up.
        So, Dr. Atlas or Holtz-Eakin--or I will open it up to
    anybody--what do you see, if we go to a one-size reimbursement
    for Medicaid, Medicaid to all of our hospitals and our
    providers, what kind of healthcare system would you see? For
    instance, we know under H.R. 3 that 50 percent of the drugs
    that would be priced under H.R. 3 are not available in Canada.
    They are not. They are just not available. That is just a fact.
        And so, what would you see with our----
        Dr. Atlas. Well, I will answer about the drug pricing issue
    that hasn't been brought up. You look at what a single-payer
    system does with drug pricing, we can look at the NHS. They
    have a budget impact test of 2017. They set a number, and if
    the system is going to cost 20 million pounds or more for a
    drug, they are not going to have that drug available, and they
    are going to ``negotiate,'' and they give themselves 3 years.
        If your wife has breast cancer and wants one of these new
    drugs, she is going to sit there for 3 years while the
    government, the NHS, negotiates that price down. It has been
    calculated by the NHS itself and the Alzheimer's Foundation in
    the U.K. that a drug for Alzheimer's would have to cost less
    than $4 a month to be approved, because so many people need it.
    So if you look at this way, ironically, the more people that
    need the drug when you are capping the total expenditure--the
    more people that need the drug, the less likely it will be
    available. That is what the NHS Budget Impact Test does.
        You can't have the government, a third party--the
    government doesn't care if your wife doesn't get her drugs. She
    cares if she doesn't get them.
        Mr. Guthrie. Well, this is what I want to point out, is
    that we can't just sell that we are creating a whole new
    payment system and not affect the healthcare system we have. I
    think people are envisioning we are going to have exactly what
    we have and somebody else is paying for it, and that is not
    what will happen, in my opinion.
        Dr. Atlas. Well, we know that the CMS Actuary just now said
    it that their warning in 2018, hospitals and nursing facilities
    and in-home care are going out of business because they are
    losing money per patient. If you lose money per patient, you
    don't make up for that in volume, as the old joke goes.
        Mr. Guthrie. Dr. Holtz-Eakin--well, I am out of time.
        Mr. Holtz-Eakin. Yes, I mean, that restricts access to
    existing technologies. And in the data we see that increasing
    quality, which is the adoption of a medical innovation, is
    correlated with higher reimbursements, you put all that risk.
    And the international evidence shows it. Our domestic evidence
    shows it as well.
        Mr. Guthrie. Thank you very much. I yield back.
        Ms. Eshoo. The gentleman yields back.
        I have a factoid, and that is a lot of people have said
    things about the Affordable Care Act. All Members of Congress
    receive their healthcare through the Affordable Care Act. All
    staffers receive their healthcare through the Affordable Care
    Act. I think there is only one member who has not accepted it,
    and that is Dr. Burgess, but that was his choice. So I think
    that we have a lot of people invested in it and I just can't
    help but say, ``Thank God for Medicare and Medicaid.'' Where
    would people in this country be without that coverage?
        So it is a pleasure to recognize the gentlewoman from
    Florida, Ms. Castor, for her 5 minutes.
        Ms. Castor. Well, thank you, Chairwoman Eshoo. And let me
    thank you for this hearing, because it isn't it refreshing that
    we can focus on how we are going to lower the cost of
    healthcare in America, expand access, build upon Medicare and
    Medicaid and the Affordable Care Act, so thank you very much.
        Dr. Rosenbaum, in your testimony you cite the lasting and
    measurable achievements under the Affordable Care Act.
        And, Peter Morley, thank you for being here and speaking on
    behalf of millions of Americans with preexisting conditions.
        When you say the Affordable Care Act, here we are 10 years
    later, it is time to take stock. What stands out to you
    overall, Dr. Rosenbaum?
        Ms. Rosenbaum. I think the remarkable effect of the
    affordability provisions, the enormous impact of the market
    reforms for people like Peter Morley, and the vision of
    combining access to affordable coverage with, actually,
    improvements in communities to access to care.
        Ms. Castor. So the protection. No longer can an American be
    discriminated against for any preexisting condition. It has
    been very meaningful for young people to stay on their parents'
    policies until they are age 26.
        And to Mr. Shimkus, who was here: Remember, the Affordable
    Care Act extended the life of the Medicare Trust Fund, and it
    strengthened Medicare, and it helped to close the doughnut
    hole. Now, the Democrats this week are going to pass one of the
    missing links to allow Medicare to negotiate prices and drive
    down drug costs and then carry that over to private insurance,
    so that is going to be a great thing for families.
        You know, coming from the State of Florida, boy, there is
    some good news and there is some really difficult news. We have
    led in the marketplace every year. We have about 1.8 million
    Floridians who sign up for affordable coverage under
    healthcare.gov. At the same time, we have a little less than a
    million of our residents who are stuck in the coverage gap.
    That means they are too poor to access the tax credits. This is
    crazy, OK. Floridians--and this goes for Texans too--we want to
    bring our tax dollars home. And Leavitt Partners did a study--
    recently it came out--$13.8 billion of your tax dollars, they
    want to give them back to the State of Florida so that about a
    million of our residents can get signed up for Medicaid health
    services.
        Chairwoman Eshoo, when you talk about this cohort of people
    who don't have health coverage, because of that Florida, the
    fact they haven't expanded Medicaid, 10 percent of all working
    adult or all uninsured adult population comes because of that
    coverage gap, so I appreciated Chairman Pallone and
    Congresswoman Matsui highlighting this.
        Dr. Rosenbaum, can we just--we can look at Mr. Veasey's
    legislation to increasing incentives, but I mean $13.8 billion,
    we would cover people, it would help our GDP, we would be able
    to hire, we would be healthier, infant--I mean across the
    board. What else can we do? We have to just go ahead and say we
    intended Medicaid to be expanded under the Affordable Care Act.
    Do we have to craft that again and pass it, and would it
    withstand scrutiny of the Supreme Court?
        Ms. Rosenbaum. Well, certainly, further incentivizing
    States to expand coverage is a good idea. Why a State would not
    expand coverage is a bit of a mystery, especially since the
    expansion would not only extend coverage to all the people who
    are left out, but would actually bring down the cost of
    premiums in the marketplace because, in States that start their
    marketplace coverage at 138 percent of poverty, the premiums
    tend to be lower, so it is good all around.
        Ms. Castor. Can we just pass the law? Go back and----
        Ms. Rosenbaum. Unfortunately, the Supreme--well, the
    Supreme Court has said that expansion on a mandatory basis is
    no longer constitutional, but certainly many people have
    thought--I am among them--that sweetening the pot is a very
    good thing to do in hopes that the expansion will happen.
        Ms. Castor. So, Peter Morley, thank you for providing a
    real-world example of how meaningful it is to have healthcare
    coverage. You know, we are in the holiday season now, and is
    there any better gift to a loved one than health insurance? And
    remind us what the deadline is.
        Mr. Morley. First of all, thank you for saying that. I
    spent 3 days in Congress last week, in the House and the
    Senate, making videos with people like Congresswoman Castor.
    The deadline, the Federal exchange deadline, is December 15th.
        Ms. Castor. Wow. That is Sunday, I think.
        Mr. Morley. It is Sunday. Go to healthcare.gov. That is the
    way that we keep enhancing the ACA. And just to add, when you
    talk about Medicaid expansion, a lot of people--I have heard
    for the majority of people in Texas and Florida--those are two
    major States that have not expanded Medicaid, and I am very
    sympathetic and compassionate to that, so thank you for
    mentioning that.
        Ms. Castor. Thank you.
        Ms. Eshoo. I made the announcement, December 15th, whomever
    is tuned in.
        It is a pleasure to recognize the gentlewoman from
    Delaware, Ms. Blunt Rochester, for her 5 minutes of questions.
        Ms. Blunt Rochester. Thank you, Madam Chairwoman. And I
    want to thank both panels for your testimony and the
    deliberations.
        As I was sitting here listening to the testimony, I thought
    of a quote from Martin Luther King that says of all the forms
    of inequity, injustice in healthcare is the most shocking and
    inhumane. A decade ago, this very subcommittee debated one of
    the country's most sweeping and comprehensive pieces of
    healthcare policy, the Affordable Care Act. Twenty million
    Americans gained health coverage through either the marketplace
    or Medicaid expansion, and for the first time, patients
    received critical protections from things like coverage denials
    because of a preexisting condition, like you shared, Mr.
    Morley, or lifetime limits on essential health benefits.
    Delaware alone saw the State's uninsured rate drop to 5
    percent.
        But an issue that it still plaguing our healthcare system
    is cost. I held town hall meetings, I met with families, I met
    with small businesses in my State, and three things kept coming
    up. For many, the out-of-pocket costs were unaffordable. For
    some there were gaps in coverage or they were underinsured.
    And, number three, health inequities and disparities still
    persist, which is why we are still talking about maternal
    mortality in this country.
        Since hearing those concerns, I have been working on a
    comprehensive strategy, the Cap Costs Now Act. I am going to
    say it again, the Cap Costs Now Act. My bill would cap out-of-
    pocket costs, including premiums, deductibles, and copays, so
    no one is spending their whole paycheck for healthcare, no
    matter where they are getting their health insurance. The Cap
    Costs Now Act would allow us to achieve truly universal
    coverage by automatically covering everyone through an easy-to-
    navigate system with new options for coverage such as a
    Medicare E program for those 50 to 64. Finally, the bill would
    align incentives in our healthcare system to better tackle
    health inequity and continue our nation's move towards value-
    based care.
        Unaffordable, out-of-pocket healthcare costs aren't just an
    issue in my State. The Commonwealth Fund has found that about
    one in six Americans face healthcare costs they can't afford,
    even with health insurance. Deductibles alone have tripled in
    the last decade. More than 4 in 10 workers enrolled in a high-
    deductible plan reported that they don't have enough savings to
    cover their deductible. In other words, in the words of one of
    our previous witnesses, if you can't afford it, you don't have
    it.
        So I would like to thank my colleagues for their
    leadership, who were on the first panel, and their work on the
    various pieces of legislation, and I would like to thank all of
    you who are on this panel. We all want our constituents to have
    quality healthcare, and we all want our constituents to be able
    to afford it. With my plan, we can move towards affordable,
    universal coverage without starting from scratch or removing
    the 180 million Americans in employer-sponsored insurance from
    their existing plans. We can immediately get to the work by
    building on the current foundation of our Nation's healthcare
    system to provide everyone with coverage that is affordable and
    universal.
        As I begin to roll out my healthcare proposal in the
    upcoming weeks, I want to encourage my colleagues to look out
    for it and to support the Cap Costs Now Act. Thank you, and I
    yield back.
        Ms. Eshoo. The gentlewoman yields back. A pleasure to
    recognize the gentleman from Georgia, Mr. Carter, for his 5
    minutes of questioning.
        Mr. Carter. Thank you, Madam Chair. And thank all of you
    for being here. I appreciate this very much, you taking time
    out. This is extremely important, extremely important to the
    future of our country, to the future of healthcare in our
    country in particular.
        I find it interesting that we are having this discussion
    during the same week that we are also going to be voting on
    Speaker Pelosi's bill, H.R. 3, that is going to essentially
    keep up to a hundred lifesaving drugs from coming to the market
    if it were to be enacted, and that comes from the Economic
    Development Commission, and that is what they have proposed.
    Even CBO tells us that we can expect anywhere from 8 to 15
    drugs not to come to market if this were to be passed.
        But, Dr. Atlas, I wanted to ask you, because I think your
    testimony really tells the full story. It has come up in our
    debates about the anticures bill, H.R. 3, as you mention in
    your testimony as well that other single-payer systems have far
    fewer choices in terms of medicines available to them. Is that
    correct?
        Dr. Atlas. That is absolutely true. And, since most new
    drugs are cancer drugs, people die because of that.
        Mr. Carter. You cited some figures. I listened attentively
    to your opening statement about other countries and comparing
    us to what is available here in America as opposed to what is
    available in those other countries. Do you have that by chance
    again?
        Dr. Atlas. Yes, I do, because I was speaking so quickly
    that probably no one remembers what I said.
        Mr. Carter. I would like to make sure they do remember what
    you said, because I certainly heard it.
        Dr. Atlas. The latest data on the 54 new cancer drugs
    launched from 2013 to '17 in the world, within the 2 years, the
    United States' patients had 94 percent available, Brits had 70
    percent, Canada's cancer patients had 53 percent of those
    drugs, France 43 percent, Australia 28 percent. It is proven in
    economics but not in--and in drugs in particular. when you cap
    prices, you are going to stop the production, the availability
    of good and the innovation of that good.
        The real solution to drug prices is to figure out why they
    are costing so much, because the cost of developing a drug has
    exploded over the past decade to $2\1/2\ billion in 15 years,
    and nobody is going to develop a drug if they are not going to
    get that money back. So we as a government, really, have added
    a lot of bureaucracy and a lot of hurdles and therefore cost to
    the development of new drugs, and that is where the attention
    should be focused.
        Mr. Carter. And, you know, for those of you who don't
    know--and I am sure members of the committee know--currently I
    am the only pharmacist serving in Congress. I spent my
    professional career dealing with this. I have seen nothing
    short of miracles.
        Ms. Eshoo. We are so glad that you said it.
        Mr. Burgess. Yes, who knew?
        Ms. Eshoo. Who knew? That is right.
        Mr. Carter. Excuse them.
        But anyway, I have seen nothing short of miracles through
    the way of research and development and what has come on the
    market. I give the example all the time of the drug Sovaldi.
    Now here is a drug that, when I first started practicing
    pharmacy in 1980, if you were diagnosed with hepatitis C, you
    were going to die. I mean, that is all there was to it. Now how
    phenomenal is it that we can cure that disease with a pill?
    That is simply phenomenal to me. Someone who was there at that
    time, who saw people who came in who were diagnosed with that
    disease and knew that they were diagnosed that they were going
    to be dying soon, but now we can treat them. That is
    phenomenal.
        Now, you know, the thing that concerns me so much is that
    both sides, both Democrats and Republicans, want the same
    thing. I get it. I understand that if a drug costs $85,000 and
    is not accessible to you, it does you no good whatsoever. I get
    the fact that we need to bring prescription drug prices down.
    But I also understand that there are other things that we can
    do aside from what is being posed in H.R. 3 that will lower
    drug prices without stifling innovation, and that is what I am
    trying to get to here.
        And let me ask you, Dr. Atlas, why would these countries
    restrict their patients' access to these medications? Is it
    simply just to manage the cost of government?
        Dr. Atlas. That is exactly--well, they are trying to
    minimize the cost that they are paying out for their healthcare
    system, and the way that they all do it is to restrict the use
    of care, the availability of technology, the availability of
    drugs, and their results of their survivals in these specific
    diseases are worse than ours.
        Mr. Carter. Exactly. And again, I don't fault my colleagues
    on the other side of the aisle. They want the same thing I
    want. We all want the same thing, to bring the prescription
    prices down, and we can do that. And I see the need for
    transparency so much, because I know what is going on here and
    I know that there are middlemen who are bringing no value
    whatsoever to the system but are taking profits out of the
    system.
        And thank you again, Dr. Atlas, for being here and for
    bringing up this important point. Thank all of you for being
    here. Thank you, Madam Chair, and I yield back.
        Ms. Eshoo. The gentleman yields back. It is a pleasure to
    recognize the gentleman from Massachusetts, Mr. Kennedy, for
    his 5 minutes of questions.
        Mr. Kennedy. Thank you, Madam Chair. I want to thank my
    colleagues for, I think, unanimously, as this one, all agreeing
    how important this hearing is. Grateful to be here for it. I
    want to thank our witnesses for your courage, for your
    testimony, for your service, and for your perspective. It is
    important that we get this right.
        Let's start by just walking through some of the comments
    that I think some of our colleagues have made and has been put
    forward in testimony, this question that some aspect of a more
    robust guarantee of access to coverage is somehow going to make
    sure that drugs are not available. Ms. Ross, are you familiar
    with the statistic that roughly 26 percent of patients in need
    of insulin ration their care?
        Ms. Ross. I am.
        Mr. Kennedy. And so does that seem like insulin is in fact
    readily available in the United States of America?
        Ms. Ross. It does not.
        Mr. Kennedy. When we talk about the fact that procedures
    might end up in expanded wait times, are you aware that for
    GoFundMe, that popular crowdsource fundraising website, that a
    third--a third--of the donations of a GoFundMe page are used
    for healthcare costs. Were you aware of that?
        Ms. Ross. I am aware of that.
        Mr. Kennedy. Are you aware that the founder of GoFundMe
    said that, quote--I will get this more or less right--that he
    did not, they did not intend to found a site that would be one
    of the most influential healthcare companies, but it turns out
    that they did, as a GoFundMe page?
        Ms. Ross. I did hear that, yes.
        Mr. Kennedy. And we talked about wait times and access to
    care. Are you aware, Ms. Ross, that 55 percent of the counties
    in our country do not have a single practicing psychiatrist,
    psychologist, or social worker?
        Ms. Ross. I am aware.
        Mr. Kennedy. Are you aware of the fact that about over 50
    percent of the adults in this country in need of mental
    behavioral illness will not get the access to care today?
        Ms. Ross. Yes.
        Mr. Kennedy. Are you aware of the fact that that is
    actually worse for kids?
        Ms. Ross. Absolutely.
        Mr. Kennedy. So I was at a regional hospital on my district
    a little while ago--keep in mind, in a State with 98 percent,
    98 percent of people covered with health insurance, 98--there
    was a little boy that was waiting that was being boarded. He
    had been waiting for over 150 hours and counting, waiting for a
    bed. That they couldn't get the stretchers down the hallways in
    the emergency room because there are so many patients suffering
    from mental illness waiting for a bed.
        That a mom had come in to my office, now a couple years
    ago, detailing her daughter's challenges with mental behavioral
    illness, and at one point their daughter was boarded on the
    neurology floor at an academic medical center in Boston for 19
    days as they called looking for a bed from Virginia to Maine.
    Nineteen days. Any guess as to how much it would cost to board
    a child at a neurology floor waiting for a bed in Boston?
        Ms. Ross. A lot.
        Mr. Kennedy. That sounds about right to me.
        Mr. Holtz-Eakin, I think, would agree with ``a lot''
    figure. Fair enough?
        Mr. Holtz-Eakin. It is a good estimate.
        Mr. Kennedy. So I point these stories and these statistics
    out because I think the reality that I think many of us
    experience in our healthcare system today is that, when we talk
    about quality, when we talk about access, when we talk about
    what treatments are available, without question--without
    question--they are right. Without question from a perspective,
    Dr. Atlas, what you just said is correct.
        The challenge--where I would challenge you and challenge
    others on this is that the focus of that system ends up being
    on those who have access to it and not the drastic number of
    Americans that don't. And the fact that, even today in a place
    like Massachusetts that is so proud of the healthcare industry
    that we have invested in and that we have nurtured, that a
    story that ran in the Boston Globe about 8 months ago--no,
    about a year ago--about an African-American woman who slipped
    and fell in a minority part of Boston, broke her wrist, got in
    a cab and went to Boston Medical Center, the old city hospital.
    She broke her wrist out in front of or down the block from New
    England Baptist. It is where the Boston Celtics go to get an
    orthopedic surgery. She didn't even know that the hospital was
    there. And, even if she did, it wouldn't have mattered, because
    it is a private hospital and they don't take Medicaid.
        But when we have, when Medicaid--shifting gears--is the
    largest payer of mental behavioral services in this country,
    and the vast majority of providers won't take Medicaid because
    the reimbursement rates are so low, yes, if I can afford to pay
    out of pocket, I have access. But for so many others that
    don't, they don't. Mr. Morley would not be here but for the
    grace of God, of Affordable Care Act, and the fact that
    certainly--I mean, Mr. Morley, you have been eloquent about
    your story, but how many people in this country, how many
    people are even forced to have to tell your story?
        Mr. Morley. Honestly, I have lost track. I really--it is, I
    mean, I will never understand why all can't just work together
    to bring that access for everyone.
        Mr. Kennedy. And so, my time is up here. I will just say
    this. This is complex, and this is complicated, and there are
    tradeoffs. But the core question here is that, for a system
    that every single one of us will draw on, whether you are born
    into a system or whether you welcome a new child or watch a
    loved one pass through it, why would we not want to make sure
    that it is a system that is there for everyone else, the same
    system that we want for a loved one? And I yield back.
        Ms. Ross. Could I add one comment to that?
        Mr. Kennedy. That is up to the chair.
        Ms. Ross. Would I be allowed?
        Ms. Eshoo. Well, I think we need to move along because it
    is 24 minutes past--or yes, seconds past the gentleman's time.
    I now would like to recognize the gentleman from Virginia, Mr.
    Griffith, for his 5 minutes of questions.
        Mr. Griffith. Thank you, Madam Chair..
        Ms. Ross, we try to get along on this committee. If you
    have something short, say it.
        Ms. Ross. Thank you. It is very difficult for me to hear
    the comparisons to other countries' single-payers with the
    constant comment that people are dying and denied care. As long
    as the for-profit motive is present in this country, that is
    what is happening now. The only way for them to make their
    profit is to deny care.
        Mr. Griffith. Well, and I don't necessarily agree with you
    on that and would take exception, but we try to be courteous on
    this committee and try to work together.
        That being said, Dr. Atlas, today many rural hospitals are
    closing because they cannot afford to stay in business, leading
    to access problems for sick Americans. One of the major reasons
    for these closures is that Medicare--and Mr. Kennedy mentioned
    Medicaid--doesn't pay hospitals enough. According to MedPAC,
    hospitals are unable to make money caring for Medicare
    patients. If it wasn't for privately insured patients, even
    more hospitals in rural communities would close. Research by
    the consulting firm Navigant predicts that a Medicare public
    option plan would put up to 55 percent of rural hospitals at
    high risk for closure.
        Now I say this with the backdrop that my rural western
    Commonwealth of Virginia district has lost two hospitals in the
    last few years. We are trying to get one of them back. But many
    of the plans we are discussing today involve expanding
    Medicare. If more patients are covered by government
    healthcare, won't that lead to even more rural hospital
    closures and access problems?
        Dr. Atlas. Well, absolutely, of course. Like I said before,
    the CMS Actuary put out the statistic that--and in fact the
    statement that--we expect access to Medicare-participating
    physicians to become a significant issue, quote/unquote. And
    the reason is because Medicaid and Medicaid pay not just lower
    than private insurance, but below the costs of delivering the
    care. That is the point. And so it brings you back to what I
    believe is the whole solution that should be the focus, which
    is to reducing the cost of care without needing to limit or
    restrict the use of care. If you reduce the cost of care,
    everybody gets access, including those on government programs.
        Mr. Griffith. Yes, and I appreciate that. And I guess, you
    know, the question is begged, How can we guarantee access to
    care for patients in rural areas on a Medicare for All plan if
    there are no open hospitals in rural communities? And, for
    those who haven't heard me say this before, sometimes you can
    look at a map and Point A to Point B doesn't look like it is
    very far, but when you have a mountainous district like I do--
    it may be Haysi to Dickenson--the mayor of Haysi plans on an
    hour if he is going to a meeting in Dickenson for travel time.
        And the same is true when we closed down the Scott County
    Hospital. That meant a minimum of 45 minutes to an hour for
    many of the people in Scott County to get to the nearest
    hospital just for basic stuff, not even counting something that
    might be more complex.
        But how can we guarantee that those folks are actually
    going to have care? It is not like getting in a cab and going
    to the next hospital down the road. There is no hospital down
    the road.
        Dr. Atlas. Well, that is--again, the solution is to
    introduce the forces that bring down the prices for every other
    good or service in the United States. That is how you ensure
    access. Not just based on price, but based on value or quality.
        Mr. Griffith. Dr. Holtz-Eakin, anything to add to that?
        Mr. Holtz-Eakin. Well, I think that is the essence of it. I
    don't think anyone is here to defend the status quo. The
    question is, How can you go forward and what set of reforms
    would deliver a downward pressure on delivering the cost of
    quality care?
        Mr. Griffith. I appreciate it. And with that, I yield back.
    Thank you.
        Ms. Eshoo. The gentleman yields back. Actually, you know,
    the GAO analyzed data and found that rural hospitals in States
    that had expanded Medicaid as of April 2018 were less likely to
    close compared with rural hospitals in States that had not
    expanded Medicaid. So we deal with a lot of complexities, but I
    think the facts need to be stated so that, you know, that we
    build on the foundation of facts. And it seems to me that we
    are in an era where that foundation continues to be eroded on a
    daily basis.
        It is a pleasure to recognize the gentleman from
    California, my friend Mr. Cardenas, for his 5 minutes of
    questions.
        Mr. Cardenas. Thank you, Madam Chair, and I appreciate the
    opportunity to have this hearing. And also, to the Ranking
    Member Burgess, thank you so much. And I want to say thank you
    for pointing out that statement that, when the politicians take
    the politics out of their decision making, more people have
    access to healthcare under the current system, which you just
    pointed, out with certain States not accepting that
    responsibility and opportunity. I appreciate the opportunity to
    hear from my colleagues and other experts such as yourselves--
    thank you very much--on what it is most important of the issues
    facing our Nation. I am proud to serve on a committee that does
    not shy away from topics simply because they are difficult.
        And I myself know what it is to grow up in a family, a
    working family, where my parents faced the choice between going
    to the doctor or having enough food to feed their family, a
    choice that too many American families face today. To say that
    the establishment of federally qualified health centers changed
    our lives is an understatement. For the first time, we could
    get preventive care. We could go to the doctor when we first
    started feeling sick instead of when it was a dire emergency.
        The Affordable Care Act provided these same opportunities
    for more than 20 million Americans that before then did not
    truly have access to healthcare. Many of them live in the very
    district that I am proud to serve. Although I was not yet a
    member of this committee when the Affordable Care Act passed
    the House, I know many of my colleagues were. I think most of
    my Democratic colleagues are united in our firm belief that all
    Americans deserve access to quality health coverage. Together
    it is imperative that we continue that work, because while many
    Americans have benefited from these reforms, there are still
    too many without care. That is why it is so important that we
    are having this hearing today and discussing this very critical
    issue.
        Mr. Atlas, some of the comments that were made--and you, in
    fact, pointed out that some hospitals are closing. Hospitals
    closing, is that a new phenomenon in the United States, or have
    we had that happen over the past decades, hospitals closing
    and/or every American having access to healthcare? Are those
    two new phenomenons? Do all Americans have access to healthcare
    today?
        Dr. Atlas. Well, it is illegal to turn somebody away when
    they come to the hospital, so the answer----
        Mr. Cardenas. Yes, OK. You know, OK, I am sorry. Let me
    qualify my question a little bit better. How many Americans
    actually have healthcare coverage and direct access to
    preventive care today, a hundred percent or not?
        Dr. Atlas. Well, everyone with insurance has free
    preventive care.
        Mr. Cardenas. Does that cover a hundred percent of
    Americans?
        Dr. Atlas. No, not everybody opts for insurance.
        Mr. Cardenas. OK. OK, got it.
        Dr. Atlas. And if I could----
        Mr. Cardenas. Thank you, Mr. Atlas, reclaiming my time. I
    was trying to have a nice dialogue with you and a simple one,
    but you are complicating the answer.
        The bottom line is this: In the United States of America,
    we have--a hundred percent of Americans have never had truly
    access to healthcare. Just like I outlined in a period of time
    in my family's history when I was growing up, we truly didn't
    have access to healthcare, preventive care. Excuse me. Today,
    Americans don't--before the Affordable Care Act we never were
    at a hundred percent. During the Affordable Care Act, the new
    system, we are not at a hundred percent. Hospitals have closed
    and opened, et cetera, over the history of time in the United
    States of America.
        My point is this: What I don't appreciate is, when Members
    of Congress try to point out that today's system is the worst
    that it has been, and that is just not true. We have a system
    that needs improvement. That is true. We have a system that is
    trying to get more working families and every family and every
    child more access to healthcare, and to me that is what the
    core of this hearing is about today. How do we improve our
    system? How do we get to a better system where the percentages
    go up and the individuals and the families and the children
    truly have access to real healthcare, preventive care, et
    cetera? I hate to point out that an emergency room cannot turn
    somebody down, that is a conversation for another day. I hope
    we never have to narrow ourselves to that conversation.
        So the main thing that I think this hearing is about today
    is, How can we as elected Members of Congress in the House of
    Representatives--the people's house--how can we advance some
    legislation that will bring us to a better state, a better
    place where more Americans can appreciate the fact that they
    can live through a healthcare situation instead of die because
    of nonaccess to healthcare? That is at the core of what this
    hearing is about, and I really do appreciate all of you coming
    forward.
        Mr. Morley, thank you so much for your bravery of coming
    forth before all of us and letting us know that no one should
    suffer through what you have had to suffer through.
        Thank you very much, Madam Chair. I yield back.
        Ms. Eshoo. The gentleman yields back. The Chair now
    recognizes the gentleman from Florida, Mr. Bilirakis, for his 5
    minutes of questions.
        Mr. Bilirakis. Thank you, Madam Chair. I appreciate it so
    much.
        Dr. Holtz-Eakin, does Medicare for All repeal Obamacare?
    That is the first question.
        Mr. Holtz-Eakin. Yes.
        Mr. Bilirakis. OK. If so, why would Democrats now support
    to repeal Obamacare?
         Mr. Holtz-Eakin. You will have to ask them. I don't know.
        Mr. Bilirakis. OK. Could this be taken as an admission of
    Obamacare's failure to make healthcare more affordable and more
    accessible through increased government intervention and
    mandates?
        Mr. Holtz-Eakin. Again, I would direct you to the authors.
        Mr. Bilirakis. OK. Let me ask you this: Can it be
    guaranteed that taxes will not be raised on the middle class to
    pay for Medicare for All, or that individuals and families will
    not lose coverage under Medicare for All or that seniors'
    benefits will not be changed or reduced? Of course, your
    Medicare Advantage is very popular in my district. About 40
    percent of Medicare recipients are on Medicare Advantage, and
    we have got to protect Medicare Advantage and Medicare for
    seniors in general.
        So that is what my main concern is. Are seniors that are on
    Medicare now--traditional Medicare but also Medicare
    Advantage--could they be affected by this Medicare for All
    bill?
        Mr. Holtz-Eakin. The bill would eliminate Medicare,
    Medicare Advantage included, so that would be gone. So would
    Medicaid. It would eliminate private insurance, so those
    individuals would definitely be affected. The bill is silent on
    financing the costs, which are substantial. I personally
    believe having looked at a variety of these that it is
    implausible to imagine that that taxpayer cost could be picked
    up by a small subset of affluent Americans. It is simply too
    big of a number.
        Mr. Bilirakis. OK, so when you say that Medicare for All--
    did you feel that the reimbursement would be cut for hospitals,
    doctors and nurses, et cetera, healthcare providers in general?
        Mr. Holtz-Eakin. Reimbursements would be cut to Medicare
    reimbursement rates and some variations slightly above that,
    which is well below the average of what they get now from
    commercial players, and this would produce financial stresses,
    and those would be solved by either diminishing access and
    quality or by raising other reimbursements and the taxes
    necessary to finance it.
        Mr. Bilirakis. OK, thank you.
        Dr. Atlas, does Medicare for All lead to government
    rationing? If so, why?
        Dr. Atlas. Well, the purpose of Medicare for All, as other
    single-payer systems, part of it is going to be controlling
    costs. And the way that controls costs is certainly not by
    letting people be price-sensitive. It eliminates concern for
    price. So yes, the only way to control costs in the single-
    payer systems is to restrict care, and that means rationing of
    care. Yes.
        Mr. Bilirakis. OK.
        Dr. Atlas. That is proven all over the world.
        Mr. Bilirakis. Yes. Well, give me a specific country where
    that takes place, the rationing, please.
        Dr. Atlas. Well, the United Kingdom, Canada, every Western
    European--you know, Denmark, Netherlands, Italy, France,
    everywhere.
        Mr. Bilirakis. OK, thank you very much. I appreciate the
    answer. This is very dear to my heart. I am cochair of the Rare
    Disease Caucus. Increasing access to breakthrough cures and
    treatments, again, are one of my priorities, and I am sure the
    entire committee, both Democrats and Republicans, that is one
    of their priorities as well. How would Medicare for All impact
    patients with rare diseases, in your opinion, Dr. Atlas?
        Dr. Atlas. Well, I think that there is sort of an indirect,
    longer-term problem with single-payer systems, and that is they
    don't just control the costs by restricting access to things
    like new drugs. I mean, the drugs, new drugs, are the basis for
    the new survivals for these rare diseases, generally speaking,
    but they also are going to inhibit innovation because, if you
    are reducing the costs by restricting the use and restricting
    the upside of developing new technology and new drugs, the
    goods are not produced. That is just a fact.
        Mr. Bilirakis. OK, thank you very much.
        Madam Chair, if no one else wants my time, I will yield
    back. And I do appreciate you holding this hearing and then
    allowing us to ask the questions.
        Yes, I will be happy to yield, if you would like, please.
        Ms. Kelly. Thank you so much. I just wanted to----
        Ms. Eshoo. Put your microphone on, please.
        Ms. Kelly. I was looking right at you, Ms. Ross, so--and
    you were shaking your head. I just wanted to give you an
    opportunity to respond to my colleague's question or comments.
        Ms. Ross. Well, obviously we are not proponents of denying
    care to people. We are proponents of making sure that everybody
    gets them. There has been a lot of discussion about the rural
    hospitals, very near and dear to our hearts too. You are right.
    The main reason is the nonexpansion of Medicaid, but the other
    is the for-profit motives of private employers, hospital
    corporates that come in and they opt for a model that will
    serve them better, make them more money, so they close off
    services that people in those communities really need and they
    move them to other places so that our patients cannot get the
    care that they need that they once were able to. So Medicare
    for All actually has globalized budgets, and it has a budget
    for special projects which ensures that those rural hospitals
    and others will be built and opened.
        Ms. Eshoo. Does the gentleman yield back?
        Mr. Bilirakis. Yes.
        Ms. Eshoo. Thank you. The gentleman yields back. Pleasure
    to recognize, from California, Dr. Ruiz for his 5 minutes of
    questions.
        Mr. Ruiz. Thank you very much for having this hearing, this
    very, very important hearing, and I am so happy that we are now
    presenting a variety of different options that can move the
    healthcare system in America forward, because I truly believe--
    and I know many of us in this room believe--that every American
    should get the care they need when they need it at an
    affordable low cost, and that should be our goal. Our goal in
    order to achieve that should be universal coverage. Everybody
    should have coverage. And that is how we should, (1), look at
    our efforts, and (2), making sure that out-of-pocket costs are
    low for people, for patients.
        Ms. Ross, you and I are made from the same fabric because
    we worked in the emergency departments, and so we know what it
    means to fight for people, for our patients, and put them at
    the very center of our universe. And, you know, we have made
    some progress. The ACA went a long way in moving us towards
    that goal. In fact, because of the ACA, over 20 million
    individuals are now insured.
        Let me just remind people that being uninsured is a health
    risk. Some may say how can that be? I tell you straight up it
    is a health risk, because if you don't have insurance you can't
    afford your medicine if you get sick, and you will get sicker.
    And you will present to the emergency department, if you make
    it, with ICU-type-level care and your ability to recuperate is
    even worse. So yes, being uninsured is a risk factor, health
    risk factor, and you can die for not being able to prevent
    certain illnesses.
        So this is of important urgency for all of us. We can see
    the benefits of Medicaid expansion when we look at expansion
    States versus nonexpansion States in terms of the providers and
    the hospitals. If you just expanded Medicaid in those States
    that could expand Medicaid but for political reasons chose not
    to, you would reduce the uninsured rate by 5 percent, just by
    that alone.
        So--but, unfortunately, the ACA has not been fully
    implemented. There has been a lot of changes since then to make
    it worse because the number-one singular goal of the--of, you
    know, the Republican Party since Obama passed this--was to
    destroy it, to sabotage it, to then say, ``See, it is not
    working,'' at the expense of the American people's health.
        And so, what are our next steps? You know, well, definitely
    we need to stabilize the market. We need to reduce overall
    healthcare costs. And then we have got to look at adding some
    provisions that would increase the ability for Americans to
    have coverage and therefore to eliminate the uninsured problem,
    health risks, of the American people here.
        So, Professor Rosenbaum, you know, there are a variety of
    Federal public option plans that we have looked at today to
    accomplish universal coverage. And I know the specifics of how
    we do that varies, but can you talk generally about the
    benefits of adding a public option to our current system?
    Specifically is there research to suggest that a public option
    will increase competition, lower costs?
        Ms. Rosenbaum. Yes. Thank you very much. I do believe that
    adding a strong public option both gives people access in
    communities that right now are poorly served by private
    insurance plans and by injecting additional competition into
    the system helps stabilize the cost of care and keep it under
    control.
        Mr. Ruiz. Well, you know, the thing we have to focus here
    is that we need a preferential option. We need not just any
    option, we need a preferential option. And when you look at
    health insurance, you want to make sure that it is expansive
    and protects you and will cover what you need to be covered.
    And let's--I am an emergency medicine doctor, so there is
    nobody who is immune to accidents. Nobody is immune to that
    unfortunate surprise diagnosis that you get that you never
    thought you would ever get, like cancers and whatnot.
        So we need to make sure that it is affordable and that it
    can cover as many ailments that we need to protect patients. In
    addition to that we must address a couple of other issues, and
    one is the provider shortage that we have in our country. We
    need to. We don't have enough nurses. We don't have enough
    doctors. And we need to also look at the delivery of our
    healthcare system and where we focus our resources for
    prevention and public health, not on expensive end-of-life kind
    of care, but the prevention and the public health at the
    beginning. Thank you.
        Ms. Eshoo. And the gentleman----
        Mr. Ruiz. Yields back.
        Ms. Eshoo [continuing]. Yields back. That is right. A
    pleasure to recognize the gentleman from North Carolina, Mr.
    Hudson, for his 5 minutes of questions.
        Mr. Hudson. Thank you, Madam Chair. I appreciate you
    holding this hearing today. I thank the witnesses for your time
    being with us today.
        While I support the broad goals of all the pieces of
    legislation we are considering today, which is to expand access
    to affordable health coverage, I have grave concerns with the
    impacts these bills would have on real people who need to
    access our healthcare system.
        And, Madam Chair, my friend from California just finished
    speaking, and he is and truly my friend, but I have to disagree
    with his characterization that Republicans want to destroy the
    healthcare system to score some political point. I think
    everyone in this room wants to make the system better, wants to
    make it more affordable, and I think the question is, How do we
    get there?
        First, broadly speaking, the population we are trying to
    help is roughly 28 million Americans who cannot afford
    insurance or who have decided not to purchase insurance. By
    comparison, 293 million Americans do have insurance, which is a
    little more than 9 out of every 10 people in this country are
    insured. Medicare is already going broke. The program currently
    covers roughly 44 million people in this country. Under
    Medicare for All, it would have to cover 327 million people.
    That is seven times the size it currently covers. To think that
    we could add seven times more people to the Medicare program
    without a cut in benefits defies common sense.
        Second, we would also be eliminating an entire segment of
    our economy and giving providers a massive pay cut. I shudder
    to think what would happen to access to care in rural areas in
    my district which are already hamstrung. For example,
    Montgomery County in my district, there is only one
    psychiatrist and only two part-time psychiatrists for the
    entire county, and further cuts in benefits or pay rates would
    exacerbate this problem.
        Dr. Atlas, you spoke at length in your testimony about the
    quality of care in this country compared to other countries,
    including wait times experienced by those patients. Have you
    ever studied the private systems that exist alongside the
    public system in those countries, such as in Canada or Great
    Britain, and if so, can you speak to who has access to these
    private systems?
        Dr. Atlas. Yes. There is an increasing trend in countries
    with single payers--specifically the U.K. is a florid example,
    but also all the other countries of Western Europe--that people
    with money opt out of the system--or not opt out, they pay
    their taxes, but they then supplement. There is a significant
    increase in buying private insurance, significant increase in
    paying out of pocket, and they all avoid using their single-
    payer system of the people who are affluent enough to do it.
        And that was my point, that the only people stuck with the
    single-payer system are the very people that everybody in this
    room wants to help, the low-income people.
        Mr. Hudson. So in single-payer countries the average
    taxpayer has to wait while wealthy customers don't have to.
    They can see a doctor immediately.
        Dr. Atlas. Well, that is exactly right. There is a parallel
    system, basically, in the U.K. as there is here, really, with
    the Medicaid system, which everybody in this room probably
    knows has worse outcomes than comparable patients with private
    insurance. To celebrate an expansion of Medicaid when no one in
    Congress would want that coverage for their family I find a
    little bit unconscionable.
        Medicaid has worse outcomes from surgery, cancer, heart
    procedures, lung transplants than the same patients with
    private insurance, because of the restrictive access to
    technology and drugs that Medicaid covers. My plan is to make
    Medicaid money go for a bridge towards private insurance. We
    want everybody in the country to have excellence, to have
    access to the excellence of American healthcare, not a separate
    parallel pathway for poor people.
        Mr. Hudson. I agree. It doesn't sound fair to have one
    system for the wealthy and a different one for those who
    aren't. You also testified that the trend in single-payer
    countries is moving towards private options for health
    insurance to supplement or even completely circumvent the
    government-run system. Why do you think it is, and should it be
    instructive for us as we examine these extreme proposals
    looking forward?
        Dr. Atlas. What is the question? I didn't hear it.
        Mr. Hudson. Well, just to continue on the thought, you are
    saying that, for the folks who can afford it, private insurance
    options are supplementing or replacing it. And maybe you have
    answered it already, but why do you think this phenomenon is
    happening in these other countries, that the wealthy go to a
    separate system and everybody else is stuck in the government?
        Dr. Atlas. Because the single-payer coverage restricts
    care. And as we see in the United States, we can expand
    Medicaid all we want, but Medicaid is not accepted by more than
    half of doctors, including doctors who have signed contracts to
    accept Medicaid, according to HHS data. So you label someone as
    insured, but that is not the same as having access to care.
        Mr. Hudson. All right. Well, as my time is expired, Madam
    Chair, I will yield back and thank you.
        Ms. Eshoo. The gentleman yields back.
        I just want to add, Dr. Atlas, what you said about
    Medicaid, Mr. Morley would not be alive were it not for it.
        Now we would like to----
        Dr. Atlas. Yes. We are talking about data, not individuals.
        Ms. Eshoo. Well.
        Dr. Atlas. I am talking about the data in the medical
    literature.
        Ms. Eshoo. So that doesn't include Mr. Morley?
        Dr. Atlas. No, it does. I am thrilled he is here. I mean,
    it is fantastic.
        Ms. Eshoo. Yes, we all are. And we have many Mr. Morleys in
    our country.
        The Chair now would like to recognize the gentlewoman from
    California, Ms. Barragan, for her 5 minutes of questions.
        Ms. Barragan. I thank you.
        So there was a conversation about a system for the wealthy
    and a system for the poor. That, actually, very much describes
    what we have happening in this country. You have--it is even
    worse. You have people who don't have access to any care at
    all. And so, this is the problem, and this is why we need to
    figure out how to get to universal care, because access to
    healthcare is a human right. Everybody should have access to
    it.
        Now I represent a district that is a majority minority
    district. It is almost 90 percent Latino, African American, and
    it is very working class. One of my colleagues likes to hand
    out a list of where your congressional district lies by income.
    Mine is 358 out of 435. People are struggling, and people don't
    have access to healthcare. Now, the ACA was a step in the right
    direction. It did help increase access to healthcare, but there
    are still a lot of people who are left behind, still a lot of
    people who don't have that access. And some people who may have
    something, they get duped into buying some of these junk plans,
    and then they realize they really don't have coverage.
        And so, I want to thank the panelists for being here today
    and for this conversation. Ms. Ross, I want to thank you for
    your work. My sister is a nurse, and I know that you have been
    on the front lines of fighting for Medicare for All in making
    sure that everybody has access to healthcare. And I think the
    bottom line is we can probably all agree that everybody should
    have access to healthcare, and the disagreement happens to be
    on how we get there.
        And I mentioned to you the district, the makeup of my
    district. Can you explain what the benefit would be to
    communities of color if we had Medicare for All and how the
    bill would reduce minority health disparities?
        Ms. Ross. I think I would point to again what I talked
    about with how it is administered, the globalized budgets.
    There would be negotiations between the hospital and the
    regional directors, and you would look at what you would need
    for the following year, looking at what you needed for the year
    before, for one thing, and then you would project. So if you
    knew you had rural hospitals, communities that are underserved,
    and you needed more staff in those hospitals, maybe you needed
    to build a hospital, those are the kinds of things you would
    look at putting into the budget so that people who had
    previously been unserved and underserved would be able to get
    care.
        Ms. Barragan. Great. Thank you. Ms. Ross, in addition to
    being a registered nurse, you are also a national union leader.
    As the president of the largest union of registered nurses in
    the country, we often hear politicians telling us that Medicare
    for All would be bad for union members and that unions wouldn't
    support it. But your union does support Medicare for All, as do
    many national and local unions across the country. Ms. Ross,
    can you tell us, why do unions support this bill?
        Ms. Ross. Well, right now, there is at least 9.3 million
    unions that represent New Yorkers that do want Medicare for
    All. And I think, if you look back at our history, we are to
    the point now where we can't negotiate anymore for better wages
    and working conditions, pension benefits, because everything is
    taken up with bargaining for healthcare. If you look at most of
    the strikes across the country in the last several years, they
    have all been over healthcare benefits. So I think we see the
    handwriting on the wall. And also, I know union workers who
    might like to switch jobs, but they are afraid to because they
    have got their insurance tied to their employer.
        Ms. Barragan. Thank you.
        Mr. Morley, thank you for your advocacy. You are on the
    Hill all the time, and you are very active on social media and
    you are telling your story and telling people about how
    important it is for us to fight on healthcare, something that I
    am proud Democrats have been doing and have been working on a
    bipartisan basis to make sure we find solutions as best we can
    under current conditions.
        Mr. Morley, is there anything you want to share with us,
    any considerations you want to tell us about any of the bills
    before us today?
        Mr. Morley. I just want to say I really think it is so
    important for--I would love to see more of a bipartisan effort.
    There was no need to bring up anything about H.R. 3 today
    because this is not an H.R. 3 hearing, so that makes me kind of
    angry. So any and all bills that will get us towards coverage,
    increase our coverage towards all Americans, is what I am
    trying to achieve as a patient and for all the patients that
    have reached out to me through social media. That is all I have
    ever wanted. And to protect the protections for preexisting
    conditions that are already in place, the expanded Medicaid,
    the ways that the ACA has helped Medicare, that is all I have
    ever wanted, and I don't want to see those protections removed.
        Ms. Barragan. Great. Thank you all for your work. I yield
    back.
        Ms. Eshoo. The gentlewoman yields back. The Chair now
    recognizes the gentleman from Montana, Mr. Gianforte.
        Mr. Gianforte. Thank you, Madam Chair. This is a very
    important hearing for the future of our country. I appreciate
    the panelists being here.
        Medicare is critical to Montana seniors. We should work to
    protect these benefits that they have earned. I believe the
    Federal Government must honor the commitment it made to our
    seniors, but Medicare for All will destroy Medicare as we know
    it. To a casual observer, Medicare for All sounds appealing on
    its face, but it is really just a marketing gimmick. To dig
    deeper beyond the slick marketing efforts of a catchy name,
    Medicare for All is nothing more than a government-run, single-
    payer healthcare system. It would end Medicare as we know it
    and leave our seniors in the cold. Medicare for All in practice
    is Medicare for none.
        Now, some of my Democrat colleagues will claim Medicare for
    All is a proposal out of a fringe, out-of-touch wing of the
    Democrat Party, but the truth is it has taken over the
    Democratic Party by storm. Many Democrats jockeying for the
    presidency in 2020 support Medicare for All, and half of the
    Democrats in the House have cosponsored Medicare for All. Let's
    be clear. Medicare for All would gut Medicare and the VA for
    our veterans and force 225,000 Montana seniors who rely on
    Medicare to the back of the line. Montana seniors have earned
    these benefits, and lawmakers shouldn't undermine Medicare and
    threaten healthcare coverage of Montana seniors.
        Medicare for All would devastate rural healthcare, we have
    heard that on the committee today, especially those in Montana.
    They already face overwhelming challenges. Since 2010, more
    than a hundred rural hospitals have closed their doors, and
    nearly 40 percent of all rural hospitals operate on a budget
    shortfall. Under Medicare for All, hospitals in Montana would
    take a 40 percent payment reduction. Hospitals in our rural
    areas would struggle further, and patients would lose access
    entirely to critical providers, like oncologists and heart
    surgeons. Medicare for All will lead to worse access to care in
    our rural communities.
        In addition to gutting Medicare and eliminating access to
    care in our rural communities, Medicare for All is a fiscally
    irresponsible budget buster. Elizabeth Warren, a frontrunner in
    the Democrat primary, has proposed Medicare for All that would
    cost $52 trillion. With a straight face, she campaigns that her
    plan will not raise taxes on the middle class. I don't believe
    that. It doesn't pass the reasonability test. Medicare for All
    would terrify Americans who rely on Medicare and who like their
    employer-sponsored plans. Under Medicare for All, private
    insurance would be banned.
        Folks, this is a government takeover of healthcare, plain
    and simple. We are not a socialist country. Medicare for All
    will gut Medicare and the VA as we know it and put Montana
    seniors at the back of the line. To force 225,000 Montanans who
    rely on Medicare to share their pool with everyone isn't fair
    to Medicare seniors, Montana seniors.
        In reality, Medicare for All is Medicare for none. Instead
    of a reckless government takeover of our healthcare system, we
    should take a bipartisan approach to fix our broken healthcare
    system. We should protect patients with preexisting conditions,
    increase transparency and choice, preserve rural access to
    care, and lower costs. Let's get to work on that and end this
    socialist charade.
        Now, Dr. Atlas, as I said earlier, it seems like our rural
    providers will struggle under a Medicare for All proposal. What
    do you believe will happen to rural hospitals and other
    providers under Medicare for All?
        Dr. Atlas. Well, under a single-payer system where private
    insurance is banned, we already know that Medicare pays less
    than the cost of delivering the care. These hospitals survive
    because of the extra reimbursement they get from the private
    insurers. So it is very naive to think that, oh, we are just
    going to wipe out private insurance and have the Medicare
    payments support all these hospitals. The hospitals will go out
    of business, just like the CMS Actuary said in 2018.
        Mr. Gianforte. OK. Dr. Atlas, would you agree that this
    legislation and bills like it would also require taxpayers to
    fund elective abortion with no limitation?
        Dr. Atlas. I don't know the answer to that.
        Mr. Gianforte. How would you rate--well, with that, Madam
    Chair, I am glad we are having this hearing today. It is very
    important for the American people that we preserve access to
    quality care and get costs down, and with that I yield back.
        Ms. Eshoo. The gentleman yields back. The gentleman from
    Maryland, Mr. Sarbanes, is recognized for 5 minutes.
        Mr. Sarbanes. Thank you, Madam Chair. I want to thank the
    panel.
        First of all, I want to push back pretty hard on the
    doomsday scenario that is being painted by some of our
    colleagues on the other side of the aisle, which to me amounts
    to fearmongering. There is a lot of distortions of what the
    cost of the Medicare for All proposal would be, these scenarios
    about what would happen to hospitals, rural hospitals. The fact
    of the matter is that, under the current Medicare and Medicaid
    programs there is a lot of investment, and that is what it is
    that goes into those kinds of hospitals and delivery systems.
    And so, if you had a Medicare for All system, I think you would
    continue to see that kind of investment. It is not like we
    would just walk away from these critical parts of our delivery
    system, so that has to be accounted for when we are having this
    discussion.
        The thing about the Medicare for All proposals--and there
    are many that have been presented, they all have different
    merits--to me it is the most honest in the sense that I think
    that is where we are going to land, ultimately. The fact of the
    matter is, Americans like Medicare, they like Medicaid, they
    like the veterans' healthcare system, they have basically
    already made a judgment that these systems that are delivered
    and led out of the public sector are ones that give them a
    sense of confidence about their healthcare, and so I think that
    it is just a matter of time before we get to a place where we
    have a Medicare for All system.
        As Representative Jayapal described it, it has got the
    three things you want. It has got universal coverage and access
    so everybody is covered. It has got a comprehensive set of
    benefits so people understand that when they need to see a
    doctor, they need to go to the hospital, they need to get care,
    that that is going to be available to them. And it eliminates
    the wasteful overhead and the predatory practices of the health
    insurance industry, which have inflicted a lot of suffering on
    people for decades now. So that is what Americans want. That is
    where we are going to be, ultimately.
        The discussion that we are having--we are seeing it play
    out even in the sort of the presidential sweepstakes--is how do
    you transition? How quickly do you get there? I think there is
    an appetite to get there as quickly as we can, and that is
    being discussed and it is part of what I think are very robust
    and meaningful and carefully executed analyses of the Medicare
    for All plan that have been put forward. So it doesn't help
    things to just engage in this kind of knee-jerk denigration of
    Medicare for All, pulling out of thin air some of these
    numbers, predictions, and fearmongering. That is not a
    constructive contribution to the discussion.
        Now, I wanted to ask Ms. Ross--the only thing, I only have
    a minute and a half left because I couldn't stop talking. But
    there is--Maryland just--there is just a report released by CMS
    about Maryland's all-payer model, which includes global
    budgeting, and it did show that, when you put global budgeting
    in place, in that instance you are reducing Medicare
    expenditures by 2.8 percent, hospital expenditures by 4.1
    percent, reducing admissions and avoidable hospitalizations,
    and I was just curious to get your perspective on kind of
    global budgeting.
        Obviously, many of the proposals included here, Medicare
    for All as well, incorporates, conceptually, this idea of more
    global budgeting. And so, if you could speak to how that would
    promote transparency, potentially lower costs, and benefit
    patients in underserved and vulnerable communities, if you
    think that kind of approach would achieve those things.
        Ms. Ross. I do, indeed. And I think we are lucky that we
    have the example of Maryland, because it has worked so well
    there. For those who might not know, Maryland started their
    what amounts to global budgeting in 2010, and they started with
    rural hospitals, and it was so successful then they put it in
    the rest of their hospitals, private and public. And what they
    found was--I have got some figures. Their global budget saved
    Medicare as a payer over 420 million in just 3 years. And,
    originally, their goal was to save 330 million over 5 years, so
    it was a whopping success. And, from a nurse's perspective,
    what it does for patients is wonderful, because it reduced
    infection rates, it improved care, it reduced readmission
    rates, and those are all things to look at.
        Ms. Eshoo. I need to interrupt. The gentleman's time has
    expired.
        Mr. Sarbanes. Thanks very much.
        Ms. Eshoo. And we have votes on the floor. I just want to
    inform Members that the Members that are not part of the
    subcommittee I don't think are going to have the opportunity. I
    would stay were it not for the fact that we have votes on the
    floor.
        So where is Mrs. Dingell? Is she here?
        All right, I am going to call on Ms. Kelly from the State
    of Illinois for her 5 minutes. And if Mrs. Dingell comes back,
    I will take her, but then we are going to have to close the
    hearing. So the gentlewoman from Illinois is recognized for her
    5 minutes.
        Ms. Kelly. Thank you all for your testimony today and your
    patience. One thing I have to say, you know, we worked hard
    on--I wasn't here, but my colleagues worked hard on the
    Affordable Care Act, and I don't think there is a Democrat that
    would say that was a perfect bill. But a lot of people that
    didn't have coverage received coverage, but as we know there is
    still about 27\1/2\ million people that don't have the
    coverage.
        But when I came here, instead of spending time and time and
    time trying to repeal the bill, we should have been working on
    how we could make it better, but all we faced was a wall, and I
    think we voted to repeal it 63-plus times. So, you know, let's
    be honest about, you know, what happened. And then there was
    the trifecta of Republican Senate, House, and the President,
    and we still didn't improve healthcare in this nation.
        I am the chair of the Congressional Black Caucus Health
    Braintrust, so I am very concerned about the disparities in
    health for minorities. We, when it comes to morbidity and
    mortality, I mean we lead the cause. I had a bill, the MOMMA's
    Act, that dealt with maternal mortality, and as some of you
    know black women die at 3 to 4 times the rate of white women. I
    had a bill that would take the Medicaid coverage to a year
    instead of 2 months, but I could not get one Republican on that
    bill even though we talk about, you know, we don't want two
    different healthcare systems for the poor and for the rich, but
    then when we have the opportunity we don't do it. Now we got a
    bill out, but we had to water it down.
        Now, Ms. Rosenbaum, you mentioned the need for coordination
    across healthcare, public health education, and job development
    service systems. Could you expand upon this and explain what
    are the ways to address disparities and improve community
    health aside from increasing access to care, which we all know
    is needed?
        Ms. Rosenbaum. Yes. I would like to actually begin by
    disagreeing with Dr. Atlas. I think the infant mortality
    problem in the United States is very real. It is not simply a
    matter of numbers and how we count, and it is made all the more
    real by the terrible disparities on the basis of race and
    income.
        I think it is very important to couple any health coverage
    reform legislation with provisions that do the kinds of things
    that the Braintrust has been such an advocate for, which is
    bulking up public health, bringing healthcare providers under
    sort of a broader public health umbrella, making sure that part
    of the healthcare experience is care management to be able to
    get better access to the kinds of services and interventions
    that we commonly call the social determinants at this point,
    making sure that when you walk in the door for healthcare you
    not only have good healthcare, but you have access to
    nutrition, to housing assistance, to the other things that make
    people healthy.
        The Affordable Care Act actually did a good job of starting
    that process of bridging between health and healthcare. The
    community health center expansion was, of course, incredibly
    important. The Public Health Trust Fund was important. And I
    think it is absolutely key that the Black Caucus continue as it
    was, it was the leader on those kinds of equity measures, that
    it continue to lead on these issues.
        Ms. Kelly. Thank you. And because of time, I yield back.
        Ms. Eshoo. The gentlewoman yields back. And do we have
    anyone else? Is--Mrs. Dingell leave?
        All right, I am going to place in the record the following
    documents: an article from the Century Foundation, ``Health
    Reform's North Star;'' report from the Century Foundation,
    ``Road to Universal Coverage;'' coalition letter from Advocates
    for Youth, et al.; a letter from NAACP, et al., regarding
    Medicare for All; letter from the Fraternal Order of Police in
    support of H.R. 4527; letter from the International Association
    of Fire Fighters in support of H.R. 4527; letter from the
    Healthcare Leadership Council; statement from the American
    Nurses Association; and the statement from Representative
    Cedric Richmond; and a statement from BCBS of California; as
    well as the documents that Congressman Shimkus asked to be
    entered in the record. Hearing no objections, so ordered.\1\
    ---------------------------------------------------------------------------
        \1\ The information has been retained in committee files and also
    is available at https://docs.house.gov/Committee/Calendar/
    ByEvent.aspx?EventID=110313.
    ---------------------------------------------------------------------------
        Ms. Eshoo. We will recognize the gentleman from Virginia
    for his additions.
        Mr. Griffith. Thank you, Madam Chair. I ask unanimous
    consent to include the following into the record. I understand
    these documents have been shared previously with the majority.
    It would be statements from the American Hospital Association;
    America's Health Insurance Plans; Blue Cross Blue Shield
    Association; Chamber of Commerce; Partnership for America's
    Healthcare Future; Partnership for Employer-Sponsored Coverage;
    Texas Hospital Association; March for Life letter; National
    Right to Life; Ethics and Religious Liberty Commission; Susan
    B. Anthony List; American Action Forum; American Hospital
    Association; Committee for a Responsible Federal Budget;
    Heritage Foundation; Mercatus Center; Partnership for America's
    Healthcare Future; polling from Partnership for America's
    Healthcare Future; news articles and op-eds from the Hill, the
    Washington Post; one-pagers from Blue Cross Blue Shield
    Association; Congressional Pro-Life Caucus; Partnership for
    America's Healthcare Future; and Partnership for Employer-
    Sponsored Coverage.
        Thank you, Madam Chair.
        Ms. Eshoo. So ordered.\2\
    ---------------------------------------------------------------------------
        \2\ The information has been retained in committee files. The
    American Hospital Association, Heritage Foundation, and Mercatus Center
    reports also are available at https://docs.house.gov/Committee/
    Calendar/ByEvent.aspx?EventID=110313.
    ---------------------------------------------------------------------------
        Ms. Eshoo. All Members, pursuant to committee rules, have
    10 business days to submit additional questions for the record
    to be answered by the witnesses who have appeared today, and I
    ask each witness to respond as promptly as possible to any
    questions that are submitted to you.
        Before I gavel the adjournment of the subcommittee, I want
    to thank each one of you. You have taken a great deal of your
    time, put a great deal of effort into your written testimony.
    Each one of you has the passion that you have brought to the
    witness table. You have traveled to come to be with us. I thank
    each one of you.
        At the beginning of this year, as when my colleagues
    elected me the chairwoman, the question was asked, ``Will you
    have a hearing on Medicare for All?'' And I said that I would.
    No one had to twist my arm off for it. This subcommittee has
    been the most productive subcommittee of the Energy and
    Commerce Committee, so it may be December that we are having
    this hearing, but we have taken up major legislation all year
    long. And that was appropriate, and now this hearing.
        So I thank all the advocates that have traveled to be with
    us. Thank you for your passion, for your big dreams--keep it
    up. And with that, the subcommittee is adjourned.
        [Whereupon, at 1:57 p.m., the subcommittee was adjourned.]
        [Material submitted for inclusion in the record follows:]
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