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

                          HEALTHCARE LIFELINE: THE AFFORDABLE CARE
                               ACT AND THE COVID-19 PANDEMIC

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

                                VIRTUAL HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                         WEDNESDAY, SEPTEMBER 23, 2020

                                   __________

                               Serial No. 116-126

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

          Printed for the use of the Committee on Energy and Commerce

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

                                   __________

                       U.S. GOVERNMENT PUBLISHING OFFICE
    56-465 PDF                  WASHINGTON : 2024

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

                        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...............................     2
        Prepared statement...........................................     3
    Hon. Greg Walden, a Representative in Congress from the State of
      Oregon, opening statement......................................     4
        Prepared statement...........................................     5
    Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, opening statement.........................     6
        Prepared statement...........................................     8
    Hon. Michael C. Burgess, a Representative in Congress from the
      State of Texas, prepared statement.............................   122

                                   Witnesses

    Benjamin D. Sommers, M.D., Ph.D., Huntley Quelch Professor of
      Health Care Economics, Professor of Health Policy and
      Economics, Professor of Medicine, Harvard Medical School, and
      Brigham and Women's Hospital...................................    10
        Prepared statement...........................................    12
    Douglas Holtz-Eakin, President, American Action Forum............    21
        Prepared statement...........................................    23
        Answers to submitted questions \1\
    Aviva Aron-Dine, Ph.D., Vice President For Health Policy Center
      on Budget and Policy Priorities................................    32
        Prepared statement...........................................    34
    Dean Cameron, Director, Idaho Department of Insurance............    46
        Prepared statement...........................................    48
    Peter V. Lee, Executive Director, Covered California.............    50
        Prepared statement...........................................    52

                               Submitted Material

    Letter of April 3, 2020, to Ms. Seema Verma, from Members of the
      Energy and Commerce Committee, submitted by Ms. Eshoo..........   124
    Letter to Ms. Eshoo, from Charles E. Allen, Executive Director,
      American Federation of State, County and Municipal Employees
      Council 57, submitted by Ms. Eshoo.............................   128
    Statement of September 23, 2020, from Margaret A. Murray, Chief
      Executive Officer, Association for Community Affiliated Plans,
      submitted by Ms. Eshoo.........................................   130
    Report of on August 24, 2020, by Seto J. Bagdoyan, Director of
      Audits, and Howard Arp, Director of Investigations, Forensic
      Audits and Investigative Service, GAO, submitted by Ms. Eshoo..   139
    Letter of September 22, 2020, to Ms. Eshoo and Mr. Burgess, by
      Andrew Lautz, Policy and Government Affairs Manager, the
      National Taxpayers Union, submitted by Ms. Eshoo...............   168
    Statement from Community Catalyst, submitted Ms. Eshoo...........   175

    ----------
    \1\ Mr. Holtz-Eakin did not answer submitted questions for the
      record by the time of publication.

    HEALTH CARE LIFELINE: THE AFFORDABLE CARE ACT AND THE COVID-19 PANDEMIC

                                  ----------

                         WEDNESDAY, SEPTEMBER 23, 2020

                      House of Representatives,
                                Subcommittee on Health,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 10:00 a.m., via
    Cisco Webex online video conferencing, 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),
    Upton, Shimkus, Guthrie, Griffith, Bilirakis, Long, Bucshon,
    Brooks, Mullin, Hudson, Carter, Gianforte, and Walden (ex
    officio).
        Also present: Representatives Schakowsky, O'Halleran, and
    Rodgers.
        Staff present: Jeffrey C. Carroll, Staff Director; Waverly
    Gordon, Deputy Chief Counsel; Perry Hamilton, Deputy Chief
    Clerk; Saha Khaterzai, Professional Staff Member; Una Lee,
    Chief Health Counsel; Aisling McDonough, Policy Coordinator;
    Meghan Mullon, Policy Analyst; Joe Orlando, Policy Analyst;
    Kaitlyn Peel, Digital Director; Tim Robinson, Chief Counsel;
    Chloe Rodriguez, Deputy Chief Clerk; Rick Van Buren, Health
    Counsel; Nolan Ahern, Minority Professional Staff, Health; Mike
    Bloomquist, Minority Staff Director; William Clutterbuck,
    Minority Staff Assistant; Peter Kielty, Minority General
    Counsel; Ryan Long, Minority Deputy Staff Director; Clare
    Paoletta, Minority Policy Analyst, Health; and Brannon Rains,
    Minority Policy Analyst.
        Ms. Eshoo. The Subcommittee on Health will now come to
    order.
        And due to COVID-19, today's hearing is being held,
    obviously, remotely. All Members and witnesses will be
    participating via video conferencing.
        As part of our hearing, the microphones will be set on mute
    to eliminate background noise. So members and witnesses, please
    unmute your microphone each time you wish to speak so that we
    don't have to go through, can you hear me, am I--I see lips
    moving but no sound.
        Documents for the record, will be sent to--or should be
    sent to Meghan Mullon at the email address we have provided to
    the staff, and all documents will be entered into the record at
    the conclusion of the hearing.
        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

        We begin our hearing today on a really very somber note.
    This week, our country passed the tragic milestone of losing
    200,000 of our fellow Americans to COVID. And last Friday,
    America lost its most consequential jurist of our time, Justice
    Ruth Bader Ginsburg, to pancreatic cancer. These painful losses
    are why we are having this hearing today.
        Millions of Americans are struggling. They are sick, many
    are hungry, so many are jobless. Yet on November 10, the Trump
    administration, along with Republican attorneys general, will
    argue before the Supreme Court that it should strike down the
    entirety of the Affordable Care Act. If successful--and they
    may be--21 million Americans will lose healthcare immediately.
        Protections for the 133 million Americans with preexisting
    conditions, such as asthma, diabetes, and the lasting health
    conditions caused by COVID, which has infected 7 million
    Americans to date, will be gone. Young adults will lose their
    ability to stay on their parents' health insurance until the
    age of 26. Approximately 109 Americans will face lifetime
    limits on their coverage, keeping them from being able to
    afford care for expensive illnesses like cancer, hemophilia,
    and mental health conditions.
        The title of today's hearing calls the Affordable Care Act
    a lifeline. This is the first recession where Americans who
    lose their job-based health coverage have the lifeline of
    affordable coverage because of the ACA. A recent study by the
    Kaiser Family Foundation found that for workers who filed
    unemployment claims during the pandemic, more than 20 million
    may be eligible for the ACA's Medicaid or marketplace coverage.
        Some States, including my home State of California, have
    embraced the Affordable Care Act's lifeline and offered special
    enrollment periods. As we will hear from Peter Lee, the CEO of
    Covered California, the State offered a special enrollment
    period during the pandemic. Between March 20 and August 31,
    nearly 290,000 Californians signed up for coverage through the
    enrollment period.
        I would like to enter into the record the letter I received
    from AFSCME Council 57 that said, quote: California's decision
    to have a special enrollment period for the ACA has been a game
    changer in the lives of those who have lost their healthcare
    coverage when they lost their jobs during the pandemic or have
    been impacted by the wildfires. Sadly, the Trump administration
    has not offered a special enrollment period, keeping Americans
    from the ACA's lifeline.
        The American Medical Association wrote in a friend-of-the-
    court briefing that striking down the Affordable Care Act,
    quote, at a time when the system is struggling to respond to a
    pandemic, would be a self-inflicted wound that could take
    decades to heal, unquote.
        I ask my Republican colleagues to avoid these self-
    inflicted wounds, end your decade-long fight to repeal and
    weaken the Affordable Care Act. Join us in passing the HEROES
    Act to shore up Medicaid coverage for nearly 73.5 million
    Americans across our country and help save the jobs and health
    coverage of firefighters, of police officers, teachers,
    hospital workers, and other essential workers across our
    country.
        I thank everyone, and I look forward to--we all look
    forward to welcoming and hearing from our witnesses.
        [The prepared statement of Mr. Eshoo follows:]

                    Prepared Statement of Hon. Anna G. Eshoo

        We begin our hearing today on a somber note. Earlier this
    week our country passed the tragic milestone of losing 200,000
    of our fellow Americans to COVID-19, and last Friday, America
    lost the greatest jurist of our time, Justice Ruth Bader
    Ginsburg to pancreatic cancer.
        These painful losses are why we're having this hearing
    today. Millions of Americans are struggling, sick, hungry, and
    jobless, yet on November 10th the Trump Administration along
    with Republican Attorneys General will argue before the Supreme
    Court that it should strike down the entirety of the Affordable
    Care Act.
        If successful, and they may be, 21 million Americans will
    lose health coverage immediately.
        Protections for the 133 million Americans with preexisting
    health conditions such as asthma, diabetes, and the lasting
    health conditions caused by COVID-19 which has infected 7
    million Americans to date, will be gone.
        Two million young adults will lose their ability to stay on
    their parent's health insurance until the age of
    26.Approximately 109 million Americans will face lifetime
    limits on their coverage, keeping them from being able to
    afford care for expensive illnesses like cancer, hemophilia,
    and mental health conditions.
        The title of today's hearing calls the Affordable Care Act
    a ``lifeline.'' This is the first recession where Americans who
    lose their job-based health coverage have the lifeline of
    affordable coverage because of the ACA. A recent study by the
    Kaiser Family Foundation found that for the workers who filed
    unemployment claims during the pandemic, more than 20 million
    may be eligible for the ACA's Medicaid or Marketplace coverage.
        Some states, including my home state of California, have
    embraced the Affordable Care Act's lifeline and offered special
    enrollment periods. As we'll hear from Peter Lee, the CEO of
    Covered California, the state offered a special enrollment
    period during the pandemic. Between March 20th and August 31st
    nearly 290,000 Californians signed up for coverage through the
    enrollment period.
        I'd like to enter into the record a letter I received from
    AFSCME Council 57 that said, ``California's decision to have a
    special enrollment period for the ACA has been a game changer
    in the lives of those who have lost their healthcare coverage
    when they lost their jobs during the pandemic or have been
    impacted by the wild fires.''
        Sadly, the Trump Administration has not offered a special
    enrollment period, keeping Americans from the ACA's lifeline.
        The American Medical Association wrote in a Friend of the
    Court Briefing that striking down the Affordable Care Act. ``At
    a time when the system is struggling to respond to a pandemic.
    would be a self-inflicted wound that could take decades to
    heal.''
        I ask my Republican colleagues to avoid these self-
    inflicted wounds. End your decade-long fight to repeal and
    weaken the Affordable Care Act. Join us in passing the Heroes
    Act to shore up Medicaid coverage for nearly 73.5 million
    Americans across the country and help save the jobs and health
    coverage of firefighters, police, teachers, hospital workers,
    and other essential workers across the county.
        Thank you and I look forward to hearing from our witnesses.

        Ms. Eshoo. The Chair now recognizes Dr. Burgess, the
    ranking member of the Subcommittee on Health, for 5 minutes for
    his opening statement. And please remember to unmute.
        Is Dr. Burgess with us?
        If not, then I will recognize the ranking member of the
    full committee, Mr. Walden.

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

        Mr. Walden. Well, thank you very much, Madam Chair. I
    assume you can hear me now. I will go ahead and start. I don't
    know where Dr. Burgess is, but I want to thank you for this
    hearing. It could give us a great opportunity to hear from the
    experts--and I hope wewill--on how COVID-19's pandemic has
    affected healthcare coverage in this country.
        And so we all need to have this discussion. We know
    Americans were promised, when the Affordable Care Act passed, a
    $2,500 reduction in our insurance premiums, and lo and behold,
    that obviously never happened; in fact, just the opposite.
        I remember all the stories when the ACA took over about
    people who were promised they could keep their health plan or
    their doctor, and neither of those things panned out well
    either. And meanwhile, we still have their--you know, a lot of
    folks who have no access to care, still in the 10 to 20 percent
    range in some places.
        But I think even as troubling, if not more so, is the
    issues that have arisen around the edges. Chairman Pallone and
    I have worked a lot on this issue of surprise medical billing,
    something President Trump has been out front and leading on for
    most of the time in office. And we are very close it Should
    become law, to stop this practice of surprise medical billing,
    where people think that--who have played by all the rules,
    think that they should be covered. And then as we heard in our
    hearings, turns out they get stuck with a bill for $50,000
    because somebody contracted out some facility within a hospital
    that their insurance said was covered, and they get stuck.
        I am really troubled that we have not provided for
    continuous and robust funding for our community centers. It is
    a travesty that this Congress has not done that. As you know,
    Chairman Pallone and I, with our bill on surprise medical
    billing, could have funded that. And yet for whatever set of
    reasons, that hasn't happened either. And so our community
    health centers are left wondering, in the lurch, how long will
    they have their funding, how can they do their hiring, and they
    are hanging out there.
        And so while we are having this hearing today and certainly
    will be informed thereby, I just sort of suspect that it will
    go down the lines of my friend's opening statement and perhaps
    trigger into some of the politics of healthcare as we are 45
    days out from the election or whatever it is. And so it is
    unfortunate. We have worked together on a lot of issues, and
    there is certainly a lot we could do going forward.
        It is unfortunate that we did not find common ground on the
    issues related to high cost of prescription drugs. But trading
    off innovation for--and cures, especially as we are seeing the
    fight on COVID, for the illusion that you are going to get
    cheaper prices just doesn't make sense.
        And here we are, having worked together on 21st Century
    Cures legislation in the past and investing in our National
    Institutes of Health record amounts, looking forward to the
    various companies that have spent night and day trying to come
    up with a vaccine as they move through their trials. We have
    never needed innovation more, not only in the vaccine world,
    but also in the world of therapies.
        And finally I would just say, we need to work together to
    modernize the Strategic National Stockpile. There have been a
    lot of lessons learned at every phase as we have dealt with
    this unprecedented pandemic, a pandemic that, by the way, has
    killed millions across the world, hundreds of thousands. And it
    is not just in the U.S.
        And so I think that Operation Warp Speed is something that
    we should be proud of, as the administration has moved at
    record pace to break down bureaucratic barriers while
    maintaining safety and efficacy of whatever pharmaceuticals
    become available, either treatments, which they are working on,
    therapies, as well as vaccines. These are twin needs for the
    American people and the healthcare of American people, and the
    administration has moved at record speed through this process
    to get these cures out to the public.
        So I would close with this: I know the issue of preexisting
    conditions is something that is being raised, but let's not
    forget for those Republicans in 1996, as part of ERISA, put
    preexisting condition protection into law. I have multiple
    times this Congress, from day one, literally said, if we are
    going to have this litigation in the courts, shouldn't we come
    together as a Congress and reaffirm the preexisting conditions
    for American people, and that effort has been shot down every
    time by my friends on the other side of the aisle.
        So there is a lot we can find common ground on, Americans
    expect us to do that, and I hope that after this hearing gets
    behind us, we could still work together this fall and get good
    things done.
        And I yield back.
        [The prepared statement of Mr. Walden follows:]

                     Prepared Statement of Hon. Greg Walden

        Thank you, Madame Chairwoman. And welcome to our witnesses,
    thank you forbeing here today to offer your expertise.
        Today's hearing could offer us a great opportunity to hear
    from experts about how the COVID-19 pandemic has affected
    healthcare coverage in this country. We could also discuss how,
    despite the Affordable Care Act still being the law of the
    land, the underlying costs ofhealthcare have continued to rise
    and are now being borne by patients who may have lost their
    employer-based care. Furthermore, we could also explore ways
    for the economy to safely reopen in coordination with public
    health efforts to ensure furloughed workers can come back to
    their jobs and regain the benefits they have bargained for and
    earned. I hope this hearing is an opportunity to discuss those
    worthy issues, which I believe should be of bipartisan
    interest.
        I can't help but feel, however, that today's hearing is
    somewhat political in nature. That this topic will be used as
    an excuse to admonish the Trump Administration and celebrate
    the Affordable Care Act, to relitigate partisan debates of the
    past.
        I want to be perfectly clear: Republicans support
    affordable healthcare for Americans. We also fully support
    protections for patients with pre-existing conditions. In fact,
    measures we've put on the House floor to affirm these
    protections have been denied four different times by Democrats.
    This issue is not up for debate. Holding a hearing that drudges
    up old arguments about the Affordable Care Act in an attempt to
    label Republicans as anti-patient is not only disingenuous, it
    is a waste of precious time.
        In addition to supporting pre-existing conditions
    protections, we also want to address the cost of healthcare, an
    underlying problem that I hear from my constituents about on a
    regular basis. Americas were promised their premiums would go
    down by $2500 a year if we passed the ACA but they did the
    opposite. Addressing the cost of care is why I have worked in a
    bipartisan fashion with Chairman Pallone and Senators Alexander
    and Murray on the Lower Healthcare Costs Act, a bill that would
    bring much-needed transparency into our healthcare system and
    end the nefarious practice of surprise billing. These are the
    kinds of policies we should be discussing today, policies that
    put patients back in control of their healthcare and put
    dollars back in their pockets.
        States, as the laboratories for democracy and public
    policy, are innovating to keep healthcare coverage accessible
    and affordable. My home state of Oregon, by working with both
    the Obama and Trump Administrations, has successfully applied
    for multiple waivers from CMS to invest in care and drive down
    the cost curve.
        I'm also thrilled to have Director Cameron here from my
    neighboring state of Idaho. Director Cameron: I look forward to
    hearing about your partnership with providers to keep costs
    down for patients, especially during the COVID-19 pandemic.
        As for the federal response to COVID-19, we have worked in
    a bipartisan fashion to provide trillions of dollars in relief
    to our communities. We have made testing and associated visits
    free to all patients regardless of their insurance status. We
    have poured funds into state Medicaid programs and set aside
    $175 billion for medical providers to bring accessible testing
    and treatment to patients across the country. We have greatly
    expanded coverage of telehealth services and given patients
    more flexibility in how they spend their hard-earned dollars on
    healthcare expenses during the pandemic.
        We do not believe, however, that the answer to every
    challenge is billions of dollars in increased federal spending.
    We have seen how one-size-fits-all approaches have affected the
    underlying cost of care, and we should be wary of the
    politicization of this crisis as a reason to massively expand
    federal programs. There are many types of coverage, including
    government programs, designed for times like this.
        Dr. Holtz-Eakin: I look forward to your testimony on how we
    can target our response to directly address the challenges
    created by the economic downturn associated with this pandemic.
        I want to close by urging my colleagues on both sides of
    the aisle to resist the temptation to engage in partisan
    politics; to be forward looking in our response to the COVID-19
    pandemic; and to constructively engage our witnesses to tackle
    the legitimate public policy issues that have arisen during
    this crisis. If we simply retreat into our corners and use this
    hearing as an excuse to throw rocks at the other side, the
    American people will not benefit. I yield back.

        Ms. Eshoo. Part 3 contained legislation. Cost of
    therapeutic drugs--Stockpile.
        The Chair now recognizes the chairman of the full
    committee, Mr. Pallone. There is some terrible background
    noise.
        Mr. Walden. Ma'am, I am having trouble hearing you. I would
    like to suspend this----
        Ms. Eshoo. Would everyone mute so that we don't have that?
    It is really--thank you. Oh, there it goes again.
        Frank, I think you are going to have to speak against this
    background noise.

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

        Mr. Pallone. Well, how is it now? Do you hear me well or
    not?
        Ms. Eshoo. I can hear you, yes.
        Mr. Pallone. All right, let me try to----
        Ms. Eshoo. It is still there. It is still there.
        Mr. Pallone. Thank you, Chairwoman Eshoo.
        The COVID-19 pandemic has caused an unprecedented health
    and economic crisis. As many as 200,000 Americans have lost
    their lives, more than 6 million have been infected with the
    disease, of course, tens of millions have lost their jobs. And
    millions of American families are justifiably anxious and
    concerned about both their health and their financial security.
        So as you know, the HEROES Act, which the House passed more
    than four months ago, would provide a lot of support and
    assistance to struggling families by expanding the healthcare
    safety net, increasing support to States to fund the Medicaid
    programs, and ensuring access to free treatment for COVID-19.
    But unfortunately, Senator McConnell and the Trump
    administration either do not understand the need for the
    Federal Government to take bold action, or worse, they prefer
    to willfully ignore and downplay the seriousness of the
    challenge before us.
        So let me be clear, further delay in passing the HEROES Act
    or coming up with some kind of a consensus bill will cost us
    countless lives, lasting damage to our economy, and
    immeasurable financial hardship to millions of American
    families. And unfortunately, the Trump administration is not
    interested in working with Congress to address this crisis.
        I know the President says he wants this or that, he wants a
    big bill, but hasn't really seriously sat down with the House
    leadership to come up with something that we can all agree on.
    Instead, the administration is actually seeking, in my opinion,
    to do further damage to our healthcare system and to the social
    safety net that millions of Americans have turned to during the
    crisis, and that is because the President continues to support
    this Republican lawsuit that is now before the Supreme Court to
    strike down the entire Affordable Care Act in the middle of
    this pandemic.
        And now, the President and Senate Republicans are trying to
    jam a Supreme Court nominee through the Senate, just a month
    before the Presidential election, and I believe a big part of
    that is an attempt to seal the fate of the ACA and ensure its
    demise, because the hearing before the Supreme Court begins in
    November.
        And I want to remind folks that what is at stake here, if
    the Trump administration succeeds and they do strike--and the
    Supreme Court does strike down the ACA. We would have 20
    million Americans who would lose their healthcare coverage,
    protections for more than 133 million people with preexisting
    conditions would be eliminated, and everyone who has been
    infected with COVID-19 now has a preexisting condition and, in
    my opinion, could qualify as a preexisting condition. Also, tax
    credits for affordable health coverage would be gone, and young
    adults would no longer be able to stay on their parents'
    insurance until they turn 26. And of course, there is a lot,
    much more that would be repealed with the ACA, like the Indian
    Healthcare Improvement Act, and the list goes on.
        But it doesn't have to be this way. Instead of attacking
    the ACA, the Trump administration could use it to help people
    in time of crisis. According to a Census Bureau survey, over 3
    millions Americans have lost employer-sponsored coverage
    between April and July of this year. Yet the administration has
    refused to establish a broad special enrollment period to allow
    uninsured Americans to sign up for coverage through the ACA
    marketplace. And the Trump administration also refuses to
    invest in outreach and enrollment efforts to make Americans
    aware of their coverage options, and instead has imposed
    arbitrary barriers seemingly intended to deter enrollment.
        In contrast, State-based marketplaces that have implemented
    broad emergency special enrollment periods have reported
    significant enrollment during the pandemic. People want to sign
    up.
        Now, the Trump administration also continues to undermine
    Medicaid, even though it has been a lifeline for millions
    during the pandemic. According to one estimate, since February,
    Medicaid enrollment has increased by 6 million people. It is
    never a good time to be without health insurance, and it is
    especially dangerous during a pandemic.
        A study by the University of Michigan found that even
    before the pandemic, Medicaid expansion had saved the lives of
    over 19,000 adults between the ages of 55 and 64. Medicaid is
    helping people keep healthcare coverage when they need it most.
        So today's hearing is an opportunity to better understand
    the ACA's impact on the status of health coverage amidst the
    COVID-19 and what needs to be done to expand and improve access
    to qualify--to quality affordable healthcare. And it is also an
    opportunity to reflect on what is at stake when the Supreme
    Court hears oral arguments in Texas v. California on November
    11.
        While the ACA has been a lifeline for millions during the
    pandemic, its future, once again, hangs in the balance of the
    Supreme Court, and I can't imagine, Madam Chair, that the
    stakes could be higher right now. So I look forward to the
    discussion. I think this hearing is very timely. And thank you
    again, Ms. Eshoo.
        [The prepared statement of Chairman Pallone follows:]

                       Prepared Statement of Mr. Pallone

        The COVID-19 pandemic has caused an unprecedented health
    and economic crisis--200,000 Americans have lost their lives,
    more than six million have been infected with the disease and
    tens of millions have lost their jobs. Millions of American
    families are justifiably anxious and concerned about both their
    health and their financial security.
        The Heroes Act, which the House passed more than four
    months ago, would provide more support and assistance to
    struggling families, by expanding the healthcare safety net,
    increasing support to states to fund their Medicaid programs,
    and ensuring access to free treatment for COVID-19.
    Unfortunately, Senator McConnell and the Trump Administration
    either do not understand the need for the Federal Government to
    take bold action, or worse, they prefer to willfully ignore and
    downplay the seriousness of the challenge we face. Let me be
    clear--further delay in passing the Heroes Act will cost us
    countless lives, lasting damage to our economy, and
    immeasurable financial hardship to millions of American
    families.
        Unfortunately, the Trump Administration is not interested
    in working with Congress to address this crisis. Instead, the
    Administration is actually seeking to do further damage to our
    healthcare system and to the social safety net that millions of
    Americans have turned to during this crisis.
        President Trump continues to support the Republican lawsuit
    that is now before the Supreme Court to strike down the entire
    Affordable Care Act (ACA) in the middle of a pandemic that has
    claimed the lives of more than 200,000 Americans. And now, the
    President and Senate Republicans are trying to jam a Supreme
    Court nominee through the Senate just a month before the
    Presidential election, in attempt to seal the fate of the ACA
    and ensure its demise.
        I want to remind folks what is at stake here if the Trump
    Administration succeeds:
         20 million Americans would lose their healthcare coverage;
         1Aprotections for the more than 133 million people with
    pre-existing conditions would be eliminated and everyone who
    has been infected with COVID-19 now has a pre-existing
    condition;
         1Atax credits for affordable health coverage would be
    gone;
         1A young adults would no longer be able to stay on their
    parent's insurance until they turn 26; and much, much more.
        It doesn't have to be this way. Instead of attacking the
    ACA, the Trump Administration could use it to help people in
    time of crisis. According to a Census Bureau survey, over three
    million Americans have lost employer-sponsored coverage between
    April and July of this year alone. Yet, the Administration has
    refused to establish a broad Special Enrollment Period to allow
    uninsured Americans to sign up for coverage through the ACA
    marketplaces.
        The Administration also refuses to invest in outreach and
    enrollment efforts to make Americans aware of their coverage
    options, and instead, has imposed arbitrary barriers seemingly
    intended to deter enrollment. In contrast, state-based
    marketplaces that have implemented broad emergency Special
    Enrollment Periods have reported significant enrollment during
    the pandemic. The Administration also continues to undermine
    Medicaid, even though it has been a lifeline for millions
    during the pandemic. According to one estimate, since February,
    Medicaid enrollment has increased by 6 million people
    nationwide. There's never a good time to be without health
    insurance, and it's especially dangerous during a pandemic. A
    study by the University of Michigan found that even before the
    pandemic, Medicaid expansion had saved the lives of over 19,000
    adults between the ages of 55 and 64. Medicaid is helping
    people keep healthcare coverage when they need it most.
        Today's hearing is an opportunity to better understand the
    ACA's impact on the status of health coverage amidst COVID-19,
    and what needs to be done to expand and improve access to
    quality, affordable healthcare. It is also an opportunity to
    reflect on what's at stake when the Supreme Court hears oral
    arguments in Texas v. California on November 11. While the ACA
    has been a lifeline for millions during the pandemic, its
    future once again hangs in the balance with the Supreme Court.
    The stakes could not be higher.
        I look forward to the discussion today and I yield back.

        Ms. Eshoo. The gentleman yields back.
        To Mr. Walden, do you want to--do you have an opening
    statement for Dr. Burgess? And if not, then we will proceed
    with introducing the witnesses.
        Mr. Walden. Unless anybody else on our side wants the time?
    If not, I think we are prepared to go on to the hearing, Madam
    Chair.
        Ms. Eshoo. OK. Thank you, Mr. Walden.
        The gentleman yields back.
        And the Chair will once again remind Members that pursuant
    to committee rules, all members' written opening statements
    will be made part of the record.
        I now would like to welcome and introduce our witnesses for
    today.
        The first, Dr. Benjamin Sommers, is the Huntley Quelch
    professor of health policy and economics at Harvard, its T.H.
    Chan School of Public Health. Welcome, and thank you, Dr.
    Sommers.
        Mr. Douglas Holtz-Eakin is the president of the American
    Action Forum. Thank you for once again coming to our committee
    and being a witness. We appreciate it. You are always welcome.
        Dr. Aviva Aron-Dine is the vice president for health policy
    at the Center on Budget and Policy Priorities. Welcome to you,
    and thank you.
        Mr. Dean Cameron is the director of the Idaho Department of
    Insurance. Welcome to you, and on behalf of the subcommittee,
    we thank you.
        And last but not least, Mr. Peter Lee, the executive
    director of Covered California. I have said it before, and I
    would like to say it again, that the Lee family in California
    are legendary. His grandfather founded the Palo Alto Medical
    Clinic. Everyone in that generation, from his grandfather and
    father and uncles and aunt, were all MDs.
        So, Dr. Sommers, you are recognized for 5 minutes. And you
    can unmute so we can hear you. Welcome again, and thank you.

    STATEMENTS OF BENJAMIN D. SOMMERS, M.D., PH.D., HUNTLEY QUELCH
    PROFESSOR OF HEALTH CARE ECONOMICS, PROFESSOR OF HEALTH POLICY
    & ECONOMICS/PROFESSOR OF MEDICINE, HARVARD T.H. CHAN SCHOOL OF
      PUBLIC HEALTH/BRIGHAM & WOMEN'S HOSPITAL; DR. DOUGLAS HOLTZ-
       EAKIN, PRESIDENT, AMERICAN ACTION FORUM; AVIVA ARON-DINE,
     PH.D., VICE PRESIDENT FOR HEALTH POLICY CENTER ON BUDGET AND
    POLICY PRIORITIES; DEAN CAMERON, DIRECTOR, IDAHO DEPARTMENT OF
         INSURANCE; AND PETER LEE, EXECUTIVE DIRECTOR, COVERED
                               CALIFORNIA

             STATEMENT OF BENJAMIN D. SOMMERS, M.D., Ph.D.

        Dr. Sommers. Chairwoman Eshoo, Ranking Member Burgess, and
    other distinguished members, thank you for having me here today
    to discuss this important topic. I am a professor at the
    Harvard School of Public Health, a health economist, and a
    physician, and I would like to make three main points in my
    testimony today.
        The Affordable Care Act produced the largest drop in the
    uninsured rate in the U.S. since the creation of Medicare and
    Medicaid more than 50 years ago, with far-ranging benefits to
    public health. Twenty million people gained health insurance,
    and nearly a decade of research has shown that the law has
    produced significant benefits to families of improved
    affordability and financial security, improved access to
    primary care, prescription medications, and care for chronic
    conditions, and downstream improvements in health status across
    a range of conditions, including surgical diseases like
    appendicitis, heart disease, cancer, kidney disease, and
    overall survival. The research is now showing that the ACA has
    literally been a life-saver.
        The second point is that even with the Affordable Care Act,
    there are still nearly 30 million people in the United States
    without health insurance before the pandemic. And this number
    has been rising since 2016. This erosion of coverage has
    happened during a period of low unemployment, and though the
    ACA has narrowed disparities, coverage rates are still lowest
    among low-income families and communities of color.
        The recent growth in the uninsured rate has happened due to
    a combination of factors where the administration has taken
    policy steps to actively undercut the law. These policies
    include shortening open enrollment periods, cutting funding for
    advertising and outreach, repeated efforts to repeal the law,
    which surveys showed left up to a quarter of the public
    confused as to whether the law was still in effect, as well as
    defunding important aspects of the law, including cost-sharing
    reductions for low-income families.
        Finally, the administration has allowed, and in some cases
    encouraged, States to implement policies that make it harder
    for people to enroll and to maintain their health insurance.
    The reason this latter point matters is because the uninsured
    is not a stable population where everyone in it has been
    uninsured for years and years. Many people move in and out of
    coverage over time. This is often called churning, and this
    particularly happens when enrollment in public programs and
    staying in public programs is made difficult.
        One prominent recent example encouraged by the
    administration was work requirements in Medicaid. In research
    that we recently published, we found that work requirements in
    the State of Arkansas, the first State to implement them, led
    to 18,000 people being disenrolled from Medicaid, even though
    our study found that more than 95 percent of the target
    population should have been eligible for coverage but got
    caught up in red tape and complications with the new policy.
    Rather than helping people get enrolled, these policies are
    roadblocks.
        All told, roughly half of the 30 million uninsured
    Americans, before the pandemic, were already eligible for
    either Medicaid or marketplace subsidies. Doing better
    outreach, eliminating red tape, and helping people keep their
    coverage over time are key policies to reduce this number.
        The third point is that the COVID pandemic threatens to
    leave millions more without health insurance, but the ACA is a
    critical safety net for many who are losing their jobs. Prior
    to the Affordable Care Act, when U.S. workers lost their
    coverage through work, roughly one in four no longer had that
    insurance by the end of the year.
        But when we went back and analyzed this data after the
    implementation of the ACA, what we found was that job loss did
    not lead to a significant risk of being becoming uninsured.
    While people did lose their employer coverage, large increases
    in Medicaid and marketplace coverage more than offset that
    loss.
        And more broadly, our research shows that the Affordable
    Care Act produced its largest coverage gains among blue collar
    workers, those in agriculture, transportation, construction,
    and service jobs, many of whom are essential workers during the
    pandemic but are also at high risk for losing their jobs during
    the economic downturn.
        Finally, on a personal note, I am a primary care doctor,
    and I work in a community health center in Boston. I was there
    yesterday afternoon seeing patients. Many of my patients are
    essential workers, stocking grocery store shelves, cleaning
    subway stations, delivering packages, cooking at restaurants,
    and caring for sick patients in nursing homes and hospitals.
    The community I work in has been hit very hard by COVID.
        Even in the best of times, the difference between having
    health insurance and not having it can mean financial security
    or financial ruin. It can mean life or death. And in a
    pandemic, health insurance means being confident that you can
    get seen, get tested, and get treated if you get sick.
        To conclude, there is a simple question for the members of
    the committee here today to face. Do we make it easy or hard
    for people to get coverage and stay enrolled? During a
    pandemic, as a primary care doctor and as a public health
    professor, the community answer is incredibly clear. We have to
    be doing everything we can to get people access to health
    insurance and healthcare.
        I appreciate the opportunity to be here today and to
    participate in this critical conversation.
        [The prepared statement of Dr. Sommers follows:]

        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you very much, Dr. Sommers, for your
    superb testimony.
        It is a pleasure now to recognize Douglas Holtz-Eakin. You
    are recognized for your 5 minutes. And please unmute.

                  STATEMENT OF DR. DOUGLAS HOLTZ-EAKIN

        Dr. Holtz-Eakin. Well, thank you, Chairwoman Eshoo, Ranking
    Member Walden, members of the committee. It is a privilege to
    be here today. And I will make three brief points in these
    remarks, and then I look forward to answering your questions.
        The first is the obvious one, which is that the large-scale
    job losses in the second quarter of 2020 really raised the
    specter of sharp increases in the number of uninsured in the
    United States. We saw 22 million people lose their jobs in
    March and April, 20 million in April alone, ten times more than
    the previous 1-month job loss in U.S. history. And I was among
    those who was deeply concerned that there would be a sharp
    decline in employer-sponsored insurance, and as a result, the
    specter of large increases in the uninsured during the middle
    of a pandemic.
        Since then, we have had a number of studies which have
    tried to get a handle on just what the risks are on this front.
    The Kaiser Family Foundation estimated about up to 27 million
    Americans were at risk of losing their insurance, but pointed
    out that all but a few million of them would have some other
    option, a spouse's employer-sponsored insurance, Medicaid,
    Affordable Care Act, things like that.
        There was some work done by the Urban Institute that said
    about 10 million people might lose their insurance, but all but
    3 million of those would find coverage somewhere else.
    Similarly, we have seen estimates of about 5.5 million by
    Families USA and about 6 million from the Economic Policy
    Institute. So all of these suggest that, you know, you could
    have potentially a 25 percent increase in the uninsured, and
    that is a serious concern for this committee.
        The Census Bureau, as I noted in my written testimony, has
    undertaken a remarkable effort to keep track of the welfare of
    American families during the pandemic through a weekly
    Household Pulse Survey which they have constructed. This asks a
    wide range of questions about the economic and personal welfare
    of the families and includes questions about health insurance
    status.
        Remarkably, if you look at those data, which began on April
    23 and have been collected through August 31, they show that
    over that period, there has been a tiny increase in the rate of
    insurance in the United States. I think a correct reading of
    those data is that they bounce up and down on a weekly basis,
    but we have seen no significant change in the number of
    uninsured, the rate of uninsurance, in the United States.
        That is, I think, promising news, that the large-scale
    losses, which we feared early in the downturn, have not yet
    come to happen, but I don't think it is truly a cause for
    complacency. We need to keep an eye on the options that people
    will have if they do lose their employer-sponsored insurance.
    And certainly among those options, first and foremost, is the
    marketplaces of the Affordable Care Act, where it seems to me
    that the major question is the issue of special enrollment
    periods. If an individual loses their employer-sponsored
    insurance due to job loss, they are automatically eligible to
    enroll in the ACA marketplaces. The question is whether we want
    to have special enrollment periods to actively recruit those
    who were not insured prior to the pandemic and now want to take
    up the opportunity to get into the ACA.
        Similarly, we have options for Medicaid as coverage. In the
    Great Recession and as a precedent, the Congress undertook to
    subsidize COBRA coverage. Giving people help in their COBRA
    makes some good sense from the point of view of keeping them in
    their current insurance product, keeping them in their--as a
    result, their current care networks, not switching their
    physicians in the midst of a pandemic.
        The downside to that is, the takeup wasn't particularly
    good in our last experience with this, and so whether it would
    be an effective outreach or not, I think, is an open question.
        And then as a matter of completeness, the last option on
    the table would be the short-term, limited-duration insurance
    plans, which are a recent innovation. These may not be ideal
    for long-term insurance coverage but seem good as a stop-gap
    measure in the midst of the pandemic.
        So I am thrilled to have the chance to be here today. I am
    pleased that the committee is looking at this issue, and I look
    forward to answering your questions.
        [The prepared statement of Dr. Holtz-Eakin follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you very much for your testimony and for
    joining us once again. The gentleman yields back.
        Now it is a real pleasure to welcome Dr. Aviva Aron-Dine.
    You are now recognized for 5 minutes. And please unmute. Thank
    you again.

                  STATEMENT OF AVIVA ARON-DINE, PH.D.

        Dr. Aron-Dine. Thank you, Madam Chair and members of the
    committee, for inviting me to testify today. I will talk about
    the role that Medicaid and the ACA are playing in the crisis,
    the need for action to further strengthen health coverage
    programs, and the catastrophic harm that would occur if the
    Supreme Court struck down the law.
        Medicaid has long played a key role in protecting coverage
    during recession. During the Great Recession, for example,
    increased Medicaid in CHIP enrollment fully offset the loss of
    private coverage for children, preventing any increase in the
    children's uninsured rate.
        But before the ACA, this safety net had a gaping hole. It
    left out many of the adults who were most vulnerable to
    recessions. With Medicaid expansion and the ACA marketplaces
    now filling that gap, we would expect coverage programs to be
    even more responsive to need than in the past. The data
    suggests that is exactly what is happening.
        Through July, Medicaid enrollment in States with available
    data was up about 8 percent and expansion enrollment was up
    about 13 percent. Extrapolated nationwide, that would mean
    Medicaid is covering about 6 million people who might otherwise
    have become uninsured, with about a quarter covered through
    expansion. Mid-year sign-ups for ACA coverage seem to be up
    too, especially in those States that created special enrollment
    opportunities that are easier to access than the standard SEP.
        Medicaid and the ACA are also aiding the response to the
    crisis in other ways. In States that expanded Medicaid, the
    program covers almost 40 percent of low-income essential
    workers, such as home health aides, and hospital, transit, and
    grocery store workers, and low-income people in those jobs are
    about half as likely to be uninsured in expansion compared to
    nonexpansion States.
        States are also using Medicaid authorities to respond to
    the pandemic, for instance, by increasing payments to nursing
    homes and other health providers, expanding access to home- and
    community-based services, and increasing the use of telehealth.
        Congressional action is needed to make sure that the safety
    net doesn't fray under strain. The growing need for Medicaid
    coverage and other demands on the program coincide with the
    historic State budget crisis. In past budget crises, States
    restricted Medicaid eligibility, made it harder for eligible
    people to get in-State covered, eliminated or cut important
    benefits, cut provider payments, and cut other non-Medicaid
    health programs, especially behavioral health. Cuts like those
    would be especially harmful right now.
        Congress, with bipartisan leadership from this committee,
    took a crucial first step back in March, temporarily raising
    the Medicaid match rate and pairing those funds with strong
    protections for beneficiaries coverage. But the growing number
    of States that are making or considering harmful cuts to
    Medicaid shows that additional Federal funding is needed.
        Congress should also strengthen the health safety net for
    this and future recessions by filling remaining gaps. That
    involves both reversing administration policies that have
    undermined coverage and taking affirmative steps to improve the
    ACA's premium tax credits, to make it easier for eligible
    people to get and keep their coverage, and to add to the
    incentives for States to expand Medicaid.
        Unfortunately, as we have already talked about this
    morning, there is also a very real danger that the ACA could
    disappear altogether due to the lawsuit. Before the pandemic,
    Urban Institute researchers estimated that would cause 20
    million people to lose coverage, which means that about 1 in
    every 14 nonelderly people in the country would lose their
    health insurance, and about 1 in 10 among Black and Hispanic
    people. And this year or next, those coverage losses would be
    significantly larger, because more Americans are turning to ACA
    programs due to the crisis, as all of today's witnesses
    discussed in our written testimony.
        Striking down the law would also end protections for people
    with preexisting conditions, from heart disease to cancer to
    diabetes, to the millions of Americans who just acquired a new
    preexisting condition, having had COVID-19. And striking down
    the ACA would weaken health insurance for those still covered,
    from the tens of millions of people with employer plans, whose
    plans imposed annual or lifetime limits before the ACA, to
    Medicare beneficiaries for whom striking down the law could
    raise prescription drug costs.
        It is worth noting that the lawsuit would, at the same
    time, cut taxes for the highest income, one in a thousand
    Americans, by an average of $198,000 per year, which would also
    reduce the revenue flowing to the Medicare Trust Fund and speed
    its insolvency.
        Before I close, I would like to just address the notion
    that there is some viable alternative to the ACA or a
    forthcoming plan that would avoid those harmful consequences.
    Examining the actual ACA replacement proposals put forward
    since 2010 show that they near, rather than avert, the harmful
    consequences of the lawsuit. That includes jeopardizing
    coverage for people with preexisting conditions.
        Thank you, and I look forward to answering your questions.
        [The prepared statement of Dr. Aron-Dine follows:]
       [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you, Doctor. It is really a pleasure to
    have you with us.
        The Chair now recognizes Mr. Dean Cameron. You are
    recognized for 5 minutes. And please unmute.

                       STATEMENT OF DEAN CAMERON

        Mr. Cameron. Thank you, Madam Chair. It is a pleasure to be
    with you. And thank you for the opportunity to testify
    regarding Idaho's experience regarding health insurance, the
    ACA, and the COVID-19 pandemic.
        Idaho's perspective and experience may be unique from what
    you have previously heard. I hope it will be helpful as you
    consider broad public policies and the implications on unique
    demographics of each individual State.
        Idaho prides itself on being creative and collaborative in
    finding solutions. It is that collaboration and our regulatory
    approach which led to the creation of our State-based exchange,
    the only Republican State to establish a State-based exchange.
    It is that collaboration and regulatory approach--and by the
    way, that is one of the most successful exchanges in the
    Nation. It is that collaboration that has provided consumers
    with up to five competing carriers participating in the
    individual insurance market. And it is that collaboration which
    proved critical and improved outcomes during this pandemic.
        At the outset, the pandemic in Idaho's emergency
    declaration, the Department of Insurance began meeting
    virtually, weekly, with our carriers. We began collaborating on
    finding solutions to the barriers and dilemmas caused by the
    pandemic, which included everything from testing to treatment,
    to telemedicine, to provider support, to enrollment, to
    pharmaceutical guidelines.
        The results are rather remarkable. Without mandating,
    without requiring, without threatening, all five carriers
    waived copayments, deductibles, and coinsurance on testing, and
    physician visits associated. All five carriers waived
    copayments and deductibles and coinsurance on treatment related
    to COVID-19. All five carriers expanded their telehealth
    network dramatically, allowing easier access for telehealth
    visits, allowing nearly every provider to see their patients
    remotely, and paying those providers as if the patient were
    being seen in person.
        Our telehealth usage increased by 120-fold from February to
    April and 250-fold from April 2019 to April 2020. We went from
    233 telehealth visits in February to 28,503 telehealth visits
    in the month of April alone. This was especially helpful to our
    citizens who needed their mental health provider, where we went
    from 97 visits in February to 11,333.
        We allowed for early refill of prescriptions and the
    ability to obtain a 90-day supply without signature logs or in-
    person visits.
        We waived eligibility requirements, allowing employees to
    maintain their coverage while working fewer hours, allowing
    coverage to be more quickly obtained upon return to work, or
    allowing furloughed employees to even stay on their group plan.
    We extended grace periods and reinstatement periods. All five
    of our carriers did this.
        All five of our carriers also provided millions of dollars
    in timely assistance to providers and consumers of the COVID-
    19--as non-COVID-19 claims decreased. And I won't take the
    time, in the interest of time, to go into all of those.
        Several of our carriers recently provided millions of
    dollars in refunds and credits to consumers, some as much as 50
    percent in 1 month. The carriers also contributed greatly to
    our community efforts, participating in governor's task forces
    and et cetera.
        From my perspective, the carriers have collaborated really
    well and have really stepped up at a time when all of their
    employees were working remotely.
        There was a huge uncertainty, also, of the impacts of
    COVID-19. Since then, carriers have filed their individual
    market premium rate increases, and I am proud to report that
    the net increases is 1 percent. Three of our carriers actually
    requested a rate reduction, and two of our least expensive
    carriers had a slight increase.
        Lastly, just a note on Medicaid. We have seen a dramatic
    uptick in the number of folks applying for Medicaid during the
    pandemic and a number who qualified for Medicaid expansion.
    That continues to grow. Even with the expanded FMAP match,
    those numbers are concerning to our State budget at this time
    where our economy is good but precarious.
        Madam Chairman, and these collaboration efforts didn't
    happen by accident. They required communication, understanding,
    commitment to our State and our citizens, and I am honored to
    be part of that process. And thank you for allowing me to tell
    part of the story.
        [The prepared statement of Mr. Cameron follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Well, thank you very much for telling your
    story. It is a good story, and we thank you for being with us.
        Last but certainly not least, Peter Lee. It is wonderful to
    see you again. Thank you for always accepting our invitation to
    testify at our subcommittee. You are recognized for 5 minutes.
    And please unmute. We don't want to miss a word.

                         STATEMENT OF PETER LEE

        Mr. Lee. Good morning, Chairwoman Eshoo, and thank you for
    your remarks. I would hope that my uncle, Phil Lee, is watching
    you as we speak today. Also, thank you, Ranking Member Walden,
    distinguished members of the committee. I am Peter Lee. I am
    the executive director of Covered California, which is one of
    the Nation's 13 State-based marketplaces.
        My remarks, written testimony, and just-released report
    from Covered California, reflect our experience working for
    almost ten years to effectively implement the Affordable Care
    Act, and more recently, respond to the COVID-19 pandemic.
        The pandemic and the resulting economic recession have
    demonstrated that, if implemented well, the ACA is working as
    it was intended to do. California, like most States across the
    Nation, red and blue, through the Affordable Care Act, have
    expanded Medicaid, providing coverage to millions.
        Here in California, immediately after Governor Newsom
    declared a state of emergency, Covered California opened a
    COVID-19 special enrollment period and spent millions of
    dollars to make sure Californians who lost their jobs knew they
    could come to us. Results? Yes. We enrolled over twice as many
    people than the same period the year prior, with almost 290,000
    Californians gaining coverage through our COVID-19 special
    enrollment period.
        In stark contrast, we project that nearly 500,000 more
    Americans could have insurance coverage, had the 38 States
    served by the federally facilitated exchange, created a COVID
    special enrollment period and aggressively marketed to
    Americans to know they had options.
        These results are not accidental. They could have been
    predicted. Federal inaction left as many as a half million
    Americans without coverage during a pandemic. This failure to
    act is one of life and death. Early diagnosis and treatment are
    critical to getting good care in COVID-19 times.
        But the pandemic has also put a spotlight on the gaps and
    shortcomings of the ACA. The pandemic exposed the fragility of
    employer-sponsored insurance for many Americans and the
    weaknesses of high-deductible, lower-premium plans that many
    low-income people select in marketplaces.
        Now, we have seen, and we just heard from the gentleman
    from Idaho, that many State, Federal Government, and insurance
    companies have addressed the realities of COVID-19 by having no
    cost sharing for consumers for testing and treatment.
        It is clear that in a pandemic, the public benefits by
    having potentially infected individuals get tested and treated.
    It is less clear why the same logic does not apply to those
    infectious with other conditions, such as hepatitis, malaria,
    HIV/AIDS, or tuberculosis.
        These are common diseases that are not only extremely
    deadly and costly to our health system, but that
    disproportionately impact lower-income consumers, communities
    of color, and those who are underinsured in their employer-
    sponsored insurance markets.
        During a pandemic, when coverage is of paramount
    importance, we saw millions suddenly without coverage because
    they lost their job. We saw millions more discover the
    inadequacy of their coverage, and perhaps most problematic, we
    saw many people actually drop coverage altogether.
        This is precisely the opposite of what should happen during
    a global pandemic and economic recession. It is in the public
    interest to have everyone have coverage so they can get help to
    stay healthy and get needed care, regardless of their health
    condition.
        There are ways to strengthen and improve the ACA to make
    health coverage more affordable and accessible to all
    Americans. These are gone into in more depth in my written
    testimony, but I would like to highlight five of them.
        First, you can do what States do: Step up, do more
    outreach. But I need to note, States cannot take the role of
    Federal action. California has taken bold steps to expand
    subsidies. They can't keep doing that. It requires Federal
    action.
        Federally, we should increase subsidies for low- and
    middle-income consumers, such as using gold plans as a
    benchmark and limiting premium costs to no more than eight
    percent of income for all, getting rid of the cliff that is
    hurting middle-income consumers. We should provide options for
    Americans who aren't happy with and have employer coverage that
    isn't adequate. We need to address underlying healthcare costs,
    such as high prescription drug costs.
        And finally, we need to, as a Nation, directly address
    healthcare disparities and inequities. The disproportionate
    impact of COVID-19 on Blacks, Latinos, Asian Pacific Islanders,
    isn't an exception. Sadly, it is the rule that we should be
    addressing.
        The ACA is the right law to build upon, and we risk
    catastrophe if we turn our backs and abandon millions of people
    it protects.
        I look forward to responding to the committee's questions.
    Thank you very much for holding this hearing today, Chairwoman
    Eshoo.
        [The prepared statement of Mr. Lee follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you very much, Mr. Lee. You are always
    welcome at our committee.
        And to all of the witnesses, thank you for your testimony.
        We will now move to member questions, and the Chair will
    recognize herself for 5 minutes of questions.
        I have a few rapid-fire questions to each witness to
    establish a baseline of fact, so please answer yes or no.
        Dr. Sommers said in his written testimony that, quote, "the
    ACA provides a highly effective safety net for workers who lose
    their jobs," unquote. Mr. Holtz-Eakin said in his written
    testimony that the ACA, quote, appears to be meeting the need,
    unquote, during the pandemic and recession.
        Dr. Aron-Dine, Mr. Lee, and Mr. Cameron, yes or no, do you
    agree with your fellow panelists that the Affordable Care Act
    is a critical part of our social safety net?
        Mr. Lee. Absolutely.
        Ms. Eshoo. Dr. Dine? Mr. Lee?
        Dr. Aron-Dine. Yes.
        Ms. Eshoo. Mr. Cameron?
        All yeses.
        President Trump was interviewed on July 19 on FOX News and
    promised, quote, a full and complete healthcare plan within 2
    weeks.
        Yes or no, are any of you aware of the details of any
    comprehensive care plan, healthcare plan from the Trump
    administration? Dr. Sommers?
        Dr. Sommers. No, I am not.
        Ms. Eshoo. Mr. Holtz-Eakin?
        Dr. Holtz-Eakin. No.
        Ms. Eshoo. Dr. Aron-Dine?
        Dr. Aron-Dine. No, except for the repeal policies they put
    forward in prior budgets and proposals.
        Ms. Eshoo. Yes. Well, that is a wrecking ball.
        Mr. Cameron?
        Mr. Cameron. I can't say that I am.
        Ms. Eshoo. Mr. Lee?
        Mr. Lee. No.
        Ms. Eshoo. Last week, President Trump said during an ABC
    News townhall, quote, we are going to be doing a healthcare
    plan very strongly and protect people with preexisting
    conditions.
        Yes or no, are you aware of the details of any Trump
    administration policy that protects people with preexisting
    conditions? Dr. Sommers?
        Dr. Sommers. No.
        Ms. Eshoo. Dr. Holtz-Eakin--Mr. Holtz-Eakin?
        Dr. Holtz-Eakin. No.
        Ms. Eshoo. Dr. Aron-Dine?
        Dr. Aron-Dine. No.
        Ms. Eshoo. Mr. Cameron?
        Mr. Cameron. Many State laws already protect preexisting
    conditions, including Idaho, who was well in front of the ACA.
        Ms. Eshoo. But are you aware of any details of the Trump
    administration policy to protect people with preexisting
    conditions, yes or no?
        Mr. Cameron. Madam Chairman, I have heard the Trump
    administration and others speak of their intent to protect
    preexisting conditions, and we stand with that as well.
        Ms. Eshoo. I don't know what you are standing with. Are you
    aware of the details? That is what I am asking. Yes or no?
        Mr. Cameron. Madam Chairman, have I seen an actual bill?
    No, I have not seen a bill. Have I heard them speak of----
        Ms. Eshoo. OK. Mr. Lee?
        Mr. Lee. No, I am not, but I would also, Madam Chair,
    welcome the chance to expand on that.
        Ms. Eshoo. All right. Well, let's see how much time I have
    left.
        Mr. Lee. Absolutely.
        Ms. Eshoo. Yesterday, Politico reported that President
    Trump is planning to sign an executive order on healthcare
    coverage later this week.
        Dr. Aron-Dine, you served as senior counselor at HHS and
    Acting Deputy Director of OMB. In your experience, how long
    does it take for the policy ideas espoused in an executive
    order to go through rulemaking so it can be implemented?
        Dr. Aron-Dine. New rulemaking is typically a lengthy
    process, and that is true even when the objectives and legal
    authorities are clear.
        Ms. Eshoo. And when you say they are extended or it takes a
    long period of time, give us an approximation of that.
        Dr. Aron-Dine. A rapid rulemaking process, really starting
    from scratch, could still be a year-long process.
        Ms. Eshoo. Oh. On April 3, I led a letter with every
    Democratic member of the Energy and Commerce Committee, to CMS
    Administrator Seema Verma, asking her to allow Americans to
    enroll in coverage through healthcare.gov during a special
    enrollment period. Six months later, there is still no
    response. No response.
        Mr. Lee, California provided a special enrollment period.
    You spoke to it in your both oral and written testimony. That
    enrollment period was March 20, in response to the COVID
    pandemic. What was the outcome of it?
        Mr. Lee. Yes. The results of that special enrollment period
    were a doubling of enrollment compared to the prior year,
    meaning we enrolled during that period almost 300,000
    Californians, which means about 150,000 more than would have
    but for that effort.
        And I do want to underscore, it is not just a special
    period, because many of those people would be eligible in a
    normal period. It is marketing, it is outreach, it is letting
    people know that our doors were wide open. Those were the
    factors that helped make sure we got so many Californians in
    the door.
        Ms. Eshoo. Thank you.
        I think that my time has expired. And I see that Dr.
    Burgess--am I right--Dr. Burgess has joined us. So I will call
    on Mr. Burgess and then--when the time is appropriate so that
    you can be recognized.
        Do I recognize him now?
        I will recognize Dr. Burgess now for his 5 minutes of
    questions.
        We missed you in the beginning, but we are glad to see that
    you have joined us. You can unmute.
        Where are you?
        I guess he is still not here. So I will recognize Mr.
    Walden, the ranking member of the full committee, for your 5
    minutes of questions.
        Mr. Walden. Thank you, Madam Chair. And thanks to all our
    witnesses for your testimony as we work together on these
    issues to make sure people have adequate access to affordable
    healthcare.
        And again, I would repeat that I think we still have a lot
    of work to do, especially in the area of surprise billing. And
    it is unfortunate that this has not gotten across the finish
    line yet, and hopefully we can get there so that people who are
    covered and play by all the rules don't end up getting a bill
    that they should never get. I mean, there is a big rip-off
    going on out there, and we need to address it thoughtfully, and
    I think we have bipartisan legislation that will do that.
        I would like to go to Mr. Cameron in Idaho. Do you all take
    advantage of the Children's Health Insurance Program?
        Mr. Cameron. Yes, we do, sir.
        Mr. Walden. And what percent of that program is funded by
    the Federal Government in Idaho? I know in Oregon it is about
    99 percent.
        Mr. Cameron. Yes. I believe it is close to 80 percent in
    Idaho.
        Mr. Walden. All right. Do you know off the top of your head
    how many kids and mothers are signed up on CHIP in Idaho?
        Mr. Cameron. You know, I had that data, and I don't have it
    at my fingertips, so I can get it for you, Congressman.
        Mr. Walden. As your neighbor just to the west, because I
    represent all of eastern Oregon, obviously we pay close
    attention on that side of the State to what you all are doing.
    And it has been interesting, States and laboratories. And I
    would like you to go through again, in terms of the--using sort
    of a free-enterprise model, it sounds like, in Idaho, the
    effects you have gotten by competition in your insurance
    market.
        Mr. Cameron. Thank you, Congressman. And I did find that
    number for you on CHIP. We are at 25,846 in 2019.
        Mr. Walden. Is that 25,000?
        Mr. Cameron. 25,000.
        Mr. Walden. Yes. I think in Oregon, we are over 122,000
    kids. And under Republican leadership, we passed a 10-year,
    fully funded extension of CHIP when I chaired the committee.
    That is double the length of any extension that the Children's
    Health Insurance Program.
        And I think on the issue of preexisting conditions, it was
    Republicans in 1996 who led the effort under ERISA. And it is
    my understanding, as you pointed out, your State has
    preexisting protections in place, irrespective of what the
    Supreme Court may do. I put forward legislation and multiple
    initiatives on the floor of the House this Congress to double-
    down on that so that we can protect people regardless of what
    the Supreme Court decision is, people with preexisting
    conditions would be protected.
        But I want to get back to the marketplace in Idaho, what
    you have seen, what is working.
        Mr. Cameron. So our experience is contrary to what some
    others testified earlier. Our uninsured population actually
    went up with the passage of the ACA. In fact, it dramatically
    went up and then started to wane, and then as we got into the
    2013 and 2014 year, we started seeing significant numbers of
    individuals leave the marketplace. They were being forced out
    of coverage. We believe that is----
        Mr. Walden. Why?
        Mr. Cameron [continue]. Because prices were too high, and
    they could not qualify for subsidies. We are a rural State, and
    many of our folks could not qualify for the subsidies. And it
    is not just because they were eligible for Medicaid expansion,
    but it was because they are farmers and their incomes are
    unpredictable, or they are spouses to schoolteachers and they
    couldn't qualify for subsidy.
        So we have seen a dramatic exodus from our individual
    market. We have attempted to try and bring those individuals
    back, bring back the young and the healthy. Many of the
    provisions of the ACA, in fact, push the young and the healthy
    away, which drives prices up, which causes more people to
    leave.
        And it is a little ironic, because some of the numbers that
    are counted on the uninsured population also include faith-
    based programs, which a large number of our citizenry has gone
    to, or short-term plans. We have created a new plan, call it
    enhanced short-term plan, that is more like an ACA plan and is
    tied to the same risk pool to try and address those issues.
        Mr. Walden. And what kind of premiums can you get to charge
    for that enhanced short-term duration plan?
        Mr. Cameron. So our premiums are about 50 percent lower
    than the ACA plans, but I want to emphasize that we aren't
    pulling people away from the ACA into those programs. They are
    part of the same risk pool. So when the carrier filed their
    rate increases with us this year, that was a net 1 percent,
    some of them a decrease, that included those numbers from their
    enhanced short-term plans as well.
        We have two carriers offering those plans. There has not
    been as great an uptick as we had hoped because of the
    pandemic, I believe, but I think it is a solution that is worth
    exploring.
        Mr. Walden. All right. Well, I thank you for your
    participation, and to all our witnesses today.
        My time is expired, and I yield back, Madam Chair.
        Ms. Eshoo. The gentleman yields back.
        It is a pleasure to recognize the chairman of the full
    committee, Mr. Pallone, for his 5 minutes of questions.
        Mr. Pallonen. Thank you, Chairwoman Eshoo.
        I wanted to ask Dr. Aron-Dine about the ACA and the Supreme
    Court. You know, I know that the ACA has been a lifeline for
    millions during the pandemic, but its future hangs in the
    balance because of this Republican effort to repeal it, which
    is now before the Supreme Court hearing oral arguments November
    11. And, of course, I believe that is the reason why--or a
    major reason why the President and McConnell are trying to push
    a new nominee, to, you know, vote against the--it is a vote in
    favor of the ACA repeal.
        So, Dr. Aron-Dine, if the Supreme Court agrees with the
    Republican position that the ACA should be struck down in its
    entirety, how many individuals would lose coverage?
        Dr. Aron-Dine. Pre-pandemic estimates were that 20 million
    people would lose coverage, and that number would be larger
    today because millions of people are turning to Medicaid
    expansion or the marketplaces for coverage during the
    recession.
        Mr. Pallone. And then, Doctor, based on what you know about
    health insurance prior to the ACA, would people with
    preexisting conditions still be able to get affordable health
    coverage in the event of the Supreme Court repeal?
        Dr. Aron-Dine. Prior to the ACA, the individual market
    really didn't work for people with preexisting conditions or
    other serious health needs. They could be denied coverage, they
    could be charged higher premiums, plans could have major
    benefit gaps, or annual and lifetime limits.
        And I do just want to address this point that States could
    somehow protect their markets against those effects. To the
    extent States try to do that, they face a few big barriers.
    First, they don't have jurisdiction to reimpose protections in
    the self-insured, large-group market. Also, they generally
    don't have the moneys. They are not going to be able to replace
    the tax credits that actually make a market that helps people
    with--that works for people with preexisting conditions work
    for all. A State can't do that by itself without the Federal
    funding that would be eliminated.
        Mr. Pallone. Thank you.
        Now, according to the Mayo Clinic, COVID-19 condemn is a
    long brain and hard and possibly have long-term health
    consequences. Given that, again, if the Supreme Court throws
    out the ACA, is it likely that having COVID-19 would be
    considered a preexisting condition?
        Dr. Aron-Dine. My expectation is yes, and I think this goes
    for a larger problem with insurance markets that don't have any
    coverage standards, which is that there is a really strong
    economic logic behind a race to the bottom. So if you are an
    insurer who doesn't treat COVID as excludable preexisting
    condition, you would worry all your competitors are doing that
    and you are going to cover all of those people and have to pay
    their costs, so you end up excluding it, too. And that same
    logic applies wherever you don't have benefit standards.
        So whether it is excluding maternity or excluding high cost
    drugs, and on and on, you get this race to the bottom that
    leaves people without an option for comprehensive coverage.
        Mr. Pallone. Well, thank you.
        Once again, you know, I am very concerned that the Supreme
    Court holds the future of healthcare for millions of Americans
    in its hands, and the Republicans' and President's efforts to
    jam through a justice, you know, that would vote against the
    ACA jeopardizes its future even further.
        Let me go to Dr. Sommers. I have a little over a minute.
    Could you just tell me--I know a lot of people have lost their
    job based coverage during the pandemic. You can comment on that
    or tell us, where are people turning for healthcare coverage
    during this time? And if individuals are still uninsured, you
    know, what is the reason?
        Dr. Sommers. Well, one place that people turn is if they
    are fortunate enough to have another family member with
    employer coverage, and that does explain part of why many
    people losing coverage haven't become uninsured. For those
    without that good fortune, their situation is either that they
    are going to rely on Medicaid, which, of course, depends on the
    State that you live in and the eligibility criteria. And we
    know that 12 States have not yet expanded Medicaid. And then we
    also have the subsidized coverage in the marketplaces where you
    don't have to be qualifying based on full-time benefit eligible
    employment. If you have got part-time work, if your hours have
    gotten cut and you have got lower income, you might still
    qualify, and that could be an important source of coverage for
    people during the pandemic.
        Mr. Pallone. But, you know, my concern is--and I think it
    is indefensible that the Trump administration has refused to
    establish a broad open enrollment period or invest in outreach
    and enrollment efforts during this pandemic, or people don't
    necessarily know where to turn to, and it is sometimes
    difficult to enroll even when you have lost your job. I don't
    know if you want to comment on that as well.
        Dr. Sommers. Yes, that is absolutely critical. We know that
    just making people eligible isn't enough to get them covered.
    Surveys show that people are often confused about how to
    navigate the process. So aggressive outreach, funding, and
    support for community efforts to assist people in enrolling is
    critical and is something that both States and the Federal
    Government should be doing during the pandemic.
        Mr. Pallone. Thank you, Dr. Sommers.
        And turn it back to Chairwoman Eshoo.
        Ms. Eshoo. The gentleman yields back.
        Has Dr. Burgess joined us? Are you here? Dr. Burgess I
    don't see you.
        Not seeing Dr. Burgess or hearing his voice, the gentleman
    from Illinois, Mr. Shimkus, is recognized for his 5 minutes of
    questions.
        Mr. Shimkus. Thank you, Madam Chairman, and it is great to
    be with you, and it is a great hearing.
        I want to first make a statement on just vaccine
    development. I know it is not the focus of this hearing, but I
    want to stress that while we are all focused on the work being
    done by Operation Warp Speed in expediting the development of
    select vaccine candidates, we still need to embrace the all-
    the-above strategy and continue to welcome the contributions of
    non Operation Warp Speed companies and products.
        Operation Warp Speed investment should be purely additive
    and shouldn't displace other promising solutions that could
    prove to be superior to what we thought was possible just six
    months ago.
        And I thank you for that.
        To the panelists, a real quick, easy question, should be an
    easy question, and I think it should be an easy yes or no. Is
    the Constitution of the United States the supreme law of the
    land?
        Dr. Sommers.
        Dr. Sommers. I am not a lawyer, but I believe, yes.
        Mr. Shimkus. Dr. Holtz-Eakin?
        Dr. Holtz-Eakin. Yes.
        Mr. Shimkus. Dr. Aron-Dine?
        Dr. Aron-Dine. I am also not a lawyer, but yes.
        Mr. Shimkus. You don't have to be. You could have taken
    civics as I used to teach it.
        Mr. Cameron?
        Mr. Cameron. Absolutely.
        Mr. Shimkus. And, Mr. Lee?
        Mr. Lee. Yep.
        Mr. Shimkus. So let's talk about this court case that is
    coming up. The question to the Court is whether this National
    Government can force an individual to buy a product of service
    from a private company. When this case was litigated before the
    Supreme Court, the only thing that allowed it to stand was the
    right to tax, which was not what was discussed when we had our
    hearings and we even had this debate on the floor.
        In fact, Republicans continuously said, You are standing on
    the principle that the government has the right to tax, but my
    colleagues on the left kept saying, No, no, no, we can force
    individual citizens to buy a product or service. And that is
    how the debate rolled out.
        Well, under H.R.1 that tax was removed. The simple solution
    for Democrats is to reimpose the tax, and then that way
    reestablish the Affordable Care Act. That is the solution, but
    they are unwilling to do that.
        So I would--I just want to pose that premise that to me the
    Constitution is the preeminent law of the land, and regardless
    of the good intentions of Federal legislation, that is the
    primary arbiter. And since I support jurists who are strict
    construction or originalists, that they don't interpret, based
    upon their experiences, how the founders would have written the
    Constitution, that regardless of what should happen, the
    Supreme Court's rule is, as they say, is this law
    constitutional or is it not? And that is the debate before, not
    whether we like it or we don't like it.
        It is did the Federal Government have the right to pass
    this law on the citizens of the United States? I believe it was
    an unconstitutional law because of forcing people to buy
    something that they should not be forced to buy if they don't
    want it, regardless of the good intentions.
        Now, in my final time--I can't see the clock, Madam
    Chairwoman, so if I need to gavel down, go ahead and do that.
    But in my district, like in Idaho, I hear the ACA is too
    expensive and it doesn't cover folks who need it. And we have
    seen what has happened. The co-ops proposed--there is only
    three of the 26 that are left. Short-term plans are maligned,
    and associated health plans are sabotaged.
        So if we can go to Dr. Holtz-Eakin and my colleague, my
    friend from Idaho, if they could talk about this premise, I
    would appreciate it.
        Dr. Holtz-Eakin. Well, I think, from the beginning of the
    debate over the ACA, one of my concerns has been that it was
    coverage heavy and delivery system reform light and, as a
    result, wasn't addressing the underlying costs of healthcare
    and so insurance costs would inevitably go up. It ran into
    problems on top of that, in terms of pricing, poor competition,
    often very thin at times. Some States threatened to have parts
    where only a single provider was there to offer insurance. And
    so for ten years we have seen this continual issue of the cost
    of health insurance under the ACA.
        Mr. Shimkus. Mr. Cameron?
        Mr. Cameron. Yes, I would add to it, we continue to see
    cost increases, although the last couple of years have not been
    as bad, and as those cost increases occur, and many of them
    occur because they are healthy--you know, I have got, like, the
    couple from Twin Falls, Idaho, 62 and 63 years of age, who
    can't afford $1,500 a month in coverage. They don't qualify for
    a subsidy, and so they end up opting out. And those are the
    individuals we need to be back in the pool, in the system in
    order to make the ACA or any plan affordable.
        Mr. Shimkus. Thank you very much.
        Madam Chairwoman, I yield back my time.
        Ms. Eshoo. The gentleman yields back.
        It is a pleasure to recognize the gentleman from North
    Carolina, Mr. Butterfield.
        Mr. Butterfield. Thank you very much, Madam Chair, for
    convening this hearing today, and thank you for keeping our
    subcommittee engaged even though we are facing some
    unprecedented challenges, and thank you to all of our
    witnesses. Your testimony today is very valuable.
        Before I get into my questions, I just want to respond
    briefly to my friend from Illinois, Mr. Shimkus. The Supreme
    Court is indeed the law of the land. I served as a judge for 15
    years, and certainly I recognize that, and even several years
    on my State Supreme Court. But sometimes the Court is wrong. I
    refer you to the Dred Scott case of 1857, not to mention the
    fact that the public loses confidence in the judiciary when it
    is politicized. I am just saying.
        But let me just address my question to Ms. Aron-Dine, Dr.
    Aron-Dine. We know from experience that when the economy goes
    south and people lose their jobs, their income goes down. They
    turn to Medicaid for health insurance, and enrollment in
    Medicaid increases. And so Medicaid, like SNAP and unemployment
    insurance, is a counter cyclical program, meaning that when the
    economy goes down, enrollment in these programs actually go up.
    This isn't a bad thing. Medicaid is designed to be there for
    people when they actually need it.
        So, Doctor, economic downturns can strain State Medicaid
    budgets in two ways, increase enrollment and decrease State
    revenues. Can you briefly describe for me how that works and
    what it means for State budgets?
        Dr. Aron-Dine. That is exactly right. During a recession,
    States see large drops in their revenues, and then they also
    experience additional, those smaller budget strains from more
    people signing up for Medicaid and other programs.
        In this recession, States are also seeing additional
    strains from specific COVID-19 related costs that they are
    incurring to try to address this pandemic.
        Mr. Butterfield. Now, in years past during economic
    downturns, Congress has stepped in and provided additional
    financial help in the form of increased Federal funds known as
    FMAP. Is that correct?
        Dr. Aron-Dine. Correct.
        Mr. Butterfield. And let me ask you this, the Families
    First Coronavirus Response Act included in my bill that
    increased FMAP by 6.2 percentage points for the duration of the
    public health emergency, how does that compare, if you know, to
    the FMAP increase that Congress included in the Recovery Act
    during the Great Recession?
        Dr. Aron-Dine. So the Recovery Act increase went up and
    down based on State economic conditions, but at its peak it was
    about twice the size of the assistance that was provided in
    this recession.
        Mr. Butterfield. I represent the State of North Carolina,
    and my State, which, unfortunately, has not expanded Medicaid,
    over 2 million people, including many children and seniors,
    receive necessary care from Medicaid. If our States are forced
    to make budget cuts, what coverage, what coverage would be at
    risk?
        Dr. Aron-Dine. Based on what we have seen in past
    recessions, I would be particularly worried about two things.
        One is States cutting back on optional services which are,
    in fact, quite critical, like home- and community-based
    services for seniors and people with disabilities, as well as
    dental and vision coverage.
        I would also be very concerned about States seeking to
    introduce procedural hurdles that make it harder to get
    covered, and so cutting costs by reducing the number of
    eligible people who are actually able to get access to the
    program. As well as others.
        Mr. Butterfield. Would reimbursement rates be affected, in
    your opinion, to the providers?
        Dr. Aron-Dine. Absolutely. And that is something we are
    already seeing, even with the Families First FMAP and the
    protections that came with it is that a number of States are
    cutting provider rates, including for some providers that are
    particularly financially fragile right now.
        Mr. Butterfield. Well, we haven't passed--the Senate hasn't
    passed the Heroes Act, and you certainly know that the Heroes
    Act contained a 14-point FMAP increase, and I am just so
    disappointed that our Senate Republican colleagues have just
    been unwilling to move that legislation.
        Madam Chairman, I think I am going to stop there and yield
    back. Thank you.
        Ms. Eshoo. The gentleman yields back.
        It is a pleasure to recognize now the gentleman from
    Kentucky,Mr. Guthrie, for his 5 minutes of questions. And
    please unmute.
        Mr. Guthrie. Thank you, Madam Chair, I believe that I have
    unmuted. Thank you very much.
        Dr. Holtz-Eakin, you talked about this, I think, as your
    second point if I remember your three points. And like Idaho,
    you know, I have a district that has lost small businesses,
    farmers, people that are typically in the individual market,
    quite a bit of people in the individual market, and have seen a
    large increase in premiums. And so that is what we have to
    balance, how do we get coverage, how do we get items covered,
    and how do we decrease premiums?
        And one of the ways the architects of the Affordable Care
    Act--one was individual mandate, but the other one was
    enrollment periods. And so now we are talking about, I think,
    talking about a special enrollment period has been proposed.
    And my understanding is if you are working--tell me if I am
    correct, if you have a job and employer and you have employer-
    sponsored health insurance and you lose your job, therefore,
    your health insurance, due to the crisis, then you can enroll
    in another program.
        I know we may have to do assistance, I understand that,
    that is expensive, and we have to look at that. But you would
    already have the right to enroll in another program if you lose
    your employee-sponsored health insurance under the current law?
    Is that correct.
        Dr. Holtz-Eakin. That is correct.
        Mr. Guthrie. So we have a special enrollment period. A
    special enrollment period would benefit those who made a choice
    not to purchase health insurance, either through their employer
    or individual market, therefore, made the choice not to pay
    premiums; but now that we have a pandemic and we open up the
    enrollment period, they can go into the marketplace even though
    they haven't paid premiums.
        So what would that do to the costs of health insurance for
    everybody else if people made a choice not to buy health
    insurance and now can buy it because there is a pandemic moving
    forward and they haven't been paying premiums the whole time.
        Dr. Holtz-Eakin. Certainly you run the risk of getting some
    very expensive people into the pool who are not priced by the
    insurers at the beginning of the plan year and running into
    financial difficulties for those insurers. That is not a
    hypothetical.
        We saw this repeatedly during the startup of the ACA when
    there were about 13 special provisions in which you could enter
    the marketplaces during the middle of a plan year and the
    insurers repeatedly complained about how it made it impossible
    for them to manage their offerings effectively, how they as a
    result had to have price increases to anticipate people jumping
    in, and often those individuals would then jump back out and
    get a chance to reenroll somewhere else in the next year.
        Mr. Guthrie. Well, that is not point. It is not what it
    does to insurers, but what insurers do to make up for that.
    What is the end result of that?
        Dr. Holtz-Eakin. It went up. They had to raise premiums to
    anticipate this phenomenon.
        Mr. Guthrie. So those in the marketplace pay more----
        Dr. Holtz-Eakin. Yes.
        Mr. Guthrie [continue]. If you have a special enrollment
    period? That is the concern I wanted to bring up.
        So the second thing on this economic--and as we have seen
    from Idaho and experience that I have is that that causes more
    people to fall out of health insurance. I know the person
    that--I took my car in to get a transmission fixed, and the
    guys said, Well, I am only here certain hours because in the
    morning and afternoon I drive a school bus because I am driving
    for--he goes, essentially I am driving a school bus for $1,600
    a month because that is why he is an individual small business,
    sole proprietor, transmission business.
        But in this economic downturn, we have had big effects. And
    so I want to talk about health insurance coverage and effects
    from this. How does this downturn differ from other, like the
    post financial crisis downturn? Are some of the job numbers
    that we have seen in recent weeks indicative of any of those
    differences? And as the economy starts to come back, does that
    affect what policies you recommend to address any remaining
    coverage issues?
        Dr. Holtz-Eakin. This downturn is unlike any previous
    downturn in the United States. It is characterized by a sharp
    decline in household spending, particularly spending by
    affluent households on those services which involve personal
    contact. And that began in mid-March, and it was so severe that
    in the space of 2 weeks it turned the first quarter growth rate
    into a negative number.
        It continued into the second quarter with these large job
    losses, ten times larger than anything we have seen in a single
    month in U.S. history.
        So the onset is different, it isn't that people didn't have
    income and it isn't that we had a financial disturbance, it was
    the virus, people hiding from the virus and not spending, and
    especially affluent individuals. So that is an important piece.
        For this hearing, one of the things that has happened is
    that the health sector has never before been involved in the
    business cycle, and the health sector is the business cycle. Of
    the 5 percentage point decline in the GDP in the first quarter,
    two full percentage points came from the diminished use of
    health services. People stopped going to doctors and hospitals
    and clinics.
        And what happens to the deliver system going forward I
    think is a very important question. We have seen a lot of
    consolidation in recent years. That is why prices are high.
    That is why insurance becomes expensive. And the ACA actually
    fostered some of that. Now we have got this enormous financial
    distress in the healthcare delivery system that is going to be
    important for an online. But if there is less competition as a
    result, we are going to have a big problem.
        Mr. Guthrie. OK. Thank you. And I see my time just expired.
    I appreciate your answers.
        And I yield back. Thank you.
        Ms. Eshoo. The gentleman yields back.
        It is a pleasure to recognize the gentlewoman from
    California, my wonderful friend, Congresswoman Matsui, for your
    5 minutes.
        Ms. Matsui. Well, thank you, Madam Chair, for calling this
    really important hearing, and thank you for the witnesses for
    being here today, and I just have to have a special shout out
    to Peter Lee as a wonderful Californian who has done a
    wonderful job.
        Let me just say this. The arrival of COVID-19, as we know,
    has quickly turned life as we know it upside down, and
    overnight the pandemic created unprecedented challenges that
    necessitated rapid and extraordinary responses. California has
    been a leader in preserving and expanding access to care, and
    this pandemic response has been no exception. The ACA has been
    a lifeline for millions in California, and in our current
    crisis, the law has proven vital to ensuring that we can meet
    the increased need brought on by the recession.
        Mr. Lee, I want to follow up on the previous question
    regarding the special enrollment period for previously
    uninsured. How have you seen the special enrollment impact the
    risk pool and what effect do you expect on premiums?
        Mr. Lee. Great. Thank you very much, Congresswoman Matsui.
    It is great to see you. I wish I could see you in person.
        Covered California is more sensitive than anyone about the
    importance of the risk mix. California, by enrolling more
    Californians than virtually any other marketplace, has enrolled
    healthier Californians, which means on average our premiums are
    20 percent less than they would have been.
        We engaged our health plan before we opened up the doors
    wide, and we saw 80 percent of the people signing up during the
    special enrollment period were previously eligible, but more
    came in because we marketed. But 20 percent were not eligible
    previously, but they weren't people in ICUs because of COVID.
    They were people scared about getting COVID. They were people
    who were healthy who we want to get tested. We saw those people
    come in, and we then assessed the risk mix.
        So I totally agree with the broad theories that Doug Holtz-
    Eakin noted in the early days of the ACA risk mix. We saw a
    healthier risk mix coming in during our special enrollment
    period. It is a win-win.
        You want people to not avoid healthcare during a pandemic,
    and we want to get more people enrolled, a healthier risk mix.
    It is going to lead to lower premiums as in 2021, our plans are
    priced to have a .6 percent premium increase. That is because
    they looked at risk mix; we looked at risk mix. It has been a
    win-win, Congresswoman.
        Ms. Matsui. OK. Thank you very much for that.
        House Democrats have passed legislation to protect
    consumers and help make healthcare more affordable. We pushed
    for provisions in the Heroes Act, as has been mentioned before,
    to establish an emergency special enrollment period and ensure
    access to free COVID-19 treatment. Unfortunately, the Senate
    Republicans have refused to take this up.
        Dr. Aron-Dine, the ACA brought the uninsured rate to
    historic lows. However, under the Trump administration, nearly
    3 million Americans have lost coverage. Can you discuss why the
    number of uninsured Americans began to climb? And also what
    policies should we be putting forward to make it easier for
    people to get a State covered in this and future crises?
        Dr. Aron-Dine. Thank you.
        A number of policies from the administration I think
    contributed to the rise in the uninsured rates that we saw
    prior to the pandemic during a strong economy, but let me
    single out two.
        One is the set of administration policies, but particularly
    the public charge rule, which have really created a climate of
    fear for people, for immigrants and their family members, who
    are eligible for public coverage programs but are worried about
    what might happen if they enroll. And what we saw in the latest
    census data is that the groups you would worry would be most
    affected by that, such as Hispanic people, children not born in
    the United States, were particularly likely to lose coverage.
        A second factor I would single out is the set of
    administration policies that have made it harder for people to
    get and stay enrolled in Medicaid. The worker climate policies
    that Dr. Sommers spoke to were fortunately thrown out in court
    for the most part, but other policies have also created
    procedural barriers. For example, the administration actually
    told Idaho that they had to stop doing something that made it
    easier for people to renew their Medicaid coverage and instead
    had to require more paperwork.
        And so going forward, I think some of the areas to think
    about to fill in the remaining coverage gaps include continuing
    to work on affordability policies, finding ways to make it
    easier for people to get and keep their coverage instead of
    harder, and creating more incentives for the remaining 12
    States to expand Medicaid which is just critical to filling
    that major gap.
        Ms. Matsui. All right. Thank you very much.
        And I know that my time is gone, so I yield back. Thank you
    very much.
        Ms. Eshoo. I am sorry. The gentlewoman yields back.
        Now it is a pleasure to recognize our colleague from
    Virginia, Mr. Griffith, for his 5 minutes of questions.
        Please unmute.
        Mr. Griffith. Thank you very much, Madam Chair. Can you
    hear me?
        Ms. Eshoo. Yes.
        Mr. Griffith. All right. Thank you.
        Look, you know, we have talked about the Supreme Court, and
    one of the things that I think hasn't been said is that if the
    Supreme Court were to rule the ACA unconstitutional, that
    doesn't mean that there is a vacuum that cannot be filled.
    Congress, as civics teacher Shimkus would tell us, Congress has
    an opportunity to step in and fill that and act as it sees
    appropriate, and if we are so concerned about the preexisting
    condition issue, how come we haven't we brought up a standalone
    bill like Greg Walden's H.R. 692 which would take care of that
    and make it clear to everybody? Republicans and Democrats both
    believe that preexisting conditions should be covered.
        And to Chairman Pallone's point, those who have had COVID
    may now have a preexisting condition, well, science is out on
    that. We are trying to figure that one out. And, in fact, I
    have joined an NIH study to see, having had COVID, to see what
    are the subsequent consequence of having had COVID and are
    their health conditions that may come from that 2 to 3 years
    down the road. So we will find that out, but we can fix that if
    we wanted to and we have failed to act.
        Now, let's go to the underlying ACA, and, you know, I have
    said this many times, but it is still true. More than a decade
    ago President Barack Obama visited Bristol, Virginia, in my
    district, and in front of a large crowd, he proclaimed the
    virtues of his healthcare plan, which is now the Obama Care or
    ACA.
        Under the reform I propose, if you would like, you can--if
    you like your doctor, you can keep your doctor. If you like
    your healthcare plan, you can keep your healthcare plan. He
    went on to say, Under the Obama plan, the government would work
    with insurance companies to lower premiums by an average of
    $2,500 per family annually for those who have insurance.
        Well, here is what actually happened. According to Virginia
    State Corporation Commissioner of Insurance, currently seven
    percent of Virginia's population is uninsured. Only one
    insurance company, only one, covers the 29 jurisdictions that I
    am proud to represent, only one. And in 2019, the weighted
    average insurance premiums for individuals in Virginia was
    $796.29 per month. That is up from an average of $322.41 in
    2014 and even more over 2010.
        My constituents feel the pain financially as well as
    physically. Congress continues to hear about problems with the
    ACA and what those problems are causing, even as the pandemic
    has caused more to need individual insurance claims. Since June
    of this year we have had--in my office, we have had at least 54
    separate complaints.
        Dr. Holtz-Eakin, is Virginia isolated in these experiences?
    Did the ACA fulfill its dream of allowing folks to keep their
    healthcare plans, keep their doctors, and lower their health
    insurance premiums?
        Dr. Holtz-Eakin. No. Your characterizations are shared by
    many other States.
        Mr. Griffith. I appreciate that.
        And also, Dr. Holtz-Eakin, in your testimony you discuss
    short-term limited duration plans as a potential stopgap
    measure for some people who have lost their employer-sponsored
    health insurance because of the downturn. You mentioned
    particular people had previously made too much money to qualify
    on certain exchanges when they went to enroll in their special
    enrollment period.
        Can you help me put into understandable terms, who would
    that be? How much money would someone like that had to have
    made and what their choices in how much they pay in the ACA
    exchanges versus a short-term plan?
        Dr. Holtz-Eakin. You get folks making, you know, $150,000 a
    couple and they get hit with the downturn and now what are they
    going to do. So this is a degree of flexibility that was not
    present in prior years, and it gives people an opportunity to,
    you know, have insurance during what they hope is a relatively
    short recession and recovery.
        And we have already seen job growth return to the United
    States. We saw that in May, June, July, August, and in the
    August report we saw private payrolls rising at a 20 percent
    annual rate. So there are reasons to be hopeful that this will
    turn out to be a very limited, very sharp downturn, and then a
    short-term plan is the way to ride that out and get back into
    your regular insurance after that.
        Mr. Griffith. Well, and I appreciate that, and the short-
    term plans can be helpful for some people; but let me
    underscore once again that while there has been a lot of
    discussion about preexisting conditions, neither Republicans
    nor Democrats want to see people with preexisting conditions
    not covered.
        And obviously, you know, I have told you I had COVID. I am
    one of those people that may be affected if Chairman Pallone is
    correct, and if the science bears out that there are some
    additional repercussions from having had even a mild case of
    COVID, we will just have to see what happens in the science.
        But neither Democrats nor Republicans are planning to get
    rid of the protection that is afforded to people who have
    preexisting conditions. You would agree with that, wouldn't
    you, Doctor Holtz-Eakin?
        Dr. Holtz-Eakin. Yes, I would. Both sides have put together
    proposals to preserve that protection, so there is no evidence
    that anyone is against it.
        Mr. Griffith. I appreciate it.
        And I yield back.
        Ms. Eshoo. The gentleman yields back.
        I would just add to this discussion that, on the Republican
    side of the aisle, not one Member in the entire House of
    Representatives has spoken up and said that this case at the
    Supreme Court is going to wipe this out and that they are
    deeply concerned about it.
        So I just think it is important to place that on the
    record.
        I now am pleased to recognize the gentlewoman from Florida,
    Ms. Castor, for her 5 minutes of questions. And please unmute.
    Wonderful to see you.
        Ms. Castor. Thank you, Chairwoman Eshoo. This is very
    important hearing today on the Affordable Care Act and COVID-
    19. Thank you to our witnesses who are here.
        And, Chairwoman Eshoo, you are right, some of this rhetoric
    does not match the reality. We know, it is crystal clear, that
    President Trump and Republicans are urging the United States
    Supreme Court to strike down the Affordable Care Act in its
    entirety.
        That includes protections for 130 million Americans with a
    preexisting health condition and it also means the coverage for
    1.9 million Floridians who purchase their affordable health
    insurance on the healthcare.gov marketplace. You heard that
    right, 1.9 million Floridians. That is more than the population
    of about a dozen States.
        So the stakes are high here, and it is truly unconscionable
    that this would be urged on at any time, but especially in the
    middle of a public health crisis that has tragically claimed
    the lives of 200,000 Americans. Trump and the GOP are
    attempting to rip coverage away in the courts after they failed
    to do so in Congress, try as hard as they might. What they are
    doing by bringing this case to the United States Supreme Court
    is cruel and it is wrong.
        And, in addition to actively putting the ACA's preexisting
    condition protections at risk, President Trump and his
    administration have also recklessly expanded junk health plans.
    And the result has been that many bad actors have fraudulently
    sold junk plans to consumers.
        These junk plans often do not offer comprehensive coverage,
    and they discriminate against people with preexisting
    conditions. In fact, this committee did an investigation and
    found that junk plans leave families on the hook for hundreds
    of thousands of dollars in medical bills, and they often deny
    claims for medical care that rightfully should be covered.
        In fact, the Federal Trade Commission has gone after some
    of these bad actors for their bait-and-switch tactics. There
    are a number of Federal lawsuits filed against them. But the
    Trump administration has allowed them to proliferate
    needlessly.
        The Affordable Care Act was successful in limiting these
    junk plans and ensuring that families can rely on the
    meaningful health insurance policy when they purchase one. They
    don't want to go back to the battle days when insurance
    companies could discriminate against them if they have asthma
    or cancer, now COVID-19.
        So I understand, Mr. Lee, that California has outlawed junk
    plans. Can you briefly explain why?
        Mr. Lee. I can. Thank you very much for the question.
        I think there is a lot of confusion when people talk about
    short-term plans or faith-based plans. They are cheaper, they
    are great option, they are short term. Let's be clear, it is
    not just fraud. This is what health insurance was ten years
    ago.
        These are plans that can, number one, exclude people based
    on their health status, so they winnow off people. But then
    there is no guarantee that coverage will be there when you are
    sick. It is Swiss cheese coverage. You don't know what is
    covered and what is not covered.
        And they will say, sorry, this short-term plan doesn't
    cover mental health. This one has a cap on hospital. They are a
    great deal, they are cheap if you predict the future; but if
    you could predict the future, you don't need insurance. You
    don't know if you are going to get cancer or end up in the ICU.
        And I would note that in California, we have 800,000 people
    with unsubsidized coverage because we, the State, have kept all
    of the costs down, and that has been a failure of many States
    that have priced middle class Americans out of coverage because
    they have allowed premiums to skyrocket by not marketing, not
    getting people in the door. Going back to short-term plans is a
    wrong solution. We have people come in and out of Covered
    California every month. That is a working solution because,
    when they are with us, if they get sick, they are covered.
        Ms. Castor. So, Dr. Aron-Dine, do junk plans pose a risk
    for families who contract COVID-19? What is going on here? What
    would you warn consumers about here?
        Dr. Aron-Dine. Yes, I do think they pose a risk to people
    who contract any serious illness. And I think there is a bit of
    a sort of myth out there that the people purchasing these plans
    are fully informed consumers making totally rational decisions
    to assume those risks.
        You could question whether anyone is able to make that kind
    of decision about those kinds of risks, but it is also clear
    that these plans are being marketed in misleading ways and that
    they engage, your committee reports finds, in a lot of what is
    called ex-post underwriting, which is fancy word for finding
    reasons to deny people's claims once they get sick.
        So that is not coverage that people are making an informed
    decision to buy. It is coverage that is really leaving them
    without protection.
        Ms. Castor. Thank you.
        And I yield back.
        Ms. Eshoo. I am sorry. The gentlewoman yields back.
        It is a pleasure to recognize the gentleman from Florida,
    Mr. Bilirakis, for his 5 minutes of questions.
        Mr. Bilirakis. Thank you so much, Madam Chair. I appreciate
    it very much. And thanks for holding this hearing, and I thank
    the witnesses for testifying as well.
        Like my colleagues on and off this committee and this
    administration, I, too, support protections for those with
    preexisting conditions and funding our community health
    centers. However, like many Americans, I remain concerned with
    the continued high cost of healthcare despite the ACA's
    passage.
        Dr. Holtz-Eakin, one of the major promises of the ACA was
    affordable insurance for every American. The law even went so
    far as to penalize those who didn't enroll. However, in the
    decade since its enactment, costs continue to rise. Why is
    that, in your opinion? Why is that?
        Dr. Holtz-Eakin. Well, I think one of the key features
    across the United States has been increased consolidation in
    providers, hospitals buying up doctor physician groups, and the
    like, which allow them to have more market power and higher
    prices for delivering the underlying services.
        And insurance, in the end, is a product that just shifts
    the bill from one individual to another. If the bill is too
    large, insurance is going to be very, very expensive. And so I
    think that has been a concern among health policy experts of
    all stripes, that lack of competition and how to address the
    increase in prices.
        Mr. Bilirakis. OK. Thank you.
        Director Cameron, the pandemic has further stressed the
    mental health of our communities. I think we can all agree on
    that. Recent data from my district indicates increased overdose
    rates, unfortunately, this year, with August being one of the
    deadliest marks on record.
        Congressman Soto and I introduced H.R. 5473, the Enhance
    Access to Support Essential Behavioral Health Services Act,
    which builds on landmark opioid legislation passed by this
    committee last Congress to expand reimbursement for behavioral
    and mental health services delivered through telehealth,
    regardless of whether someone has substance abuse disorder.
        Would you agree that preventive measures like the EASE
    Behavioral Health Services Act would be helpful in addressing
    our Nation's mental health crisis? And I believe that that was
    placed in Ann Wagner's bill. But we would love to get that
    through this committee but also on the floor of the House as
    soon possible.
        What is your opinion on that, on that particular bill, sir?
        Mr. Cameron. Thank you, Congressman. I have not seen the
    language, but I certainly believe that providing mental health
    services is paramount. We have been very successful in
    improving that through our telemedicine. In fact, that has been
    a real hallmark of what has happened this last year and, you
    know, certainly support any efforts in that direction.
        Mr. Bilirakis. Yes, people have to have access, no
    question.
        Again, Director Cameron, you mention in your testimony
    seeing an uptick in telehealth visits in Idaho. Pre-pandemic,
    some stakeholders cited a lack of clarity around Federal
    reimbursement for telehealth for substance abuse disorders
    under Medicaid.
        Do you agree with that sentiment? And would additional
    guidance from the appropriate agencies at HHS be helpful to
    ultimately ensure that those who needed treatment can have
    access to it?
        Mr. Cameron. Well, it certainly can't hurt. I think it is
    more complicated than that. I think people were not using
    telehealth services, A, because they weren't especially
    comfortable with it, and they got real comfortable real quick
    in the pandemic.
        I think providers weren't offering it because they weren't
    necessarily comfortable. They liked the old system of being
    able to see people face-to-face. And in many cases, that is
    ideal. But one of the things the pandemic has done is it has
    sort of blown the doors open and allowed consumers to be able
    to access and utilize it, and I think many are seeing they
    actually prefer it now.
        Mr. Bilirakis. Yes. That is what we are hearing, too,
    because they can actually do it in the privacy of their own
    home and it is so very convenient.
        Mr. Cameron. Yes.
        Mr. Bilirakis. One last question. I don't want to go over,
    Madam Chair.
        Dr. Holtz-Eakin, CMS released a report in August of 2019 on
    individual insurance market enrollment trends. Data shows that
    between 2016 and 2018, unsubsidized enrollment declined by
    approximately 40 percent. If the ACA has fulfilled its promise
    to provide affordable healthcare to all, why has this decline
    occurred? Is it an affordable issue?
        Again, thank you, Madam Chair, for allowing me to ask that
    question.
        If you could respond briefly, I would appreciate it. This
    is for Dr. Holtz-Eakin.
        Ms. Eshoo. Yes.
        Dr. Holtz-Eakin. I think it is an affordable issue, by and
    large, and I would be happy to elaborate in writing after the
    hearing.
        Mr. Bilirakis. Thank you very much.
        I yield back, Madam Chair.
        Ms. Eshoo. The gentleman yields back.
        And the gentleman from Maryland, Mr. Sarbanes, please
    unmute and you have your 5 minutes for questions.
        Mr. Sarbanes. Thank you, Madam Chair. Can you hear me?
        Ms. Eshoo. Very well.
        Mr. Sarbanes. Excellent. I appreciate the testimony today.
        Let's call a spade a spade when it comes to the Republican
    attacks on the ACA. This has been an obsession with the
    Republicans for more than ten years. The attack that is coming
    with the Supreme Court case in November and its effort to ram
    through the appointment of a new justice before the election is
    just the latest play out of that playbook that we have seen for
    years, which, in my view, is really just an effort to try to
    attack one of the legacy achievements of President Obama.
        But leaving that where it is for the moment, Dr. Lee--or,
    Mr. Lee, if you could describe, we have seen the Trump
    administration, obviously, engage in leadership malpractice
    when it comes to responding to the pandemic, and we could speak
    about the broad GOP reluctance to embrace the opportunities of
    the ACA over the last ten years.
        But if you are in the middle of a pandemic, you start to
    see huge job losses disruptive to people's coverage. It seems
    to me that if there is in your tool kit something that you can
    do using the ACA and using exchanges and you don't take
    advantage of that, that is leadership malpractice of the
    highest order.
        Describe the moment when you pulled your team together to
    demonstrate proficiency in leadership in this moment, when you
    saw what was happening and you saw the amount of people that
    were being thrown into this place of not having coverage, that
    morning, that meeting when you convened people and you said,
    Here are the tools we are going to use that are available to us
    through Covered California, because of the ACA, to make sure
    that we help people get through this crisis.
        What were the first two or three things you knew you had to
    do that unfortunately were not happening at the Federal level?
        Mr. Lee. Thank you very much for that question.
        Now, oddly, I think the first meeting we had was six years
    ago. It is not just about a pandemic. It is for the last five
    years saying we will do everything to make every Californian
    over there for them. And I think there has been a failure of
    action at the Federal level since March but also for about
    three years, cutting back on spending, not supporting
    navigators, promoting short-term plans which weaken the risk
    mix.
        But what we did this year, March 19 our Governor declared a
    state of emergency. March 20 we declared a special enrollment
    period. And we have spent $9 million in advertising, and every
    day since then, when a Californian got an unemployment check,
    they got a flier from Covered California, and our 500
    storefronts across California were open virtually taking
    enrollment by phone, and we promoted that. It is a matter of
    saying again, in America, there is half a million more
    Americans uninsured today because of Federal inaction. Those
    are people----
        Mr. Sarbanes. Can you imagine--thank you for that.
        Can you imagine if the President of the United States in
    the midst of this crisis had led with all of the efforts that
    you just described at the national level, had gotten on the
    phone with Governors across the country and States who had
    their own health exchanges and said this is what we are going
    to do as a team to respond to this crisis? But he didn't do it.
    And now he is trying to take down the ACA in the middle of this
    pandemic once again.
        Let me turn to Dr. Sommers because my head is exploding
    when I keep hearing my colleagues across the aisle talk
    reverentially about their desire to protect people with
    preexisting conditions, but you can't just pull that out of
    thin air. I mean, there are actuarial dynamics to this, the way
    insurance pools function, and all the rest of it, that can
    allow you to do that effectively, i.e., through the mechanism
    that we have set up through the ACA or to just try and pull it
    out of thin air, which is what I think their approach is going
    to be.
        Can you just talk to why, if you really want to do that
    effectively, cover people with preexisting conditions, you need
    to do it inside of a structure, an insurance structure and a
    coverage structure that actually makes sense and is
    sustainable?
        Dr. Sommers. Yes. So States before the Affordable Care Act
    did try this, and what they found was that if they made rules
    that said you have to take all comers, but they didn't have the
    infrastructure of the ACA, they didn't have the tax credits and
    the subsidies, basically what happened was only sick people
    signed up, premiums went through the roof, and the markets
    collapsed. You need to hold infrastructure of the ACA. You
    can't just put out that edict that says cover everybody.
        Mr. Sarbanes. Thank you.
        I yield back.
        Ms. Eshoo. The gentleman yields back.
        Pleasure to recognize the gentleman from Missouri, Mr.
    Long, for his 5 minutes of questions. And please unmute.
        Mr. Long. Thank you, Madam Chair, and thank you all for
    being here today.
        Dr. Holtz-Eakin, much has been made of how the affordable
    healthcare is under the--excuse me. I am going to start again.
        Much has been made of how affordable healthcare is under
    the current system, but can you talk about any trends you have
    seen that relate to the actual cost of care, not what the
    patients pay at the counter in the form of co-pay or
    coinsurance, but the underlying costs of care?
        Dr. Holtz-Eakin. I think we saw in the 2 or 3 years in the
    aftermath of the Affordable Care Act a noticeable diminishment
    in the pace of so-called excess cost growth, the rate at which
    healthcare costs go up faster than incomes in the United
    States.
        But more recently we have seen that go back to something
    closer to the bad old days, and acceleration in those costs. A
    lot is made of prescription drugs and particularly retail
    prescription drugs, but they are a small fraction of the
    healthcare bill. The vast majority of the costs are hospitals
    and doctors and other providers, and it is there that the
    attention needs to be focused if we want to slow the pace of
    the healthcare billing in the United States.
        Mr. Long. OK. Thank you.
        And, Director Cameron, I understand that in Idaho you offer
    a specific type of short-term plan that might be useful during
    the time period when folks may have a few months' gap between
    their loss of a job-based coverage and the next open enrollment
    plan. Can you talk about these plans and what kind of feedback
    you have gotten on them?
        Mr. Cameron. Certainly. Thank you, Congressman.
        So these plans should not be confused with traditional
    short-term plans. They are what we call as enhanced short-term
    plans. They are designed to be renewable. They have all of the
    same essential health benefits or requirements or coverages.
    They are not what one Congressman has called as junk insurance.
    They have the same.
        They have the same preexisting predictions or very similar
    preexisting condition protections to an ACA plan, but they are
    available and allow enrollment year around or at open
    enrollment if a person chooses to.
        They have provided an answer for us because we keep them in
    the same risk pool. So they are tied--their rates are tied to
    that of the ACA plans, and it helps attract and bring back
    those young and healthy individuals and families that need
    coverage, like the family in Oakley, Idaho, who are--the wife
    is a breast cancer survivor who knows the importance of
    coverage but can't afford $2,100 a month. They are cattlemen.
    Their prices change every day, and they don't qualify for a
    subsidy.
        So for them they are being forced out of ACA coverage out
    of no desire of their own but simply because of price. This has
    provided an alternative for them that, in essence, helps all of
    those that are enrolled by keeping it in the same risk pool.
        Mr. Long. OK. I might add that my sister has been a
    resident of Ketchum, Idaho, for 40-some years now, so I don't
    think we are getting her back to Missouri.
        And do you regulate these products to ensure that they are
    marketed fairly and honestly to consumers?
        Mr. Cameron. Absolutely. We very strongly regulate them. We
    make sure--and, by the way, I need to tell you, when I talked
    earlier about the traditional plans waiving co-payments and
    deductibles and co-sharing for COVID, so did these enhanced
    plans. They did the same things, and we regulate to make sure
    that their advertisements are not misleading, that they fulfill
    the conditions of their policies, and we go after those that do
    so inappropriately.
        Mr. Long. So instead of issuing broad mandates and
    restricting plan design, is it safe to say you have opened up
    the markets, collaborated with your health plans, and increased
    competition to make more choices available to your citizens?
        Mr. Cameron. Absolutely. Our goal is to have more people
    insured. The original goal of the ACA was to insure more
    people, and then some of the provisions actually started
    limiting who could actually obtain coverage. So our goal is to
    have more people insured. We have collaborated with our
    carriers. We will now have three carriers offering these type
    of plans this coming year.
        Mr. Long. During the pandemic you had plans set up and
    volunteered to offer credits back to consumers, make advance
    payments to providers to help get them through the downturn?
        Mr. Cameron. Yes, yes, sir.
        Mr. Long. And what effect have these policies had on
    premiums for your citizens?
        Mr. Cameron. Well, in many cases they have actually lowered
    the price from where they were previously. One of our carriers
    lowered the price by 50 percent on dental premiums, others
    lowered it by 15 percent over this next year.
        What has happened is that we don't have as many people
    taking advantage of, you know, treatment that wasn't as
    necessary, and so the amount of claims being spent has
    dramatically decreased, and so they have been refunding that
    money back.
        Mr. Long. OK. Madam Chair, I don't have any time to yield
    back, but if I did, I sure would.
        Ms. Eshoo. The gentleman yields back.
        I would just like to say to the witness from Idaho, it
    would be, I think, instructive for you to read the June 25
    report that the Energy and Commerce Committee all put together
    that found short-term plans denied and rescinded coverage for
    millions of people. And after reading that, I would look
    forward to your kind of written response to it. But I do think
    that it would be instructive. It was highly instructive to me.
        Now it is a pleasure for me to recognize the gentleman from
    New Mexico, Mr. Lujan, for his 5 minutes of questions.
        Mr. Lujan. Thank you, Madam Chair.
        Before I begin my remarks, Madam Chair, I do have a
    unanimous consent request.
        Ms. Eshoo. Would you please state it.
        Mr. Lujan. That is to submit a GAO report, the Government
    Accountability Office, August 24, 2020, ``Private Health
    Coverage Results of COVID Testing for Selected Offerings.''
        Ms. Eshoo. The unanimous consent request is approved. It is
    already a part of the record, and at the end of the hearing, I
    will name everything that has been placed in the record.
        [The information appears at the conclusion of the hearing.]
        Mr. Lujan. Thank you, Madam Chair. I am not sure if my
    clock can be reset. But nonetheless, Madam Chair, the reason
    that that report is so very much is when you go into the
    summary findings of that report, what the GAO found is when
    they were out there looking at folks that were selling what my
    colleagues on the other side of the aisle are calling short-
    term plans, that I have heard everyone else call a junk plan,
    they found that there were deceptive marketing practices
    similar to the findings from the Energy and Commerce Committee.
        And what is clearly listed here is that those short-term
    plans, the plans that I refer to as junk plans, they do not
    cover people with preexisting conditions. People need to stop
    lying to innocent folks that are out there and convincing them
    that these plans are going to cover their cancer, their
    diabetes, or if they get in an accident.
        Many of these plans don't even cover prescription drug
    costs. They don't cover ambulatory care. Enough. Let's just be
    honest. If you want to sell people these short-term plans,
    let's be honest with the American people as to what they are
    buying so that way people are not left without. That is all we
    are saying here.
        Truth and transparency. Why is it that the Trump
    administration eliminated the requirement on those junk plans
    to list exactly why they were so bad? I have screenshots from
    superintendent sites across America before President Obama's
    administration--or sorry, before President Trump's
    administration changed that rule and after, and you see that
    its name has changed. But that is a conversation for another
    day, Madam Chair.
        At this very moment, the Trump administration and
    Republican Governors and Attorney Generals are leading efforts
    with the U.S. Supreme Court in a case where they are seeking to
    strike down the entire Affordable Care Act.
        They aren't asking the U.S. Supreme Court to keep the parts
    they claim they like, such as protections for people with
    preexisting conditions. They are asking the Supreme Court to
    strike down the whole law during the public crisis that has
    taken the lives of more than 200,000 Americans.
        If the ACA is struck down, protections for people with
    preexisting conditions would be gone. That now includes the
    nearly 7 million Americans who have been infected with COVID-19
    who could be denied coverage for the rest of their lives. More
    than 20 million people would lose their healthcare coverage,
    including 226,000 New Mexicans, more than doubling the number
    of people in our State who are uninsured.
        The 9 million people who receive subsidies to make their
    premiums more affordable would be on their own. In the middle
    of a State budget crisis, States like New Mexico would be left
    to shoulder the full cost of keeping people covered through
    Medicaid.
        Now, remember that bill that Republicans tried passing in
    2017? That actually eliminated every dollar with the Federal
    Government's investments in Medicaid. Private insurance plans
    wouldn't have to cover preventative care, maternity care,
    mental and behavioral health, and other essential services.
        Young adults could no longer stay on their plans until the
    age of 26. And insurance companies could go back to charging
    more just because you are a woman, you have a health issue, or
    because of your age.
        My Republican colleagues have no plan to cover the
    preexisting conditions or to protect the American people. Their
    last proposal from a few years ago allowed insurance companies
    to charge ridiculous prices for people with preexisting
    conditions. They slapped an age tax on older Americans and
    enforced States to ration care by drastically cutting Medicaid.
        President Trump has not put forth a plan at all, although
    he has promised it for four years every two weeks. But what we
    have seen from him already is deeply troubling.
        The Trump administration has promoted those junk plans that
    we were just talking about, which looked cheaper until you get
    sick and realize the plan doesn't cover basics like emergency
    room visits or prescription drugs.
        Now, Madam Chair, I have a couple of questions.
        Dr. Aron-Dine, or Dr. Sommers, in both of your testimonies
    you talked about how Trump administration policies have chipped
    away at coverage gains achieved during the first few years of
    ACA implementation.
        Would either of you like to comment on short-term limited
    duration junk plans or other Trump administration efforts to
    sabotage not just the number of people covered but the quality
    of coverage?
        Dr. Sommers. Sure, I am happy to answer that.
        I think there are a couple of issues that I analyzed. The
    first is that people have to know about the coverage and be
    able to navigate the system to get there. And if you make the
    period that they can sign up shorter and spend less money on
    outreach and less money on assisting people on those
    applications, they don't get them covered. These are my
    patients. They struggle with the complexities of our healthcare
    system. If you make it harder for them to shine up, a lot of
    them won't.
        The other thing I will just say is that this is not a story
    where some States really suffered under the ACA. We have heard
    numbers that maybe Idaho, or Virginia, other places have
    suffered. Well, the numbers in Idaho, 100,000 more people were
    covered in 2016 compared to 2013; in Virginia, 300,000; in
    Florida, 1.6 million. Every single State in the U.S.
    experienced substantial increases in coverage under the ACA
    Act.
        Mr. Lujan. And, Dr. Aron-Dine, what would striking down the
    ACA mean for Medicaid and State budgets?
        Dr. Aron-Dine. As a starting point, it would eliminate
    Medicaid expansion, which covers 12 million people not eligible
    under pre ACA law. It is incredibly implausible that States
    could continue to cover those people who rely on that coverage.
    It would also undermine Medicaid in a host of other ways.
        Mr. Lujan. Thank you.
        Madam Chair, I yield back.
        Ms. Eshoo. The gentleman yields back.
        And now I would like to recognize the gentleman from
    Indiana, Dr. Bucshon, for your 5 minutes of questions. And
    please unmute.
        Mr. Bucshon. Thank you, Madam Chairwoman, and thanks for
    holding this very important hearing.
        First I would just like to say, you know, Republicans want
    people with preexisting conditions to have health coverage.
        I think really what we are talking about is people that are
    high-cost individuals that otherwise couldn't afford coverage
    before the mandate was put in place. But one of the biggest
    flaws of the Affordable Care Act is the way to solve this issue
    was done in a way that has resulted in dramatically increased
    costs for everyone.
        Republicans have a healthcare plan that will cover people
    with high-cost medical care, preexisting conditions but will
    allow others to get more affordable health coverage by putting
    those high-cost individuals in a separate insurance pool.
        Anyone that understands insurance knows if you put high-
    cost individuals in the same pool as everybody else,
    everybody's cost goes up.
        As a provider, I had patients with preexisting conditions,
    high-cost health problems, and that couldn't get insurance, and
    that is just wrong. We want to solve that in a different way.
    So it is really not a good narrative--it is a false narrative
    that we don't.
        Dr. Holtz-Eakin, in the GAO report that was just discussed,
    were there any of the short-term limited duration plans found
    guilty of false marketing?
        Dr. Holtz-Eakin. I am not instantly familiar with that, but
    I would be happy to get back to you after reading it.
        Mr. Bucshon. That would be great. And also, I have seen
    some comments that, in the press, people saying the Republicans
    are undermining the Affordable Care Act, a lot of it tied to
    the repeal of the individual mandate. But I would like to ask
    you whether you agree with that sentiment or whether you agree
    with the recent story from The New York Times that ran the
    headline--and this is the actual headline--Republicans Killed
    the ObamaCare Mandate. New Data Shows It Really--It Didn't
    Really Matter.
        Dr. Holtz-Eakin. So this has been a long debate among
    researchers as to just how much the mandate was effective in
    getting people into the ACA insurance, and I think the
    Congressional Budget Office, in particular, has rethought the
    effectiveness of the mandate. It really wasn't as effective as
    people had thought.
        Instead, they pointed at some things that have been
    mentioned in this hearing, which is marketing, navigators, the
    kind of outreach that recruited people and got them into the
    ACA. That was a bigger part of the story than the mandate.
        Mr. Bucshon. Yes. I mean, I think--thank you for that
    answer. I think the issue was, from my perspective, is that the
    Federal Government was mandating the American people purchase a
    product, which, in this case, was health insurance. And as you
    pointed out, the American people don't necessarily follow
    Federal mandates because, you know, we believe in individual
    freedom and individual choice.
        As a followup, I have seen also a lot about how the
    administration has depressed enrollment in the ACA exchanges,
    but what about the health reimbursement accounts rule that the
    administration finalized last year that would let employees use
    their healthcare benefits to purchase coverage on the exchange.
    Wouldn't that actually increase the number of people who might
    join the exchanges in the coming open enrollment period.
        Dr. Holtz-Eakin. Certainly when the administration put out
    that rule, they had estimates of large-scale takeup, a very
    large-scale takeup, of those HRA provisions. They haven't been
    in place long enough for us to see if that comes to fruition,
    but it is a big change in the opportunities that people face.
        Mr. Bucshon. Thank you for that answer. So I think, you
    know, this has been a good hearing. I have one more question. I
    think I have about a minute left.
        Dr. Cameron, as a provider and member of the House Doctors
    Caucus, I was encouraged to hear about your work with health
    plans in Idaho to extend various forms of financial assistance
    to providers who are suffering during the pandemic. Can you
    expand on the specifics of what plans did and what the effect
    had on access to healthcare in Idaho?
        Mr. Cameron. Certainly. Can you hear me? Thank you.
        Mr. Bucshon. I can.
        Mr. Cameron. So--and I will just target or just list a few
    of the things that they did without naming specific companies.
    Again, we have five carriers, unlike many States who are down
    to one. We had targeted loan programs. Obviously, all of the
    carriers were processing their claims quicker and suspending
    prior authorization restrictions. $1.4 million was given by one
    company in cash advances to select provider groups. Three of
    our carriers banded together and gave another $5.5 million to
    providers in a specific hospital system, and another carrier
    offered $10 million in interest-free loans or cash advances to
    providers in order to assist them in getting through this
    pandemic.
        Mr. Bucshon. Thank you very much. I would just like to say
    finally that, you know, as a provider, I want everyone that has
    high-cost health problems, so-called preexisting conditions, to
    have affordable health coverage. I just believe that it needs
    to be done in a different way, because the way that it has been
    done in the ACA has increased the costs for everyone in the
    system. We can do it in a better way.
        With that, I yield back.
        Ms. Eshoo. Dr. Bucshon yields back. We thank him.
        And it is a pleasure to recognize the gentleman from
    Oregon. Mr. Schrader, you have 5 minutes for questioning. And
    please unmute.
        Mr. Schrader. Thank you very much.
        Ms. Eshoo. Is Mr. Schrader there?
        Mr. Schrader. Yes. Thank you very much, Madam Chair. I
    appreciate the opportunity here, and I appreciate the
    panelists.
        I would agree with my good friend and colleague from
    Indiana that, you know, the individual mandate has not been as
    important as we had originally anticipated, but as our good
    friend and colleague from California has pointed out, Mr. Lee,
    that, you know, the outreach is, and, you know, that is
    important. That has been curtailed, unfortunately, under the
    current administration, and caused some problems over the last
    couple years.
        Hopefully, one of the few good things comes out of this
    pandemic is the fact that people are now realizing that
    healthcare is an opportunity and they have access. It has been
    pretty amazing to me that we have not had a huge uptick in
    uninsured people as originally expected.
        Mr. Holtz-Eakin, you testified that there are basically
    three elements that have contributed to that, you know, some
    special enrollment periods, and ability to utilize the ACA,
    some of these short-term plans, and COBRA coverage. Do you have
    any feel for which of those has contributed more or less or
    what the rough percentages are that each of those options
    contributed to keeping people insured?
        Dr. Holtz-Eakin. Yes, I don't have any firm data on that.
    It is quite frustrating trying to sort it out. My instincts are
    that COBRA has been the least important and that we have seen
    people go Medicaid, ACA, and then perhaps some short-term
    plans.
        Mr. Schrader. OK. You know, a testament to, I think,
    American healthcare system. It is not a one-size-fits-all. We
    have many options for folks that are out there depending on
    your personal circumstances and your personal inclinations
    about how you want to get healthcare.
        I have a bill, actually, with a colleague, Rodney Davis
    from Illinois, that talks about COBRA coverage and making it,
    hopefully, a better option. I would hope the committee and
    Congress would consider this as one of the things in the mix by
    making sure that, you know, it pays at least what, you know,
    the premium for that employee that would have been covered
    under that employer-sponsored healthcare program, to make it--
    at least during the pandemic here, make it so that there would
    be an option.
        Do you think, Mr. Holtz-Eakin, that that would be an
    incentive for COBRA to be a more effective help to keeping
    people insured?
        Dr. Holtz-Eakin. Well, as I said in my opening remarks, one
    of the advantages to COBRA is it avoids the churn that was
    mentioned by Dr. Sommers. And churn comes with the downside
    that you are often changing provider networks and your care
    gets disrupted, and that is the last thing you want in the
    middle of a pandemic. So getting people to stay on their
    insurance, using COBRA augmentation, is a way to avoid that
    entirely.
        And, you know, one of the difficulties for everyone, the
    experience to the American worker and for policymakers, is that
    we just cannot get a good, firm handle on how many of the job
    losses will turn out to be temporary. Of the 20 million we got
    in April, 18 million were reported as temporary layoffs. Some
    of those are going to turn into permanent job losses, and so,
    you know, which vehicle you want to use. If you are permanently
    going to lose that job, you might think very differently than
    if you are just temporarily laid off. It has been a real
    struggle thus far.
        Mr. Schrader. Thank you. Thank you for that.
        Mr. Sommers and Ms. Aron-Dine, a question on what is the--
    do you have any feel for what this issue, economic makeup, is
    of those people that are using these special enrollment periods
    to sign up for healthcare? Is it reflective of the population
    writ large or is there some difference there?
        Dr. Aron-Dine. Certainly, in general, use of the
    marketplace is as concentrated among moderate-income people.
    And job losses have also been really concentrated among low-
    wage workers, which is a consideration in thinking about COBRA.
    A big problem is a lot of the people losing their jobs may not
    have a COBRA option, particularly lower-income workers,
    particularly workers of color, who are especially vulnerable to
    becoming uninsured.
        Dr. Sommers. And I would just add briefly that, in
    addition, when workers might have had a plan that worked well
    for them when they had a higher income, if they become
    uninsured and lose their income, those copays from their
    employer coverage may no longer be adequate for them, and
    Medicaid may provide much better protection for them in terms
    of being able to get the care they need.
        Mr. Schrader. So it sounds like we need an all-of-the-above
    option like we have got currently in this country with the ACA
    and COBRA coverage and what all, you know, even the short-term
    plans for a very short period of time. But as pointed out by a
    lot of my colleagues, they do not offer a long-term option in
    terms of complete benefit protection, and we got to keep that
    in mind as we go forward.
        And I yield back, Madam Chair. Thank you.
        Ms. Eshoo. The gentleman yields back.
        It is a pleasure to recognize really just a superb member
    of our subcommittee. We are just going to miss her, miss her,
    miss her, the gentlewoman from Indiana, Mrs. Brooks. You have 5
    minutes, and I hope you are unmuted.
        Mrs. Brooks. I am, Madam Chairwoman, and thank you so very,
    very much. In fact, I would like to take this opportunity to
    thank you, to thank the ranking member, and my colleagues.
    First, I want to thank the witnesses for being here. And while
    this is an incredibly partisan hearing, so many of, in my six
    years of being on this subcommittee, I just want to remind the
    committee, we have accomplished incredible things. And there is
    still a lot more of incredible work to do on behalf of the
    American people.
        And the Energy and Commerce Committee, and particularly the
    Health Subcommittee, has an incredible track record. And I know
    we are working on this incredibly difficult issue of the ACA or
    better ways to provide healthcare for all Americans, and
    affordable healthcare, but I just want to thank you because I
    have been able to be a part of--this is my last hearing, in all
    likelihood--been able to be a part of the 21st Century Cures,
    able to be a part of CARES Act, able to be a part of PAHPA. I
    could go on and on with all the acronyms, which most Americans
    don't know much about, but you all know, as members of the
    committee, the important work we have done on opioids, mental
    health, healthcare affordability. There is so much--and
    preparing and responding for this pandemic.
        But there is a lot more work to do, and I just want to
    encourage all of you. I want to thank the staffs also. We have
    incredible staff. I have worked with really great staff on both
    sides of the aisle, and just want to thank them for their
    commitment in helping us find even better ways to work
    together.
        I am on the Select Committee on the Modernization of
    Congress, and we are going to be rolling out our
    recommendations, as we have been, and I just want you all to
    know that this completely bipartisan committee has more
    recommendations, which I hope that the body takes up, because
    we all have to do better to find the common ground. And I
    actually believe we have a lot more common ground and we can
    find more common ground if we just continue to really work
    together, talk together, find--it is difficult, I understand,
    in COVID and with us working remotely, but, you know, whether
    it is picking up the phone--I love that Kurt just mentioned
    that he is working with Rodney Davis on something, who is not
    even on the committee.
        We have got to find ways to keep working on all of these
    really incredibly important issues that this committee works
    on. So I want to encourage you all. I have great hope, and we
    have got to get through this for our citizens and our
    constituents.
        When it comes to COVID, obviously, healthcare has never
    been more important, and we are right in the middle of it. But
    the innovation that has come from our incredible health
    companies in this country, we have got to continue to support.
        I am really proud of the fact that we have been able to do
    a lot without expanding Affordable Care Act. Insurance
    companies have committed to providing COVID tests to patients
    free of charge. We are bringing our supply chains back. That is
    critically important.
        I am concerned that COVID, all these patients that have had
    it, all these citizens, will have a preexisting condition, and
    we have to, and must, and we are committed on both sides of the
    aisle, to covering preexisting conditions for all Americans.
    And now we have, you know, millions of people who have tested
    positive for COVID, and we have got to make sure we get this
    right.
        I just, in my brief time I have left, telehealth is one of
    those amazing things that we have talked about but now we are
    doing. Mr. Cameron, can you please share with us the dramatic
    increase in telehealth visits your State has seen? What are
    areas where it has been incredibly successful? Where are areas
    where maybe we shouldn't be focused on telehealth? I know it is
    great for mental health, but I talked to some dermatologists
    this week where it is really tough, in dermatology, for
    instance, for telehealth to be incredibly helpful. So can you
    talk to us in my brief time I have left.
        But I do want to thank the committee before Mr. Cameron
    answers. I have great hopes for you all, and I have loved
    working with all of you.
        Mr. Cameron?
        Mr. Cameron. Thank you, Congresswoman, and thank you for
    your service, and thank you for your comments. Telehealth has
    been in an infancy here in Idaho and not really a lot of
    takeup, mostly, I think, because a lot of providers and, as I
    said earlier, some consumers did not want to take it.
        I, myself, see a dermatologist, and I am--it is an
    interesting story that you shared. I actually, while in the
    State capitol building, did a dermatologist visit with my
    phone, to go over some of my issues and show some of my
    concerns. So it can be done, but there still has to be some
    hands-on followup.
        There are some health conditions, without getting into
    provider codes, where it doesn't fit really well, and so those
    need to be talked about. But we need to provide the services
    and the tools and the technology so that it can happen. I think
    consumers, as was said earlier, now actually prefer telehealth
    to other forms of coverage. They would rather have a telehealth
    visit than go to the emergency room, unless it is really
    dramatic,
        Mrs. Brooks. Well, thank you.
        And to my committee members, we have to continue to support
    and expand telehealth and help--I know everyone wants to help
    all Americans with their healthcare needs, especially right
    now.
        Thank you, Madam Chairwoman, and I yield back.
        Ms. Eshoo. Thank you for yielding back. And when you speak,
    you make all of us fall in love with you all over again, which
    then leads to how much we are going to miss you.
        And speaking of missing people, it is an honor to recognize
    the gentleman from Massachusetts, a really extraordinary and
    thoughtful member of the subcommittee, such value added, not
    only at our committee, but the entire Congress, the gentleman
    from Massachusetts, Mr. Kennedy.
        Mr. Kennedy. Madam Chair, thank you.
        Ms. Eshoo.
        Mr. Kennedy. Thank you. Grateful to you and to all the
    members of the committee, where I will follow Mrs. Brooks'
    example here briefly. This is, in all likelihood, my last
    committee hearing as well. It has been an extraordinary honor
    and pleasure and privilege for me to join all of you on the
    best committee in Congress, to work with all of you on both
    sides of the aisle to try to advance the interest of the
    American public.
        And to the incredible staff and committee staff here, a
    huge hats off to you, again, both sides of the aisle, for your
    work and collaboration and the effort that we have made
    together. It has been an enormous privilege for me, and I wish
    you all well going forward.
        And a number of big issues on the agenda to tackle,
    including the one, obviously, before us today, and I want to
    thank all the panelists for being here, for your work, and for
    appearing once again before the committee.
        Beyond the horrific loss of life caused by this pandemic
    and the administration's failed response, the economic
    consequence of job losses, business closures, imminent
    evictions, will last for generations.
        The national unemployment rate has more than doubled since
    February. In States like Massachusetts, it still remains
    stubbornly high. Losing your job can mean much more than the
    loss of income. It can also mean the loss of health insurance.
    And this is very much a life-or-death situation for the
    millions of people with chronic health conditions, for parents
    of children with complex medical conditions that require
    constant monitoring and treatment. Fortunately, for millions,
    Medicaid provides them with continuous quality health insurance
    so that they don't have to worry about getting the care that
    they or their children need.
        So, Dr. Aron-Dine, I want to start with you. What can you
    tell us about Medicaid enrollment since the beginning of the
    pandemic?
        Dr. Aron-Dine. It has risen, just as you would expect. What
    happens is Medicaid is supposed to be there for people as they
    lose their jobs or see reductions in income. Medicaid
    enrollment is up eight percent, generally, and up more in
    Medicaid expansion which targets some of the most vulnerable
    people.
        Mr. Kennedy. In other parlance, it is countercyclical,
    right? When you have an economic downturn, Medicaid enrollment
    increases, right?
        Dr. Aron-Dine. Exactly. Which helps people and also helps
    the economy.
        Mr. Kennedy. Right. Thank you. So I understand that many
    experts predict that Medicaid enrollment will continue to
    climb, and I would love to get your thoughts as to why that
    might be.
        Dr. Aron-Dine. I think that is likely. Even in a, quote/
    unquote, normal recession, Medicaid enrollment often lags a
    little bit because signing up is not the first thing people do.
    And in this recession, as others have talked about, people
    haven't been seeking medical care because of the pandemic if
    they--healthy people haven't been seeking medical care, and
    that is often a mechanism by which people get enrolled and
    covered, is they go to a CHC and they find out that they are
    not doing that, they may not have gotten signed up yet.
        Mr. Kennedy. And, Doctor, you touched on this already a
    little bit, but just to flesh this out for us a bit more, how
    does Medicaid expansion specifically help States to respond to
    the current unprecedented health and economic crisis?
        Dr. Aron-Dine. Sure. And we have talked about how it is
    there for the people who are newly losing their health
    insurance, but I think it is equally important that millions
    more people, 12 million more people, are covered through
    Medicaid going into the pandemic than would have been without
    expansion.
        And there is, at this point, just a lot of research showing
    that it is improving their health, improving their financial
    security, reducing evictions, and actually saving lives. And,
    in fact, has been especially important to people with
    preexisting conditions for whom it has enabled them to get
    regular treatment for chronic conditions for the first time.
        Mr. Kennedy. We had a Medicaid director, I believe from
    North Carolina, testify before the committee now several months
    ago, back when we could do in-person hearings, and he actually
    testified, if I remember correctly, that they had determined
    that the ACA had saved literally hundreds of lives in North
    Carolina through Medicaid expansion.
        And given that, I think a lot of us obviously are
    incredibly concerned that, once again, the Affordable Care Act
    is before the Supreme Court, and the Trump administration is
    urging the justices to throw out every aspect of the law. So
    despite what some have argued today, that is literally the
    legal brief that has been filed by the Trump administration.
        So, Doctor, I am not asking you to read too far into the
    tea leaves here, but if the Supreme Court agrees that the ACA
    is unconstitutional, what happens to the 13 million Americans
    currently receiving health insurance through Medicaid
    expansion?
        Dr. Aron-Dine. Medicaid expansion would be eliminated, and
    I think it is likely that the large majority of those people
    would become uninsured and lose that access to care and
    financial security.
        Mr. Kennedy. And what happens, then, in the midst of--for
    those folks when, if that does take place, in the midst of a
    flu season, an unknown yet impact of another COVID-19 winter,
    and the economic prospects of recovery?
        Dr. Aron-Dine. I think the pandemic has reminded all of us
    that it is very important for people to have health insurance,
    for their own sakes, but also as a matter of public health.
        Mr. Kennedy. Yes. Doctor, thank you.
        COVID-19 has brought about unprecedented challenges to our
    healthcare system and our economy, and it is clear from the
    witnesses' responses that Medicaid has played a vital role in
    responding to this crisis and ensuring that adults and children
    continue to have access to the care that they need. However,
    for millions of Americans, that safety and security hangs in
    the balance if the Supreme Court sides with Republican
    attorneys general and takes healthcare insurance away from 20
    million people in our country.
        Doctor, thank you very much.
        And, Madam Chair, I yield back.
        Ms. Eshoo. The gentleman yields back.
        I now would like to recognize the gentleman from Georgia,
    Mr. Carter, for your 5 minutes of questions. Please unmute.
        Mr. Carter there? Paging Mr. Carter?
        Mr. Carter. I am here. I didn't know I was next. I
    apologize.
        Ms. Eshoo. That is all right. You are recognized for 5
    minutes.
        Mr. Carter. Well, thank you. And thank all of you for
    joining us here today. I appreciate everyone who has been on
    the panel. And I certainly would be remiss if I did not also
    offer my congratulations to Representative Kennedy and
    Representative Brooks and all the other members of this great
    subcommittee and this great committee who are going to be
    leaving us. We are going to be losing some valuable members
    with great institutional knowledge, and we certainly will miss
    all of them.
        Madam Chair, I want to begin by addressing the situation
    that continues to be a problem, and that is, my colleagues
    across the aisle seeming to want to communicate--or seem to
    want to put a message out there that Republicans are not
    wanting to protect preexisting conditions. Nothing could be
    further from the truth, and I think you all realize that. That
    is something that we have worked on and we continue to work on.
    In fact, if we look at the present Congress that we are in, the
    116th Congress, one of the first floor votes that we tried to
    have was to try and protect those with preexisting conditions.
        So I want to reiterate what has been said by a number of my
    Republican colleagues on the subcommittee here today, and that
    is that we are in favor of preexisting conditions. We continue
    to be, we have been, and we will always be. We understand,
    particularly in the trying times that we are in now, with the
    problems that we are having with the pandemic, we understand
    how important covering preexisting conditions are.
        Dr. Holtz-Eakin, in your testimony, you mentioned that
    through June, there were 6.2 million workers who lost their
    employer-sponsored insurance due to job loss from the pandemic.
    And President Trump has worked to make short-term, limited-
    duration plans available to beneficiaries for up to 36 months,
    providing certainty and continuity for patients. Previously,
    the previous administration had made them available for only
    three months. How can short-term, limited-duration insurance
    plans fill the employer-sponsored insurance gap, and is there
    any indication that they have?
        Dr. Holtz-Eakin. So as I mentioned earlier, we don't have
    great data on what is happening on the ground right now, so I
    can't answer with any sort of definitiveness how many people
    are taking up short-term plans versus other options. But it is
    another option on the table. It is an option that was not
    available previously. It might hit a price point that is better
    than a price point on the ACA marketplace, and, you know, that
    would be a very valuable option in this situation.
        Mr. Carter. And wouldn't you believe that it would offer
    patients more flexibility and affordability in coverage?
        Dr. Holtz-Eakin. Certainly there is a greater variety of
    plan designs out there. That is one of the advantages. The
    concern that you have heard voiced is that people won't
    understand the plan design they are buying, but certainly there
    ought to be a way to do good consumer education, get them in a
    plan that is good for them.
        Mr. Carter. Well, I believe this subcommittee, this
    committee in general, has addressed that before. In fact, I
    know that I had advocated for us to publicize these plans more
    so that people would be educated as to the availability of
    these plans and how they could help them. But unfortunately,
    the other side of the aisle, again, are opposed to these plans,
    and did not want to offer education to our citizens as to the
    availability of these plans.
        Let me ask you also, Dr. Eakin, given that premiums have
    more than doubled during the time that the Affordable Care Act
    was signed into law, what are your recommendations for how we
    can reduce the cost of health insurance and allow people to
    shop for coverage that might best fit their needs?
        Dr. Holtz-Eakin. There are really two broad strategies. The
    first strategy is to provide greater competition in the
    insurance markets, lower the barriers to entry, allow more
    products and variety, and allow people to choose among them,
    and thus get a plan that fits their economic situation.
        The second strategy is to deal with the underlying costs
    and value proposition in the delivery system, and certainly
    there is a lot that Congress can do in that area through the
    big payment silos that are in Medicare and Medicaid, which
    really drive the delivery system in the United States.
        And something can be done at the local level. You know,
    State scope of practice, State certificate of need, all sorts
    of limitations on competition need to be addressed.
        I think the telehealth example is the best example of how
    the overregulated U.S. healthcare system couldn't respond
    flexibly to the pandemic, and it was only the emergency waiver
    of a lot of regulations that allowed telehealth to prosper.
    That should be made permanent. I mean, that is going to require
    legislation. That is a great opportunity going forward, and I
    would encourage the committee to look at that.
        Mr. Carter. So you would agree, just as the free market has
    worked in our society, that the free market can work in
    healthcare, to lower healthcare costs?
        Dr. Holtz-Eakin. Certainly if you have high prices, you
    have a supply problem, and you have got to look at the
    conditions that are limiting supply.
        Mr. Carter. Well, thank you very much.
        And thank you, Madam Chair, and I yield back.
        Ms. Eshoo. I thank the gentleman from Georgia. He yields
    back.
        Now it is a pleasure to recognize the gentleman from
    California, Mr. Cardenas, for your 5 minutes of questions.
    Please unmute.
        Mr. Cardenas. OK. I should be unmuted. Can you hear me?
        Ms. Eshoo. Yes, very well. Thank you.
        Mr. Cardenas. OK, thank you so much. Thank you, Madam
    Chair, and I appreciate the opportunity for us to have this
    important hearing. I want to thank all of our folks who are
    here to give us their opinion and expertise to be before our
    committee.
        I also want to say, thanks to the ACA, approximately 20
    million Americans have gained coverage through the law's
    various coverage protections. Nine million low- and moderate-
    income Americans received health insurance subsidies to make
    their healthcare more affordable. 130 million Americans are
    allowed to receive coverage, without being discriminated
    against by the insurance companies and made sure that, by law,
    the Affordable Care Act law, they have the right to coverage,
    even though they have a preexisting condition, and they cannot
    be charged a penny more than anybody else who is getting the
    same coverage.
        In an unprecedented and nakedly political decision, the
    Trump administration declined to defend the Affordable Care
    Act, otherwise known as the ACA, in this Republican lawsuit
    that is seeking to declare the entire law invalid. The Trump
    administration is continuing with this extraordinary decision
    in the middle of a pandemic that has claimed the lives of now
    over 200,000 Americans. If the lower court's ruling is upheld,
    millions of Americans would lose their healthcare overnight in
    the middle of a global pandemic.
        I would like to ask some questions first to Dr. Aron-Dine.
    Dr. Aron-Dine, how many Americans would lose coverage if the
    decision were upheld shortly?
        Dr. Aron-Dine. Prior to the crisis, the estimate was 20
    million, and that number would be larger today with more people
    turning to these programs for coverage.
        Mr. Cardenas. Thank you. Could you discuss the impact of
    the court's decisions on Medicaid expansion?
        Dr. Aron-Dine. Medicaid expansion would be eliminated,
    meaning that the 12 million people who are newly eligible
    because of the ACA's Medicaid expansion could lose their
    coverage, would likely become uninsured. It wouldn't be there
    for people newly losing their jobs and their coverage in this
    recession to turn to, and State eligibility would presumably
    revert to the pre-ACA levels where few parents and almost no
    adults without children were able to get coverage.
        Mr. Cardenas. So I think you just described that the
    Affordable Care Act law, once it became implemented, and still
    to this day, millions of Americans are actually being able to
    see doctors, getting healthcare basically, that before were
    either struggling or not receiving healthcare?
        Dr. Aron-Dine. That is exactly right, and we have direct
    evidence of that, including from some of Dr. Sommers' research,
    that people are getting prescriptions filled, they are getting
    treatment for chronic conditions, and that the ACA's Medicaid
    expansion, as well as the marketplace coverage, has been
    literally lifesaving.
        Mr. Cardenas. And this also would be affecting working
    families with moderate and low income?
        Dr. Aron-Dine. Absolutely. Particularly if you look at
    coverage for the people who we now refer to as essential
    workers, many of them get their coverage through Medicaid,
    especially in expansion States, and that would be wiped out.
        Mr. Cardenas. So one thing I would like to clarify, did the
    Affordable Care Act only increase the availability for
    healthcare for unemployed, people who are not working, or did
    it, in fact, increase by millions, or not, being able to have
    access to healthcare for working families?
        Dr. Aron-Dine. I am not sure I understood your question,
    but----
        Mr. Cardenas. Let me clarify what I mean, Doctor. A low-
    income family is probably a family that they have low income.
    They are actually working, but they are, say, at minimum wage
    or what have you, so therefore, providing healthcare for them
    and their children, for example, is very difficult because they
    otherwise can't afford it. And the Affordable Care Act has
    implemented an opportunity for them to actually get healthcare,
    even though they are low income, whereas before, they could not
    go out to the market and get it because they just couldn't
    afford it.
        Dr. Sommers. If I can jump in briefly?
        Mr. Cardenas. Please.
        Dr. Sommers. As described in my testimony, we actually have
    looked at this issue of working families, and the ACA's biggest
    coverage gains are in blue collar families. These are people in
    construction and mining and agriculture, concerned with jobs
    where they don't get coverage through work. So you are exactly
    right, Representative, this is a key feature that the ACA has
    helped working families substantially.
        Mr. Cardenas. Yes. Thank you so much. I am sorry my
    question wasn't that clear, but I appreciate your clarity in
    the answer.
        And then also, isn't it through the ACA now young adults
    can actually stay on their parents' coverage up through the age
    of 26, whereas before, that was not a typical coverage from the
    insurance industry?
        Dr. Aron-Dine. That is correct. That is a nationwide
    protection put in place by the ACA, and it is one of the
    reasons that young adults would see especially large coverage
    losses if the law were struck down.
        Mr. Cardenas. Yes, thank you. My time is limited, and even
    though the clock stopped, what I am going to do is I am just
    going to close by saying that I would like to thank you,
    Doctor, and also everybody testifying today, and just remind
    everybody that the truth is that the Republican lawsuit would
    have disastrous consequences on our Nation's most vulnerable
    Americans.
        Yes, Madam Chair?
        Ms. Eshoo. Thank you. The gentleman yields back.
        I understand that Dr. Burgess has joined us. Are you
    actually there?
        Mr. Burgess. Yes, I am, and unmuted.
        Ms. Eshoo. The Chair recognizes the ranking member of the
    subcommittee, Dr. Burgess, for his 5 minutes of questions. Glad
    you could join us.
        Mr. Burgess. I thank the Chair. I thank the committee's
    understanding of the morning where there was a lot of
    multitasking going on, where our time in town may be limited.
    There is a lot going on, as I am sure everyone is experiencing.
        I would ask, Madam Chair, that my entire opening statement
    be made as part of the record.
        Ms. Eshoo. So ordered.
        [The prepared statement of Mr. Burgess follows:]
        [The information appears at the conclusion of the hearing.]
        Mr. Burgess. And, Dr. Holtz-Eakin, welcome to our
    subcommittee. Thank you so much for participating with us
    today. I would just note, you know, on the issue of employer-
    sponsored insurance--I think you talked about this in your
    testimony--well, employer-sponsored insurance, right, pre-
    pandemic levels, have actually increased significantly in the
    year since President Trump had taken office. I think it was in
    excess of three million more people had the availability of
    employer-sponsored insurance.
        So of those employer-sponsored plans, now that we are in a
    situation where people are losing employment, what is the
    options that are available for someone who has lost coverage on
    an employer-sponsored insurance? They can sometimes get
    coverage on another family member's ESI plan. Is that not
    correct?
        Dr. Holtz-Eakin. That is correct. Their spouse could be
    covered, and they could acquire coverage that way.
        Mr. Burgess. So I guess, then, the question comes up, how
    does our existing safety net system work as intended to catch
    people that got hurt during the pandemic?
        Dr. Holtz-Eakin. The safety net really consists of the
    COBRA options that people have, the ACA, a place where they
    can, if they have lost employer insurance, they can go and
    enroll in a plan, and the Medicaid program. To date, I think
    that safety net has held up pretty well. As I noted in my
    written remarks, the Census Household Pulse Survey shows no
    strong trend in any direction on coverage, and that is not
    attributable to any single program but to the question of all
    of them.
        Mr. Burgess. OK. Well, then particularly appropriate to
    this subcommittee and this committee, are there any
    flexibilities that Congress has not provided to States and
    their insurance plans that would improve the uptake of other
    options?
        Dr. Holtz-Eakin. I think that something that would be
    really valuable for the committee to look at is to look at the
    waivers that have been provided by the administration on
    regulations that are due to the emergency--the declaration of
    the emergency. They have authority to waive an enormous number
    of things. Like I mentioned with the telehealth, you know, you
    can use a commercial device, use FaceTime, a waiver of
    protection against minor HIPAA violations for anything
    disclosed over that, that would allow people to actually stay
    in their homes instead of going someplace to do telehealth,
    which doesn't really make a lot of sense.
        And all that will go away when we, thankfully, get past the
    pandemic, but there is a lot of it that I think ought to be in
    law, and Congress should look at in providing flexibility. You
    know, we really learned that the U.S. healthcare system
    couldn't do two things at one time. It couldn't treat COVID-19
    and continue to provide ordinary care, and that, I think, was
    quite revealing by the sort of overregulated lack of
    flexibility.
        Mr. Burgess. Yes. I would certainly echo the overregulated
    lack of flexibility. Much of the curtailment of practice was
    actually a result of governmental direction where--tried to
    preserve capacity in an emergency room or ICU setting,
    hospitals were and medical practices and clinics were required
    to reduce their workload of elective procedures, which
    subsequently killed their cash flow and made it very difficult
    for them to recover.
        Dean Cameron, let me just ask you a question about
    populations of people are different and, arguably, Idaho and
    New York are significantly different. So the flexibility for
    States to develop plans that actually fit a State's
    population's needs is important. So could you perhaps provide
    us a little further detail about how Idaho insurance companies
    waived some of their eligibility requirements to make it easier
    for beneficiaries to maintain their access to high-quality
    care?
        Mr. Cameron. Yes, absolutely, and thank you for the
    question. As I mentioned in my remarks, we started meeting with
    our carriers and trying to talk about how we help citizens, how
    we keep them from being forced out of coverage, how they can
    access the special enrollment periods, how we can make that
    transition even easier.
        And we pointed to and found a number of provisions in State
    law, and even in some rules, that didn't seem to make sense at
    the time. For example, we had employers say to us, well, I have
    laid off my folks, but now I want to hire them back, but I
    don't want to go through a new eligibility period. Wouldn't
    make sense to do that.
        So we essentially issued bulletins, working with our
    carriers, saying, we are not going to do that. We issued
    bulletins allowing carriers to keep people that are furloughed
    on their plans even longer. Now, State law said that you had to
    be employed at least 20 hours a week in order to qualify for
    small-group coverage. We waived that.
        There were a number of provisions that way, that in sitting
    down and collaborating with our carriers, decided in this
    pandemic, that wasn't appropriate. We want people to have
    coverage, and we did everything we could to help them keep
    coverage.
        Mr. Burgess. Thank you for that. I see my time is expired.
    I have a couple of additional questions. Madam Chair, I will
    submit those for the record. I yield back.
        Ms. Eshoo. The gentleman yields back. I am so glad that you
    were able to make it, Dr. Burgess.
        It is a pleasure to recognize the gentlewoman from
    Michigan, Mrs. Dingell, for your 5 minutes of questions. And
    make sure you unmute.
        Mrs. Dingell. Thank you, Madam Chair, I did. And thank you,
    Ranking Member Burgess, both of you, for convening this
    hearing, because it is really important what is happening with
    COVID and the positive effects ACA has had and what is
    happening to people.
        And I too want to tell my colleagues how much I am going to
    miss Susan Brooks and Joe Kennedy. They are two people who
    deeply care about healthcare in this country, and we will miss
    them deeply.
        I want to touch upon a topic that we haven't really talked
    about as much as I think we need to be, which is the impact
    that COVID-19 has had on long-term care in this country and how
    it has exposed a number of issues in the way that we deliver
    it. Millions of aging and disabled people in this country rely
    on what is a total patchwork system of care to provide them
    with services and the supports that they need in their daily
    lives, and until you are in the system, you do not understand
    how broken it is.
        During the pandemic, we have all seen the tragic reports of
    how COVID-19 spreads in group settings like nursing homes.
    Compounding the tragedy is the fact that many people in nursing
    homes want to live at home with their friends and their family,
    but they are unable to because of the level of care that they
    need. And they are totally isolated, which is making it even
    worse as if they do become sick or what has happened to them in
    these last six months.
        Medicaid actually pays for things like home health aides,
    direct service providers, to help with activities of daily
    living, even modifications to make the person's home more
    accessible.
        So I would like to ask Dr. Aron-Dine some questions. Dr.
    Aron-Dine, there has been a concerted effort for over a decade,
    to rebalance long-term services and supports in Medicaid. Can
    you briefly explain what that means and why it matters so much?
        Dr. Aron-Dine. Sure. Rebalancing refers to a rebalancing
    between institutional long-term care, for instance, in a
    nursing home, versus home- and community-based services, such
    as home health aides or personal care provided to help a person
    live at home. Institutional care has always been part of
    Medicaid. The availability of home- and community-based
    services has been really expanded over time, including through
    the Affordable Care Act.
        It is very important for the reasons you note, that many
    people would prefer to receive care in their homes. It would be
    better for their health. It is also often more cost effective
    for a given person to receive care at home versus in an
    institutional setting.
        Mrs. Dingell. So--thank you for that. I understand that not
    everyone who wants to receive home and health community-based
    services, or HCBS as we call it, are able to receive them right
    away. What are some of the barriers currently for people who
    want to receive care in the community?
        Dr. Aron-Dine. One of the biggest barriers to receiving
    these services through Medicaid is State finances. I alluded to
    so-called optional services in Medicaid which makes them sound
    like frills, but actually optional services are really crucial
    things like home- and community-based services which States are
    allowed to limit because they are not mandatory. And there is a
    really big risk that during this recession, as in the past,
    that States are in a big budget crunch, this is one of the
    places they might look to cut, which can make the problem of
    HCBS waiting lists worse.
        Mrs. Dingell. Well, let me ask you two other questions. It
    is not funded enough even before COVID, is it? And is there an
    institutional bias against home-based care?
        Dr. Aron-Dine. I would agree, certainly even before COVID,
    you had this challenge, and it is a place where the Medicaid
    program has made progress over time through continued
    expansions, including the ACA's, and more is needed.
        Mrs. Dingell. So given these barriers and the threat that
    COVID poses to people in group settings, it is now more
    important than ever that we make it easier for people to
    receive care in the community. I was glad to see that the
    HEROES Act contained a policy that I, quite frankly, did work
    on to increase Federal funding for State Medicaid programs to
    spend on HCBS. And I have been working on it with my good
    friend, Mr. Guthrie, and we are trying to get more of this.
        But, Dr. Aron-Dine, the HEROES Act would provide State
    Medicaid programs with a ten percentage point increase for
    their HCBS programs. How would this help States to provide
    services to the people who need this type of care?
        Dr. Aron-Dine. I think both the targeted HCBS increase in
    HEROES and the general FMAP increase in HEROES, the 14
    percentage point bump, could be readily critical in helping to
    fill these holes in State budgets, discouraging them from
    cutting Medicaid, and making it possible for them to make some
    investments, particularly directly responsive to the pandemic.
        Mrs. Dingell. Madam Chair, I am out of time, so I may ask
    more questions for the record, and I yield back zero time.
        Ms. Eshoo. The gentlewoman has completed her questions. I
    love the red in the background, Debbie. It really jazzes up our
    hearing. We need that. It is wonderful. And I like ``Women Can
    Do It.'' We know that we can and we do.
        At this time, I would like to recognize the gentleman from
    Oklahoma, Mr. Mullin, for his 5 minutes of questions.
        Are you with us, Mr. Mullin?
        I don't hear his voice or see his face, so we will move to
    the gentlewoman from New Hampshire, Ms. Kuster. You have 5
    minutes for your questions. Great to see you.
        Ms. Kuster. Great to see you, Madam Chair. And thank you so
    much to you and the ranking member for holding this critical
    hearing on the Affordable Care Act. I have said it before, I
    will say it again, that across this country, 135 million people
    under the age of 65 have a preexisting condition. So we know
    the total number is much, much higher.
        In New Hampshire, over 500,000 Granite Staters--and that is
    over half the population that are nonelderly--live with
    preexisting conditions every single day, and could be denied
    access to healthcare, either prior to the passage of the ACA or
    if the ACA is repealed by the Supreme Court, as we now know our
    Republican colleagues are rushing to make happen.
        So even today, during this pandemic, COVID-19 would be a
    preexisting condition for an additional 7 million Americans.
    That is why I introduced the Protecting Americans With
    Preexisting Conditions Act, which has passed the House twice
    and still sits on Mitch McConnell's desk.
        And I want to particularly address my colleague, Mr.
    Carter, who said that Democrats are trying to create an
    illusion that Republicans oppose protections for preexisting
    conditions. It is no illusion, Mr. Carter. You and your
    colleagues have voted twice against my bill, and it is very
    clear that you do not want to protect Americans with their
    preexisting conditions, even COVID-19.
        Despite what this administration has claimed, this
    administration does not support protecting Americans with
    preexisting conditions. They haven't supported it when they
    encouraged repeal and replace without a replacement plan, or
    when they issued destructive guidance through the 1332 waivers,
    or when they fight in the courts to dismantle the entire law.
    And we now know that that hearing is coming just one week after
    the election in November. This is dangerous and destructive to
    the lives of the American people.
        They certainly have not supported the ACA in the midst of
    this global pandemic, which has needlessly taken the lives of
    now over 200,000 Americans. And because the stark reality is
    that every year of the Trump administration, the rate of
    Americans without health insurance has increased, this year has
    proven no different. So today, I will focus my remarks on the
    ways this administration has continued to sabotage the ACA.
        Over 40 million Americans have filed for unemployment
    benefits during COVID-19. Millions of Americans and their
    families have lost job-based healthcare, and yet this
    administration refuses to establish a broad special enrollment
    period which would allow uninsured Americans to sign up for
    coverage in the Federal marketplace. It is especially critical
    in States like my own that depend on the Federal Government as
    a partner in the ACA marketplace.
        So, Dr. Sommers, most State-based marketplaces established
    broader enrollment periods. Can you briefly discuss how
    enrollment in State-based marketplaces has compared to the
    Federal marketplaces like our own right here in New Hampshire?
        Dr. Sommers. Yes. So 12 of the 13 States that fully run
    their own marketplace have created COVID-specific special
    enrollment, and what you can see in the enrollment statistics
    that are available through the middle of the year is that there
    has been about a 15 percent increase over the open enrollment
    totals in those States. And that compares to just 11 percent in
    the States that are on the healthcare.gov platform.
        And of note, you know, the ranking member asked about
    flexibility, more than a dozen States on the healthcare.gov
    platform requested that flexibility to create a new special
    enrollment period for COVID, and so far, CMS has not granted
    that.
        Ms. Kuster. And, Mr. Lee, Covered California established a
    special enrollment period for COVID-19. How many individuals
    signed up for coverage during this period?
        Mr. Lee. Yes. About 300,000. And I want to underscore, it
    is both a special period, because 20 percent would have been
    ineligible, and they were healthy and needed coverage, but the
    rest were eligible but needed marketing, needed to be told to
    come in the door. And they doubled our enrollment from the
    prior period.
        Ms. Kuster. And based on your analysis, how many
    individuals could have gained coverage if the Federal
    marketplaces experienced the same level of growth as your State
    did during this special enrollment period?
        Mr. Lee. Yes. Our analysis is, if Federal marketplaces had
    done what we had done, half a million Americans would not be
    uninsured today. They would have insurance during a pandemic
    when you want them to have insurance to be able to get tested
    and get the care they need.
        Ms. Kuster. Madam Chair, I apologize, I have lost the clock
    on my screen. Should I yield back or if I have----
        Ms. Eshoo. Well, let's see. My clock has zeros going
    across.
        Ms. Kuster. All right. I will yield back and submit my
    questions. Thank you, Madam Chair, for your patience.
        Ms. Eshoo. Thank you. Thank you for your important
    questions and your great work at the committee.
        It is a pleasure to recognize the gentleman from Montana,
    Mr. Gianforte, for your 5 minutes of questions. And please
    unmute.
        Mr. Gianforte. Thank you, Madam Chair. I appreciate the
    witnesses being here today.
        I first want to say that my State has expanded Medicaid
    eligibility. I support a social safety net for those who need
    help, and I voted to protect coverage for individuals with
    preexisting conditions.
        Today we keep talking about coverage. Coverage does not
    equal access to care. Montana faces a provider shortage, and
    many individuals travel hours to receive the care they need.
    Besides protecting individuals with preexisting conditions, my
    guiding principals for healthcare are improving rural access to
    care and reducing cost.
        In the CARES Act, we voted to waive several rules regarding
    the provision of telehealth services. We waived rules regarding
    the origination and requirements for physicians to be
    reimbursed for services provided by audio and video. I think
    this is a great first step, and I hope we can build on ways to
    improve these waivers.
        Director Cameron, what can you tell us about what you are
    seeing as far as telehealth utilization in Idaho?
        Mr. Cameron. Thank you, Congressman, and thank you for your
    comments, and thank you for what you did pass in the CARES Act
    to eliminate some of those rules, because that has been very
    helpful, along with, as a State, we also eliminated rules.
        We really believe telehealth will provide that affordable
    access, particularly to rural States like yours and mine. We
    went from--we had a 250-fold increase. We went from--up to
    28,000--where is my numbers--we went from 28,503 televisits in
    the month of April, from the previous year was 233. Dramatic
    increases in those that are accessing telehealth, and we think
    that will continue to grow.
        Mr. Gianforte. Great. Do you have any indication that
    emergency room utilization is down with the increased use of
    telehealth?
        Mr. Cameron. Thank you, Congressman. We do have that
    indication. I don't have those numbers in front of me. We could
    certainly provide that, but we have seen dramatic increases
    in--or decreases in the emergency room utilization, but a lot
    of that is driven based on what was having to happen with the
    pandemic, who could access the emergency room. And so it might
    be a little difficult to pare out whether that is caused
    because of telemedicine or whether it is caused because of the
    pandemic. And people themselves did not want to go to the
    emergency room where they could potentially be exposed. They
    could sit at their home and they could talk to their doctor and
    get their treatment needed.
        Mr. Gianforte. Yes. In my own experience, talking to
    emergency room docs, they tell me that up to 80 percent of
    emergency room visits could have been handled through
    telehealth, if it were generally accepted, and that is
    particularly helpful in States like yours and mine where the
    farm or ranch house might be hours away from the emergency
    room. It is certainly more convenient, higher quality of care.
    Certainly, the emergency room needs to be there for folks that
    need it, but having that telehealth option can provide more
    immediate care and also lower our costs.
        In a followup, what else could we do in Congress to help
    advance telehealth adoption?
        Mr. Cameron. That is an excellent question. I think, first
    of all, continue to make those rules you have set aside more
    permanent, and continue to encourage and allow for carriers to
    be able to handle those visits through the marketplace.
    Additional support towards the technology that is needed in
    order for those providers to be able to offer telehealth
    services. I think all of those are solutions. And then, really,
    flexibility in the marketplace, allowing the marketplace to
    work, it will work. It can work.
        Mr. Gianforte. OK. So the temporary waivers we put in place
    in the CARES Act, you are saying we should consider making
    those waivers permanent. Is that correct?
        Mr. Cameron. Absolutely.
        Mr. Gianforte. OK. Well, I appreciate your testimony today.
        And with that, Madam Chair, I yield back.
        Ms. Eshoo. The gentleman yields back. And it is a pleasure
    to work with you on telehealth, which is so important and has
    really worked into its full benefits during the pandemic. We
    need to make sure that that continues.
        The Chair is pleased to recognize the gentlewoman from
    Illinois, Ms. Kelly, for your 5 minutes of questions. And
    please unmute.
        Ms. Kelly. Thank you, Madam Chair. This is a very, very
    important hearing.
        And to Rep. Gianforte, I would love to work with you also.
    I have legislation, I work a lot with Congressman Will Hurd,
    but he is leaving me. So I would love to work with you on the
    telehealth issue.
        I am chair of the Congressional Black Caucus Health
    Braintrust, and Black Americans make up 12.5 to 13 percent of
    the U.S. population, but we have accounted for 22.4 percent of
    COVID-19 deaths.
        Dr. Sommers, given the number of minority individuals who
    gained coverage under the ACA and the decreases we have seen in
    the last few years, if the ACA were to be rolled back, how
    would that affect the already severe health disparities we are
    seeing because of the emergence of COVID-19?
        Dr. Sommers. We know that the Affordable Care Act produced
    particularly large coverage effects in communities of color,
    and helped narrow, though not eliminate, the large disparities
    in coverage rates in the U.S. So any effort to undermine or
    repeal the ACA would likely worsen those disparities
    dramatically at a time when communities of color have been hit
    particularly hard by the epidemic.
        Ms. Kelly. Thank you.
        And, Dr. Aron-Dine, without opening a new enrollment period
    for individuals and the increase in the FMAP included in the
    HEROES Act, how can we prevent the deaths and health
    disparities that we see from the lack of insurance coverage and
    healthcare access, frankly, that disproportionately affect
    communities of color?
        Dr. Aron-Dine. Well, I think you would want to start with a
    do-no-harm principle. So the most important thing is to make
    sure that the coverage options people currently have don't go
    away. And then as you alluded to, it is also important that
    States not be making cutbacks in coverage in this time, and
    that is going to require additional funding to States.
        But more affirmatively, there are lots of things that could
    be done to make progress on coverage, especially for
    communities of color, including improving affordability and
    making it easier for people to access these programs.
        Ms. Kelly. I know we have gone back and forth and everyone
    has their opinion about the ACA, and who knows what is going to
    happen with the Supreme Court. But just to all the witnesses,
    if there was one thing you could suggest to improve the ACA,
    what would that be? I know you are not in a line, so----
        Dr. Sommers. I can start. I would find ways to get the 12
    States that have not expanded Medicaid to do so. And these
    States have some of the most restrictive Medicaid policies in
    the country, even before the law. These are very low-income
    populations. They are disproportionately communities of color,
    concentrated in the South. There are large health disparities,
    and Medicaid expansion could be a life-saver.
        Ms. Kelly. Next.
        Dr. Aron-Dine. And I think the second place you would go
    after that is to sort of fill the next coverage gap, which is
    low-income people who are eligible for the ACA as marketplace
    coverage but aren't enrolled, and could start by addressing
    affordability issues as a number of States have done.
        Ms. Kelly. OK.
        Mr. Lee. And if I could, I would build on those two, with a
    third of addressing needs of lower income underinsured people
    with employer coverage. Twenty-five percent of people with
    employer coverage have coverage they can't afford to get access
    to. Those people need accesses to have a choice to get to a
    marketplace or get affordable coverage that addresses their
    income, which is done in marketplaces, but not by most
    employers.
        Ms. Kelly. Thank you.
        Mr. Cameron. Thank you for the question, a very insightful
    question.
        First of all, I would work on affordability, and I would
    work on drawing those young and healthy people back into the
    risk pool, creating one singular risk pool, regardless of the
    product style, adding flexibility. If you are going to have
    subsidies--and I think we need to have subsidies--Idaho's
    market is mostly a subsidy market, but we have got to figure
    out how to fix the cliffs and the mechanisms to keep people
    from taking advantage of those subsidies or keep them from
    being able to access those subsidies.
        Ms. Kelly. Thank you.
        Dr. Holtz-Eakin. Never go last on a panel like this. I just
    want to echo----
        Ms. Kelly. You can say ditto or----
        Dr. Holtz-Eakin. I will echo number one and number two. In
    particular, you know, half of the 30 million people who were
    uninsured prior to the pandemic were eligible for the ACA. That
    is low-hanging fruit, and there is no reason not to pursue
    that.
        And then just keep an eye on the underlying competition and
    the value proposition in the delivery system. That remains the
    place that the ACA just really was not aggressive enough, and
    that has to be the challenge going forward.
        Ms. Kelly. Thank you all so much. Thanks for your patience.
        And to all my colleagues that are leaving the E & C
    Subcommittee, I wish you well, I wish you the best. Thanks for
    all your input and insight. And, of course, a special shout out
    to Rep. Shimkus because he is from my home State of Illinois,
    so thank you.
        And I yield back.
        Ms. Eshoo. That is really lovely. We really are going to
    miss the colleagues that are leaving the Congress. There is no
    question about it. And as I said earlier, they are really value
    added, not just to our internal work, but once those words
    become law, they walk into people's lives, and they are a part
    of that.
        And we are--I think I speak for all of us when I say that I
    think that we have been blessed to have you on the committee.
    It is where we really get to know each other very well when you
    serve on the committee together.
        Now I would like to recognize Mr. Mullin, the gentleman
    from Oklahoma. You have 5 minutes for your questions. And
    please unmute.
        Are you there?
        Mr. Mullin. Madam Chair, thank you so much. And you are
    right, it is bittersweet to have people leave our side.
        On one hand, I hate to lose them because they are a value
    and an asset to Congress. On the other hand, I get to move up
    on asking questions. So there is a side of me that is very
    selfish about that.
        But I do--I will say, Madam Chair, you are right, when we
    are able to meet in person and we are able to have these
    hearings in the hearing room, it is something that adds a lot
    of value and friendship, from my friendship with Lisa to Joe
    Kennedy, to even yourself and Diana DeGette, and just a whole
    host of people to everybody on our side, it is something that
    is tough to replace.
        And as you know, the stuff that I am going through
    personally with my son, our committee has just been phenomenal
    to me, so I will do the same. I will miss everybody that is
    here and we look forward to meeting everybody in person again.
        To jump into where I am going with these questions, we have
    heard a lot about ACA, and I think we all agree people with
    preexisting conditions need to have the access to market. I
    think we disagree on how to do that, obviously, and a one-size-
    fit-all approach doesn't work, and we have seen that in Idaho,
    as Mr. Cameron has pointed out in your testimony. You stated
    that in your collaboration and regulatory approach, that it has
    led Idaho to have one of the most successful exchanges in the
    country, and it is because you went at it on your own. You
    designed it specifically for the people of Idaho, and that
    approach has been very successful.
        Could you kind of point out to us, what regulatory actions
    you have taken to improve the outcomes for your patients during
    the pandemic?
        Mr. Cameron. Certainly. Thank you for the question.
        As I mentioned earlier, we began meeting with the carriers
    and talking about issues that were barriers to our consumers,
    things like prescription drugs, being able to obtain their
    prescriptions both early, both in larger supply, 90-day supply,
    and both without signing signature logs.
        We said to the PBMs and to the carriers that were
    contracting with them, You can't require a signature log and
    you can't go back and audit them. We also worked with the
    carriers in expanding how people who are on coverage, how they
    could stay on coverage, and if they left coverage, how they
    could get back on coverage without going through all of the
    hoops and the previous provisions.
        So employees that were furloughed could stay on coverage.
    Employees that lost coverage and went to a special enrollment
    period, we made it easier for them to make that transition,
    working with our State-based exchange because we have that
    connection that was able to make it helpful.
        And then we made sure that people had access to coverage.
    We actually considered an extra special enrollment period, but
    in conversing with a lot of our colleagues found that, for most
    of our citizens, it really wouldn't address the numbers like
    Mr. Lee is talking about in California. And I am glad, happy
    for him, but it wasn't what fit for us. So we believe that we
    have taken care of our consumers.
        We issued about 12 different bulletins that lightened the
    load or the responsibility on carriers and encouraged them to
    give money back to consumers, helped them so that they could
    give money to providers without it showing up as an adverse
    asset or giving back to consumers without it showing up as a
    rebate or an illegal inducement. We had them work through all
    of those things.
        Mr. Mullin. Well, can you maybe help us on the Federal
    level, we see a lot of States that only have one choice in the
    markets. How could the Federal Government help maybe
    incentivize competition in the individual markets like you have
    in Idaho?
        Mr. Cameron. Yes, I think that is a great question and one
    that warrants a lot more deeper discussion than what I am going
    to be able to give you in less than a minute.
        First of all, collaboration and working in the regulatory
    environment, discussing those rules that are keeping carriers
    out of the business, looking at their profitability and how--
    you know, in our case, we have a co-op that we share with
    Montana. We have two not-for profits. All of those aren't
    really interested in making profit, but they are not interested
    in losing hundreds of thousands of dollars either.
        So you have got to provide a balanced approach by which we
    are bringing young and healthy in order to help that risk pool
    be more stable.
        Mr. Mullin. Well, thank you. And we look forward to working
    with you more going forward.
        Switching gears real quick, just in closing remarks here, I
    heard Gianforte and Lisa both talk about telemedicine. I have
    got a whole new approach to it because the way my son has been
    having to receive healthcare lately with specialists all over
    the country through telemedicine, and it is something that is
    underutilized and something that we as a Federal Government
    should be playing a huge role in.
        It is something that has become very passionate, and I
    would like to maybe have a deeper discussion. So, Lisa, I look
    forward to working with you moving forward on this thing, too.
        With that, Madam Chair, I yield back.
        Ms. Eshoo. The gentleman yields back. And know, Markwayne,
    that our prayers follow your son every day, every night, all
    week long, all month long. We are with him, and we are with
    you, and I couldn't mean that more.
        Mr. Mullin. Well, thank you. I will tell you real quick, my
    son is going to be discharged from up here October 8.
        Ms. Eshoo. Isn't that wonderful? See?
        Mr. Mullin. And so we get to come back home, so we are
    super excited. God has just been so good to us. It has been a
    miracle throughout the whole process.
        Ms. Eshoo. And that is wonderful news. And we always have
    to remember to go back and say prayers of thanks. We are good
    at asking. We have to remember to say thank you.
        I just want to add something--and I appreciate Mr.
    Cameron's work--I also think we need to highlight what
    California has done. Idaho has a population of 1.7 million
    people. The State of California is a Nation State, 39.5 million
    Californians, and we are a highly diversified state. I don't
    know how diversified Idaho is. But the more homogeneous a
    population is relative to an insurance pool, frankly, the
    easier it is.
        So I tip my hat to Mr. Cameron for his work. But I also
    want to highlight what is taking place and has taken place in
    the largest State in the Union. If the ACA can succeed in
    California, my contention is it can succeed anywhere.
        With that, it is a pleasure to recognize the gentlewoman
    from Delaware, a wonderful, wonderful member of our
    subcommittee, Lisa Blunt Rochester.
        Ms. Blunt Rochester. Thank you so much for the recognition,
    Madam Chairwoman, and for your incredible leadership on this
    subcommittee, and thank you to the witnesses that are here
    today.
        The passage of the Affordable Care Act ushered in a new era
    for healthcare and expanded coverage to more than 20 million
    Americans. This landmark law resulted in the highest insured
    rate in our Nation's history. It included a comprehensive set
    of measures to protect Americans with preexisting conditions.
    Millions of Americans have access to affordable quality health
    insurance because of the law. The law's tax credits make
    healthcare affordable for millions of Americans, but millions
    more are still under or uninsured.
        Unfortunately, Republican Governors continue to refuse to
    expand Medicaid in some States, as was mentioned, and the Trump
    administration has deliberately made attempts to undermine this
    law.
        My question is for Mr. Lee, my first question. Mr. Lee,
    your State implemented a new program that provides enhanced
    subsidies for low and middle class consumers. How many
    individuals have benefitted? And can you briefly discuss the
    program?
        Mr. Lee. I can. Thank you very much for the question.
        I appreciate Chairman Eshoo's note about California's
    breadth of diversity. We are a very diverse State with about 30
    percent of our role is Latino, about a third Asian Americans,
    many African-Americans, but we know the ACA is not enough. So
    Governor Newsom and the Legislature expanded subsidies that
    about 600,000 or 1/3 of our enrolled has benefitted from,
    600,000. But it included having element of having subsidies for
    people that are above that 40 percent poverty clip. They now,
    instead of spending 10, 15, 30 percent of their income, are
    getting financial help, on average $500 a month to lower their
    coverage. That contributed to our last open enrollment period a
    40 percent bump of new enrollment, healthier people, and lower
    costs for everybody, as well as the unsubsidized.
        And if I may, just very briefly. We have heard all about
    healthcare costs, and we should. The healthcare costs are a
    problem. But recognize, in the last six years, while premiums
    have doubled in much of the Nation, they have risen at half
    that rate, half that rate in California because of what we have
    done to implement the Affordable Care Act.
        So, yes, let's address pharma cost, let's address
    consolidation, but recognize getting people insured is a
    benefit to everyone by a better risk mix as well.
        Ms. Blunt Rochester. Great.
        And I want to shift a little bit to the marketing and
    outreach that was mentioned before. And I know Covered
    California invested in outreach during the COVID-19 special
    enrollment period and I know--and is increasing their marketing
    and outreach budget by $30 million for fiscal year 2021.
        What benefits has Covered California seen from their robust
    investments in marketing and outreach?
        Mr. Lee. So I want to be really clear. If you are a Nike,
    if you are--I think Timberline is in your State, if you are a
    Ford Motor, you don't say people knew about us a few years ago,
    we stopped marketing. You always had a market. But beyond that,
    healthcare is different. People don't want health insurance
    because they don't think they are going to get sick. They need
    to be convinced, reminded, cajoled, nudged. We spent a lot of
    money on marketing, but for every dollar we spend on marketing
    $6 or $7 comes back to the State by lower premium costs, by
    enrolling healthier people. It is the right thing to do and
    creates a virtuous cycle by lowering healthcare costs.
        Ms. Blunt Rochester. And, Dr. Aron-Dine, how could
    investments in the ACA's marketing and outreach and in consumer
    assistance play a role in helping people recently uninsured
    because of this pandemic? Talk to me a little bit about that in
    the minute that we have.
        Dr. Aron-Dine. I think restoring funding for outreach and
    marketing could play a very big role, so could opening up a
    special enrollment period, so could improvements in premium tax
    credits, similar to what was done in California.
        And if I could just say one word about unsubsidized
    marketplace premiums, because that has come up a lot, when
    studies have looked at this, unsubsidized marketplace premiums
    are ballpark in line with premiums for comparable employer
    coverage. But people don't see the sticker price for their
    employer plan. They don't see the $7,000 because their employer
    is paying part of it, plus we provide a tax subsidy for those
    plans. And so, of course, people are surprised by those sticker
    prices in the marketplace and some find them unaffordable.
        You can go two directions with that. You can eliminate
    protections for preexisting conditions with the risk pool and
    make things a little cheaper for the healthy at the expense of
    the sick, or you can extend premium tax credits to people at
    higher income levels as the bill passed by the House earlier
    this year would do. I think that is a more logical solution.
        Ms. Blunt Rochester. Thank you so much for all of your work
    and to the panelists, and now is not a time in a pandemic to
    get rid of the Affordable Care Act, this landmark piece of
    legislation.
        Thank you, and I yield back.
        Ms. Eshoo. The gentlewoman yields back. We thank her for
    her excellent questions.
        And it is an honor to recognize another outstanding member
    of our subcommittee, the gentlewoman from the State of
    Washington, Mrs. McMorris Rodgers.
        Mrs. Rodgers. Thank you, Madam Chair. It is great to be
    here today, and I appreciate you holding this hearing and to
    all of the witnesses for participating today.
        It has been more than ten years now since the ACA was
    signed into law, and yet today Americans are still left to deal
    with expensive and burdensome policies. The ACA, Obama Care,
    was well intentioned, but it has failed in meeting many of its
    goals and failed in meeting many of its promises. Obama Care
    promised affordable health insurance for every American and
    even penalized those who refused to buy it.
        The law has distorted markets and not controlled the
    underlying costs of care. Tens of millions of Americans today
    cannot afford health insurance, and the number of people who
    delay doctor's visits because they can't afford care just keeps
    going up.
        In 1 of 5 counties, a 40-year-old making $50,000 would have
    to pay more than ten percent of their income for the lowest
    cost plan in the Obama Care marketplace. According to
    healthcare.gov itself, this is considered unaffordable.
        Unfortunately, some of my colleagues refuse to acknowledge
    some of the issues that continue to plague the ACA, such as
    higher premiums, higher taxes, and tax penalties, and even more
    Federal regulation of health insurance.
        I believe that this type of government-knows-best approach
    is what is leading to more support for one-size-fits-all
    government takeovers of healthcare like Medicare for All.
        All Americans deserve a health insurance system that
    embraces transparency and choice, protects Americans with
    preexisting conditions, like my son, supports medical
    innovation for better care and, most of all, lowers cost across
    the country.
        To Dr. Holtz-Eakin, what changes in the way that private
    health insurance has covered certain services, such as
    telehealth visits, have you seen in your examination of the
    market? And what effect are those changes having on patients,
    the delivery of care, and the costs of care?
        Dr. Holtz-Eakin. Well, again, telehealth has come up a
    number of times, and it is a really good example of a loosening
    of the regulations that allows a new service to be offered that
    is now a competitor service to the existing delivery system.
        It is not going to compete on everything. It is not a great
    way to do an initial intake of a patient, a lot of other
    examples. But in many situations it can provide a lower cost
    alternative to an in-office visit, and that is something that
    we want to always allow to flourish wherever possible.
        And we shouldn't rely on the people at CMS to sit and think
    what could we provide to. We should simply have a regulatory
    structure that is flexible enough that if someone decides they
    want to do telehealth, they can start up and do it. And I am
    hoping that what we will learn from the experience of this
    pandemic is that a lot of the restrictions on the delivery
    system are really unnecessary. The notion that scope of
    practice laws are as tight as they are really restricts
    competition.
        In the pandemic we saw doctors cross State lines and
    practice with zero problem whatsoever. There is a lot about
    this that I think is a real wake-up call to how we deliver
    health in the United States.
        Mrs. Rodgers. Thank you.
        And as a follow-up to you and to Director Cameron,
    obviously, this pandemic is tragic, and we can't underscore the
    personal costs and the toll that it has had on our country.
    From a healthcare policy perspective, it has forced us to adapt
    in ways to the environment and change the way healthcare is
    delivered in some cases.
        Using telehealth in my rural district in eastern Washington
    as an example, there are many ways that healthcare is covered
    or paid for and, in the long run, would improve the efficiency
    of this system and improve patient access. In other words,
    there is lessons that we can learn and any policies that we
    have implemented on a temporary basis I think we should
    consider for a permanent basis.
        And I would just like to ask both of you to highlight, what
    are those temporary policy changes that we should consider to
    make permanent?
        Dr. Holtz-Eakin. Want to go first, Dean?
        So I would encourage you to take a look at the list we
    compiled at the American Action Forum. We have a list of all of
    the emergency waivers that HHS has done using the health
    emergency declaration and go through that list, and anything on
    that list is fair game to be made permanent.
        I think that that has been--you know, if you needed to do
    it to address the biggest crisis we have seen in America, then
    it is something that needs to be gotten rid of permanently.
        Mrs. Rodgers. OK. Well, thank you. Thank you very much.
    Always good to hear your insights.
        And with that I will yield back. Thank you, Madam Chair.
        Ms. Eshoo. The gentlewoman yields back. It is great to see
    you.
        And now it is a real pleasure to recognize just an
    outstanding member of our committee. We are really lucky to
    have him, always thoughtful.
        Mr. Welch, you have 5 minutes, and we want to hear
    everything that you say, so unmute.
        You need to unmute. Can't hear you.
        Mr. Welch. Well, I said I was----
        Ms. Eshoo. There you are.
        Mr. Welch. I was listening to you, and you embarrassed me
    with that introduction. I am not quite sure you got that right.
        But I am actually delighted to be here, of course, with my
    colleagues on the committee, and I am not going to rehash the
    ACA issues. I want to focus on some of the things we can do to
    address the high cost of medical care. In this country, as we
    know, we pay the most and get the least. And whether we have a
    taxpayer-funded system, an employer-based system, or an
    individual pay system, if the cost of healthcare keeps
    escalating like it is, none of us are going to be able to
    afford it.
        I am going to ask, Dr. Holtz-Eakin, you make some very good
    comments, and I really do always enjoy your testimony. And the
    question I have is this. Some of the information we have now is
    that easing regulations helps. It helps on delivery and it may
    help on the cost. You mentioned telehealth, something that I am
    a very strong supporter of. But here is the question.
        If you ease regulations, do you maintain standards?
    Because, for instance, if you allow for insurance companies to
    sell policies that deny preexisting conditions, then that is an
    option for somebody. But then when they get sick, they may well
    not have coverage.
        My view--and I want your reaction to this--is that if you
    are going to ease regulations, you have to have standards so
    that a person, whether he or she is in Texas or in Vermont, has
    confidence that they will get the healthcare they need when
    they need it.
        Can you comment on that tradeoff between regulations and
    standards?
        Dr. Holtz-Eakin. So I think of this in two different areas.
    One of it is the insurance arena, as you mentioned. There is a
    difference between saying this is insurance that you are
    allowed to offer, having a strict regulatory structure that
    says what you may or may not offer, and a set of standards to
    say, OK, you can offer insurance with a minimum standard, it is
    not really insurance if it doesn't cover anything, so that is
    minimum standard to get Federal subsidies and preferred tax
    treatment.
        And then you get into transparency and consumer protections
    and adequate financial backing for the insurance company
    itself. You can't--
        Mr. Welch. OK. Let me interrupt here because that is a very
    good point. But all of those things that you just mentioned do
    require some kind of governmental action, not just free market
    action, correct?
        Dr. Holtz-Eakin. Free markets operate within a legal
    structure and the legal structure is essential. There is no way
    around that.
        Mr. Welch. Correct. No, I appreciate that.
        And I want to go to Dr. Lee. I was extremely interested in
    the point that you made that, despite the escalating premiums,
    your increase in premiums has been half of what the national
    experience has been. Is that what you said?
        Mr. Lee. That is absolutely right, Congressman Welch. I
    think it is important to note that underlying costs are still
    too high in California. We have consolidation problems, but
    premiums would have gone up half as much in the rest of the
    Nation if the rest of the Nation had implemented the Affordable
    Care Act that we did, marketing, Medicaid expansion, getting
    everyone in the door to have a healthier risk mix.
        Mr. Welch. And, Dr. Aron-Dine, could you comment on steps--
    well, first of all, just comment on what is the incredible
    pressure of high costs on any kind of sustainable healthcare
    system, number one, and, number two, what recommendations you
    would make to bring down the costs.
        Dr. Aron-Dine. Sir, I think you really put your finger on
    it. High costs are a systemwide issue, and they need to be
    addressed in large part on the provider side of the system,
    thinking about prices, thinking about utilization, thinking
    about delivery system reform.
        And so I just want to contrast that with the sort of
    implication that somehow ACA costs are especially high or the
    marketplace costs are out of control. We have a systemwide
    healthcare cost issue and then we have some affordability gaps
    in the ACA structure that are pretty easily solvable and could
    address the concerns of unsubsidized marketplace consumers.
        With respect to continuing to work on costs, I think we
    actually have a lot--there are many ideas in common among the
    panel. I was also really struck by--in thinking about
    regulatory barriers and other barriers that have been relaxed
    during the pandemic.
        Many States have also relaxed access barriers in Medicaid
    and changed and streamlined their eligibility procedures to
    make sure that people could get coverage during this period.
    And I think similar to how there are lessons on scope of
    practice, there is some lessons on eligibility there, practices
    that we could continue to take nationwide and get eligible
    people covered without compromising program integrity.
        Mr. Welch. Thank you.
        My time is up, but I want to acknowledge the testimony of
    Mr. Cameron and the successes that he was able to talk about in
    Idaho. Thank you.
        Ms. Eshoo. The gentleman has completed his questions.
        And it is a pleasure to welcome back to the subcommittee,
    she is an honorary member of our subcommittee, Ms.Schakowsky of
    Illinois, who waves on, and we are happy to have you, and you
    are recognized for 5 minutes for your questions. Please unmute.
        Jan, we can't hear you. You need to unmute.
        Ms. Schakowsky. I should be unmuted now, I hope.
        Ms. Eshoo. You are.
        Ms.Schakowsky. Thank you so much. I really appreciate your
    indulgence to let me wave on, and it has been an amazing,
    amazing hearing.
        I don't want to go over old testimony--or I mean old
    messages, but I do want to say that on this day when there are
    now 201,000 people who now have died from the COVID crisis, and
    I just want to say they deserve recognition and mourning, the
    families who have lost their loved ones, the essential workers
    who have died, and the nursing home residents that we have been
    trying to focus on who failed to be protected.
        And the one bright light really has been the Affordable
    Care Act. No one disagrees that there aren't ways that it could
    be improved; but, thank goodness, for the Affordable Care Act
    and the difference that it has made. And really the terrible
    travesty of the sabotage that we have seen--I mean, I listen to
    all of the complaints about the Affordable Care Act, and still
    there is nothing else right now that has been suggested.
        But, Mr. Lee, I have a very specific question that affects
    my State of Illinois. According to your testimony, California
    has done a number of things on its own, spent the past decade
    protecting, building on and going beyond the ACA. But my home
    State of Illinois still relies on the Federal Government
    exchange. We don't have our own exchange in Illinois.
        And so what I really wondered was how has your State-based
    exchange allowed you to do better to serve Californians,
    especially during this COVID crisis? And what would you
    recommend to other States in terms of relying just on the
    Federal exchange and instead moving toward having its own
    exchange and the options that become available?
        Mr. Lee. Well, thank you so much for the question, and
    thank you also for your observation about taking a moment to
    mourn the losses we have seen around the entire Nation.
        California is an independent exchange, but from day one we
    said we are committed to building on and making the Affordable
    Care Act work, building on. Covered California has patient
    centered standard benefit signs. There are great economic
    theories about more choices, better, but we want consumers to
    choose between plans with good choices. We have robust
    competition.
        We bring health plans in, but we also hold the health plans
    to account to make sure they deliver quality care. It is not
    just about people getting an insurance card. So we look at
    health equity. We hold our health plans to account. We have
    very robust competition. 80 percent of our enrollees have four
    or more carriers to choose from, 99.8 multiple plans. We have
    competition.
        But it is also about marketing. It is about marketing and
    getting the word out and promote it. As I note, we spent a lot
    of money on marketing. We spent $150 million in marketing and
    outreach in the coming year, and it lowers costs. It is not
    extra Federal money. It is coming out of the premiums, but the
    premiums are lower because of that spending, but part of it is
    we have navigators, we have 10,000 insurance agents.
        We have storefronts with Covered California's name on
    streets across California, 500 storefronts. Behind those
    storefronts are not government workers, but some of our 10,000
    independent insurance agents. It is navigators we fund.
        And these are the investments that the Federal Government
    should be making to stand up and make sure that all Americans
    get coverage or saving marketplaces many are doing similar
    things, and this is about getting everyone insured something we
    have wanted to do from day one.
        Ms. Schakowsky. I thank you so much. I really think that--I
    would hope that we could get Illinois to follow your lead and
    to adopt many of the suggestions that you have already
    implemented. So thank you so much.
        And I yield back.
        Ms. Eshoo. The gentlewoman yields back.
        I am sure that Peter Lee would be happy to assist you, Jan,
    but here is a warning. Do not take him away from us. He is far
    too valuable. We need him.
        I don't think that--oh, I thought that we were finished. It
    is really a pleasure to recognize a long-standing member of our
    committee, really salute him for the work that he has done over
    so many years, his conscientiousness, his friendship, his
    effectiveness, his caring for his constituents and country.
        I am pleased to recognize the gentleman from New York, Mr.
    Engel.
        Mr. Engel. Thank you, Madam Chair, and thank you for those
    kind words, and thank you for being such a good friend of mine
    all of these years.
        You have done a terrific job as Chair of this subcommittee,
    really making the subcommittee rise to an eminent place.
        We all know healthcare is just so important, and we come
    with a whirlwind of knowledge, and you actually feel it when
    people are suffering. I think you have done a fantastic job as
    Chair of the subcommittee, and I was proud to be part of it.
        This may be the last time I speak, so I want to say that
    the fight, obviously, that we have all been doing for
    healthcare and other things needs to go on because there are
    many people that want to kill it, and we know that that would
    be a tragedy.
        The ACA has helped nearly 20 million Americans get covered,
    including nearly a hundred thousand of my constituents. Many of
    these Americans gained coverage through the ACA's landmark
    Medicaid expansion.
        If the remaining 12 nonexpansion States would join the rest
    of the country, an estimated two million more Americans would
    gain coverage, and during the current COVID-19 pandemic in
    which millions of Americans have lost their health coverage,
    this would provide many low income and working families peace
    of mind.
        House Democrats passed the Heroes Act, which would provide
    a trillion dollars in State and local relief to help support
    Medicaid expansion.
        Let me ask Mr. Cameron, could you describe why Federal
    dollars to State and local relief are critical to supporting
    Medicaid expansion?
        Mr. Cameron. Well, excellent question. Certainly Idaho is
    one of those that did expand Medicaid, although we took our
    time in doing so, and certainly the increased FMAP has
    certainly been very helpful to us, and we have seen dramatic
    improvement in the number of folks--or dramatic number
    increases during the pandemic in the number of folks who
    actually accessed Medicaid.
        We do see some that prefer not to, and the way the laws
    are--the way the ACA is drafted, it doesn't give them a choice.
        So we do have some consternation over that. We would like
    to give consumers the opportunity to choose whether to be on
    Medicaid or to choose whether to be on a private sector plan
    and think that there is a solution there as well.
        Mr. Engel. OK. Thank you.
        Millions of Americans have lost their job-based health
    insurance through the economic crisis caused by the coronavirus
    pandemic, and Congress has taken steps to preserve their health
    coverage by providing more funding to States with Medicaid
    coverage.
        Like my home State of New York, we have also opened up
    special enrollment periods for the Affordable Care Act's
    exchanges to enable individuals to purchase high quality of
    coverage. And so far, 8,000 New Yorkers have used this
    opportunity to get coverage. So it is really something that is
    really important.
        Thank you, sir, for your good work.
        And I yield back the balance of my time--oh, I am sorry;
    one more here.
        Dr. Aron-Dine, what steps can States which run their own
    exchanges take to inform their residents about their special
    enrollment periods? And piggybacking with that, what else
    should Congress do?
        Dr. Aron-Dine. I think there are a lot of lessons for
    Congress in things States have successfully done to expand
    coverage, both before the pandemic and during the pandemic.
        I would put those in a big bucket of improving premium tax
    credits, improving affordability, both for the lower income
    people who are still most likely to be uninsured and also for
    people who are not currently eligible for subsidies but could
    be offered subsidies if premiums are unaffordable as a share of
    their income.
        Another big bucket is improving access, making it easier
    for people to access both Medicaid and marketplace coverage.
    That is something that New York has really been a leader on
    through its basic health program where people can enroll all
    year and can more easily move between different types of
    coverage, and then, of course, making sure that the remaining
    States expand Medicaid.
        I wonder if Peter Lee would like to answer your question
    about the best ways to promote a special enrollment period.
        Mr. Lee. Well, if I may very briefly. It really has to be
    about being all in every channel. Again, we spent $150 million.
    That is a lot of money, but we are a really big State. Any
    State should be spending, to our mind, about one percent of
    your premium dollars on marketing, and that means TV, radio,
    social media.
        In California, it means material in Spanish, in Korean, in
    Vietnamese. It is in language; but it is also on the ground. It
    is so important. We have learned half of our enrollment is
    through insurance agents and navigators. These are people in
    communities.
        Now, you cannot be a storefront and have our name emblazed
    unless you agree by our rules. But the fact that we have these
    storefronts, you know, in every community, we have got them on
    Wilshire Boulevard in L.A., Mission Street in San Francisco,
    but we have got them on Roscoe Boulevard in Panorama City, Q
    Street, in every city, which means people know we are there,
    but it is because we support agents and navigators.
        So it needs to be everything from social media to on the
    streets, which right now people still use the phone.
        So thank you for that handoff, Aviva.
        Mr. Engel. OK. Thank you very much.
        And thank you to all our witnesses again, and thanks to
    Chairwoman Eshoo.
        Obviously, we need to protect not dismantle the ACA. And,
    frankly, what the President is doing now is really a disgrace,
    and I just cannot believe that a government which is supposed
    to protect the people would do something to take away people's
    coverage which they rely on. It is absolutely mind-boggling. So
    we need to be vigilant.
        We need to make sure that these things are not taken away
    and that the American people can get equality of coverage.
        And I yield back the balance of my time.
        Ms. Eshoo. The gentleman yields back.
        It is a pleasure to recognize the gentleman from Arizona,
    Mr. O'Halleran. Please unmute. You have 5 minutes for your
    questions.
        Mr. O'Halleran. Thank you very much. Good afternoon. And,
    Ranking Member Burgess, thank you for allowing me to wave on
    today. It is an important hearing, and I appreciate the
    subcommittee's attention to the importance of the Affordable
    Care Act as our Nation is grappling with the COVID-19 pandemic.
        The lifeline caps on healthcare cannot be imposed by
    insurers and that young people can remain in their parents'
    healthcare until they are 26, these are a couple of the issues
    that are basically different than what we knew before
    affordable healthcare, along with preexisting conditions. And
    for the healthcare industry, it is costly.
        Something that is seldom discussed is the Affordable Care
    Act's role in addressing healthcare disparities among racial
    and ethnic groups, as well as by income.
        Dr. Sommers, as you note in your testimony, a staggering
    19.6 percent of Native Americans lacked health insurance,
    according to a 2018 American Community Survey, public data.
        The COVID-19 pandemic has hit Indian country hard, with the
    per capita rates in the Navajo and the White Mountain Apache
    Tribes in my district, both of which had suffered amongst the
    highest in the Nation at their peaks.
        A lack of preventative healthcare, lack of clean drinking
    water, and access to healthy food, and a high number of
    individuals without high quality health insurance worsened the
    impacts of COVID-19 in these communities. Much work still needs
    to be done, especially in light of COVID-19.
        I sponsored the legislation that would fully fund Indian
    Health Services facilities construction program to contract and
    improve the critical issues, projects across Indian country.
    The urgent need for attention to this matter is why I am proud
    to serve on the Racial Disparities Working Group led by my
    colleague, Congresswoman Clarke, and Congresswoman Kelly, which
    provides an outlet to dive deeper into some of these issues and
    work to ensure access to quality healthcare and insurance for
    all.
        Dr. Aron-Dine, thank you for joining us and for all of your
    work showing how important the Affordable Care Act has been for
    millions of Americans. My district is larger than the State of
    Illinois, meaning that we have a lot of particularly rural and
    underserved areas. We have broadband issues that I and this
    committee have been working on since I came to Congress and
    before.
        Clearly, more needs to be done. I would like to hear more
    about what ACA could do to be improved to ensure that community
    health centers, rural hospitals, and rural providers can
    continue to provide important care that those living in rural
    areas need desperately.
        Dr. Aron-Dine. It is no urging that the ACA has improved
    coverage and access to care for people in rural areas similarly
    to people in nonrural areas, and that is especially noteworthy
    given the people in rural area disproportionately live in
    States that haven't expanded Medicaid, and so they have been
    left out of some of those potential coverage bands.
        I think one of the most urgent needs right now,
    particularly to address or at least make sure some of these
    rural access issues don't get worse, is to address the State
    fiscal crisis that States are facing, which could easily become
    a healthcare crisis, particularly as States look to their
    Medicaid budgets as a place to cut, look to provider rates as a
    place to cut, and look to nonMedicaid health programs as a
    place to cut.
        Mr. O'Halleran. Thank you.
        Dr. Sommers, the pandemic has had economic impacts
    throughout our country, but that impact has been particularly
    felt throughout poor and underserved areas, including many
    Native American communities. What specific improvements can we
    see Congress take to make the Affordable Care Act work better
    for these underserved communities?
        And I wish to point out one other issue, and that is that
    some of my constituents have to drive 10 hours round trip to
    see a specialist. Many of them do, in fact. Many of our
    veterans have to do that, too. And this is just unacceptable in
    the America that we all love. And please help us, give us some
    concepts and ideas.
        Dr. Sommers. I think there has been a lot of bipartisan
    support during the discussion today on the bolstered efforts
    for telehealth, which are critical in rural areas and
    especially in some of the communities that you are talking
    about, you know, where you have things of value, commutes are
    hours from the nearest provider in some of the reservations, in
    the Navajo Nation, for instance.
        The ACA has produced substantial gains in coverage. A study
    we published looked at coverage for Native Americans and found
    that not only did Medicaid expansion lead to big increases in
    those with insurance, it was particularly a large increase for
    those living on or near reservations.
        And then the final comment I will make on this topic is the
    Representative from Montana raised a very good question of if
    you give people insurance but they can't see a provider or
    there are shortages, does it matter? Well, when we looked at
    impact of giving people Medicaid expansion in counties that had
    specific provider shortages, we still found that coverage was
    better than being uninsured. People were better able to get
    care.
        So shortages matter. We need to address them. But having no
    coverage, you don't even have an entry into the system, whether
    there are shortages or not. So coverage first, and then we need
    to also bolster the work force.
        Mr. O'Halleran. Thank you very much.
        I would just end with saying that we can have all the
    coverage in the world, which is extremely important, especially
    in Indian country because the Affordable Care Act is so
    important to it.
        But it doesn't do as much good as it needs to in light of
    the needs of the size of the State of Illinois, you know,
    750,000 people, they have to travel a long way. There is not
    enough specialists. People are sick in those areas. And we have
    to find a better way to address the needs of all of our
    citizens, not just some of them.
        I think the Affordable Care Act is the way to do it, but
    changes do have to be made in light of the need for covering
    all of Americans.
        So thank you very much.
        I think you had something to say?
        Dr. Sommers. Congressman, I was going to say one other
    thing is the chronic underfunding of the Indian Health Services
    is something that we have to talk about in this context, too,
    and that is direct funding to creating the infrastructure that
    can then provide the care that is needed. Health insurance
    coverage is important, but the Indian Health Services plays
    such a critical role, too.
        Mr. O'Halleran. And we are doing that.
        And, Madam Chair, I yield. Thank you.
        Ms. Eshoo. The gentleman yields back. And it is always a
    pleasure, we want you to know, to have you wave on.
        Mr. O'Halleran. Thank you.
        Ms. Eshoo. You are an honorary member of our subcommittee.
    How is that?
        Mr. O'Halleran. That is great.
        Ms. Eshoo. Exactly.
        It is wonderful to recognize the colleague from California,
    Dr. Ruiz, for his 5 minutes of questions. Please unmute.
        Mr. Ruiz. Thank you, Chairwoman.
        I want to also echo the sentiments of our colleague,
    Congressman O'Halleran, who has been a champion for Indian
    country and health equity in our Nation.
        You know, it is kind of stunning to me that we still have
    to hold these hearings on the importance of the Affordable Care
    Act, that the Affordable Care Act is still under attack, that
    it is still under the threat of repeal.
        Even now, during this nationwide pandemic, where families
    all across the country have relied on coverage through Medicaid
    expansion and subsidies and exchange plans, many after having
    lost employer insurance, this pandemic has laid bear the
    importance of access to affordable healthcare with
    comprehensive benefits.
        House Democrats tried to expand that access in the Heroes
    Act, which included my bill, the Care for COVID Act. The Care
    for COVID Act expands access to healthcare by creating a
    special enrollment period for anyone without insurance and
    requires insurance plans to cover treatment for COVID with no
    out-of-pocket costs for their patients so that co-pays or high
    deductibles would not be a deterrence for seeking care.
        You know, as an emergency medicine physician, I know we
    need more access to care, not less. But you don't need to be a
    doctor to get that. You don't need an M.D. To realize that
    during a pandemic we want to get more access to the proper care
    and precautions, not less.
        And yet this administration and some House and Senate
    Republicans continue to try to chip away at the ACA, while also
    attempting to completely overturn the law in court, completely
    overturn the law in court.
        We have been fighting this for years, even as millions more
    Americans have insurance because of the ACA, even as 130
    million people with preexisting conditions across the country
    can no longer be denied health coverage just because they had
    been sick before.
        But the Trump administration and if these Republican
    leaders get their way and the ACA gets overturned, there will
    be no protections for people with preexisting conditions. Keep
    in mind that anyone who has had COVID will have a preexisting
    condition.
        This means that they may have to pay much higher premiums
    for their coverage, possibly even be denied or that coverage
    might not cover anything related to their COVID illness, which
    I should add we do not know the full scope of the long term
    affects of COVID-19 yet, or they will be subject to annual
    lifetime caps or what insurance will pay. That is if they will
    be able to get insurance at all, because without the
    protections of the ACA, all of those scenarios are possible, if
    not likely, as we all remember from pre Affordable Care Act
    days.
        Dr. Aron-Dine, can you just expand on some of the impact on
    individuals with preexisting conditions if the ACA were to be
    struck down by the Supreme Court?
        Dr. Aron-Dine. I think you described we would really be
    reverting to a pre ACA world, where the individual market
    really didn't work for people with preexisting conditions or
    others with serious health needs because they could be denied
    coverage, charged higher premiums and because plans could have
    massive benefit gaps or caps on coverage.
        And if you don't mind, if I could say one word about the
    idea that we have been hearing that there are proposals out
    there that would replace the ACA's preexisting conditions
    protections. Looking at one of those bills introduced by
    Ranking Member Walden, I have some real concerns.
        Not only would it not replace the Medicaid expansion in any
    way, which is, first of all, the loss of people with
    preexisting conditions, and not replace premium tax credits in
    any way, which is crucial to making a market that protects
    preexisting conditions actually work.
        Even if you just look at the impacts on the market, on the
    insurance market reforms, people with preexisting conditions
    could still be charged more either on the basis of their
    condition or certainly on the basis of gender or age, and plans
    could leave out high-cost drugs, could leave out any other
    benefits, or just cap coverage with low annual and lifetime
    limits, so back to the economic logic that pushes you to a race
    to the bottom in an insurance market without standards and you
    really haven't protected people with preexisting conditions in
    any way.
        Mr. Ruiz. You know, this attempt to repeal the ACA through
    the courts is opposite of what health equity means because it
    is precisely people with underlying illnesses, precisely with
    people that have chronic illnesses that are most at risk of
    dying from COVID-19.
        Repealing and chipping away from the ACA will add to the
    numbers of those who die and who suffer from this pandemic,
    which would only prolong the pandemic and its economic
    devastation for our Nation. It is the opposite of doing good.
    It is doing harm.
        Mr. Lee, good to see you again. Can you talk about how
    individuals who have had COVID will be impacted by not having
    preexisting coverage protections and what this might mean with
    any long-term health effects of COVID-19? Since we know it can
    cause scarring of the lungs, this could lead to longer term
    health effects.
        Mr. Lee. So, Dr. Ruiz--I am not sure which is a better
    honorific, Congressman or Doctor, but first it could have 7
    million people not just being precluded from getting coverage,
    but potentially being charged higher premiums, imposing higher
    out-of-pocket costs and, if I may, and Aviva noted this, but
    remember, under the pre ACA, being a woman was treated as a
    preexisting condition.
        Women were charged more for insurance. And returning to
    that reality, to my mind, would be virtually medieval.
        If I may, saying that you have a policy that could preserve
    preexisting condition protections of the ACA without addressing
    the other elements is like saying, We will keep this plane in
    the air by committing to not chopping off its wings, but not
    address that you have an engine, the need to have flaps and
    rudders to steer, the need to have a landing gear to land.
    While an airplane needs wings to fly, it also needs other parts
    to keep it in the air to get passengers on the ground safely.
        You can't separate out preexisting condition protections
    from subsidies, insurance rules. So to say you can do one thing
    alone is just both an economic and healthcare fallacy.
        Mr. Ruiz. Thank you very much.
        I yield back.
        Ms. Eshoo. Thank you very much for that exchange and, Mr.
    Lee, for, I think, really an outstanding description that
    really speaks to this whole notion of I am for preexisting
    conditions and that somehow that that is something that can
    just take place like this without any other architecture
    relative to insurance surrounding it.
        I don't see any other members that are waiting to
    participate in the hearing. So I want to request unanimous
    consent to enter into the record the following documents: An
    April 2020 letter to CMS Administrator Seema Verma from Members
    of the Energy and Commerce Committee on establishing a special
    enrollment period; a letter from AFSCME Council 57; a statement
    from Margaret Murray, chief executive officer of the
    Association for Community Affiliated Plans; an August 2020 GAO
    report entitled ``Private Health Coverage, Results of COVID
    Testing for Selected Offerings''; a letter from the National
    Taxpayers Union; a statement from Community Catalyst. And
    without objection, hearing no objections, so ordered.
        [The information appears at the conclusion of the hearing.]
        Ms. Eshoo. Let me just close on this note, and it really is
    with all of my thanks, and that is on behalf of all of the
    Members of the Subcommittee.
        Dr. Sommers, you spoke so clearly and with a knowledge that
    is so broad and deep because you are caring for patients every
    single day, and you know their stories and you related them to
    us so beautifully. Thank you. Thank you for being willing to
    testify and for the quality of your testimony.
        To Mr. Holtz-Eakin, you are always welcome at this
    subcommittee. Both sides of the aisle draw a great deal of
    every testimony that you have offered, so thank you for doing
    that today. You are always thoughtful. And you are direct in
    your answers. Which we all appreciate.
        To Dr. Aviva Aron-Dine, you are outstanding. You are
    absolutely outstanding. You have deepened and broadened our
    knowledge, never being menacing in terms of your responses, but
    with a knowledge that is dazzling, and that for those of us
    that think that we understand these policies really quite well,
    you did something today to really deepen it and broaden it. And
    you are always welcome back at the committee. You added so much
    to our hearing.
        To Mr. Cameron, thank you for your testimony. To have an
    individual that represents, even though the population of Idaho
    is relatively a small one in comparison to my home State of
    California, your experience and your work to help insure people
    was high value testimony, and we appreciate it. And I think you
    have a good sense of that because you evoked important
    questions from both sides of the aisle.
        And to Peter Lee, there simply is no one like you. There is
    simply no one like you. As when we opened the hearing and I
    introduced you, I spoke you are one of the most distinguished--
    you come from one of the most distinguished families in
    California, in our country, and at the heart of their service
    and their care was healthcare. You are all physicians. So you
    are--you stand on the broadest shoulders.
        You have not disappointed anyone in generations of your
    family. You carry on that tradition, and Californians are
    deeply grateful to you. Our entire delegation from both sides
    of the aisle are grateful to you and grateful to you not only
    for your knowledge and your know-how, but that all of us can
    really sense and feel from a deep place what kind of commitment
    you have. It is called the Lee commitment, your fortitude.
        So bless all of you for working with us to really make our
    country better. We are in troubled times. It is up to us to
    help bring the American people through.
        And at the heart of that, at the heart of that, is the
    dignity of each human being. Each one has a spark of divinity
    to them, and honoring that spark of divinity is that they will
    have healthcare that they and their families can depend on.
    That is the way that we honor them.
        So thank you to all of my colleagues. Thank you to the
    witnesses.
        And with that, the Health Subcommittee of Energy and
    Commerce is now adjourned.
        [Whereupon, at 1:58 p.m., the subcommittee was adjourned.]

                    Prepared Statement of Michael C. Burgess

        Thank you, Madam Chair. I would like to set the stage by
    walking through the robust support that Congress has provided
    already this year to protect American patients during this
    novel coronavirus pandemic. In various supplemental relief
    packages, Congress has provided or required coverage for
    different coronavirus-related services. For example, Congress
    has required that commercial insurance cover coronavirus
    testing.We have also waived all cost sharing requirements for
    Medicaid and the Children's Health Insurance Program for labs
    and diagnostic services related to a coronavirus diagnosis.
    Uninsured individuals are protected because we allowed states
    the option to pay for these individuals under Medicaid and
    established a separate funding stream for provider relief to
    ensure that physicians, hospitals, and other providers are
    reimbursed for the care that they provide to uninsured
    patients. We have provided similar protections for Medicare
    beneficiaries, in addition to increasing access and
    reimbursement for telehealth services.
        We have championed policies that would keep money in
    American patients' pockets. We allowed high deductible health
    plans to cover telehealth under the deductible for two years,
    and we allowed patients to use funds in Health Savings Accounts
    and Flexible Spending Accounts for the purchase of over-the-
    counter medical products, including those needed in quarantine
    and social distancing, without a prescription from a physician.
        You have called this hearing today, in part, to celebrate
    the Affordable Care Act. If it is so comprehensive and working
    so seamlessly, then why have you called us here to discuss how
    it has struggled to provide adequate protections for
    individuals during this pandemic? From what I have heard,
    states and insurance plans have been able to adapt quickly to
    ensure flexible yet comprehensive coverage for individuals.
        My constituents continue to tell me how unaffordable the
    Affordable Care Act is. Many of those laid off because of the
    economic impact of the virus are eligible for a special
    enrollment period to sign up for an ACA plan or have become
    eligible for Medicaid. If they are choosing not to enroll, that
    is probably because of the astronomical cost of doing so.
        I would like to make it clear that there is vast,
    bipartisan support for protecting coverage for individuals with
    pre-existing conditions. Many of us on our side of the dais
    have experience with pre-existing conditions in our own
    families or providing insurance for the employeesof their
    businesses. If there was a real concern about addressing this
    issue, the Majority would have voted with Republicans on
    numerous occasions this Congress to support protections for
    individuals pre-existing conditions. They also could have
    called a vote on a severability clause bill to ensure that if
    the Affordable Care Act were struck down, these protections
    would stand. They have not taken any of these actions.
        The constituents in my district are struggling to afford
    their health insurance, and I am sure that my district is not
    the only one suffering from sky-high premiums and deductibles.
    What good is healthcare insurance if you are afraid to use it
    because you can't afford your deductible? This is an issue that
    I would like to see us tackle.
        This hearing is also in direct contrast with the hearing
    that Chairman Pallone and Chairwoman Eshoo called last
    December. The hearing notice for the December 19, 2019 hearing
    stated, ``universal healthcare coverage has long been the North
    Star of the Democratic Party.'' Their agenda is to pave that
    road to the North Star--to accomplish one-size-fits-all
    healthcare coverage. The reality is that one-size-fits all is
    really one-size-fits-no one.
        It is critical that states maintain the flexibility to
    address the unique needs of their citizens. Forcing every state
    and every American to fit into the same box will not work.
    Americans need and deserve to have choices that will work for
    themselves and their families. They should not have to worry
    about spending a substantial portion of their income on health
    insurance to have an unreasonably high deductible such that
    they fear using the insurance they pay for.
        With that, I yield back.
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                     [all]