[House Hearing, 117 Congress]
[From the U.S. Government Publishing Office]


               BUILDING ON THE ACA: LEGISLATION TO EXPAND 
                HEALTH COVERAGE AND LOWER COSTS

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

                            VIRTUAL HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 23, 2021

                               __________

                           Serial No. 117-16
                           
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                           


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

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
46-541 PDF                 WASHINGTON : 2022                     
          
-----------------------------------------------------------------------------------                        
                       
                    COMMITTEE ON ENERGY AND COMMERCE

                     FRANK PALLONE, Jr., New Jersey
                                 Chairman
BOBBY L. RUSH, Illinois              CATHY McMORRIS RODGERS, Washington
ANNA G. ESHOO, California              Ranking Member
DIANA DeGETTE, Colorado              FRED UPTON, Michigan
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          BRETT GUTHRIE, Kentucky
KATHY CASTOR, Florida                DAVID B. McKINLEY, West Virginia
JOHN P. SARBANES, Maryland           ADAM KINZINGER, Illinois
JERRY McNERNEY, California           H. MORGAN GRIFFITH, Virginia
PETER WELCH, Vermont                 GUS M. BILIRAKIS, Florida
PAUL TONKO, New York                 BILL JOHNSON, Ohio
YVETTE D. CLARKE, New York           BILLY LONG, Missouri
KURT SCHRADER, Oregon                LARRY BUCSHON, Indiana
TONY CARDENAS, California            MARKWAYNE MULLIN, Oklahoma
RAUL RUIZ, California                RICHARD HUDSON, North Carolina
SCOTT H. PETERS, California          TIM WALBERG, Michigan
DEBBIE DINGELL, Michigan             EARL L. ``BUDDY'' CARTER, Georgia
MARC A. VEASEY, Texas                JEFF DUNCAN, South Carolina
ANN M. KUSTER, New Hampshire         GARY J. PALMER, Alabama
ROBIN L. KELLY, Illinois, Vice       NEAL P. DUNN, Florida
    Chair                            JOHN R. CURTIS, Utah
NANETTE DIAZ BARRAGAN, California    DEBBBIE LESKO, Arizona
A. DONALD McEACHIN, Virginia         GREG PENCE, Indiana
LISA BLUNT ROCHESTER, Delaware       DAN CRENSHAW, Texas
DARREN SOTO, Florida                 JOHN JOYCE, Pennsylvania
TOM O'HALLERAN, Arizona              KELLY ARMSTRONG, North Dakota
KATHLEEN M. RICE, New York
ANGIE CRAIG, Minnesota
KIM SCHRIER, Washington
LORI TRAHAN, Massachusetts
LIZZIE FLETCHER, Texas
                                 ------                                

                           Professional Staff

                   JEFFREY C. CARROLL, Staff Director
                TIFFANY GUARASCIO, Deputy Staff Director
                  NATE HODSON, Minority Staff Director
                         Subcommittee on Health

                       ANNA G. ESHOO, California
                                Chairwoman
G. K. BUTTERFIELD, North Carolina    BRETT GUTHRIE, Kentucky
DORIS O. MATSUI, California            Ranking Member
KATHY CASTOR, Florida                FRED UPTON, Michigan
JOHN P. SARBANES, Maryland, Vice     MICHAEL C. BURGESS, Texas
    Chair                            H. MORGAN GRIFFITH, Virginia
PETER WELCH, Vermont                 GUS M. BILIRAKIS, Florida
KURT SCHRADER, Oregon                BILLY LONG, Missouri
TONY CARDENAS, California            LARRY BUCSHON, Indiana
RAUL RUIZ, California                MARKWAYNE MULLIN, Oklahoma
DEBBIE DINGELL, Michigan             RICHARD HUDSON, North Carolina
ANN M. KUSTER, New Hampshire         EARL L. ``BUDDY'' CARTER, Georgia
ROBIN L. KELLY, Illinois             NEAL P. DUNN, Florida
NANETTE DIAZ BARRAGAN, California    JOHN R. CURTIS, Utah
LISA BLUNT ROCHESTER, Delaware       DAN CRENSHAW, Texas
ANGIE CRAIG, Minnesota               JOHN JOYCE, Pennsylvania
KIM SCHRIER, Washington              CATHY McMORRIS RODGERS, Washington 
LORI TRAHAN, Massachusetts               (ex officio)
LIZZIE FLETCHER, Texas
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. Brett Guthrie, a Representative in Congress from the 
  Commonwealth of Kentucky, 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. Cathy McMorris Rodgers, a Representative in Congress from 
  the State of Washington, opening statement.....................     9
    Prepared statement...........................................    11

                               Witnesses

Katie Keith, Associate Research Professor and Adjunct Professor 
  of Law, Georgetown University..................................    12
    Prepared statement...........................................    15
Dean Cameron, Director, Idaho Department of Insurance............    26
    Prepared statement...........................................    28
    Answers to submitted questions...............................   194
Cindy Mann, Partner, Manatt, Phelps & Phillips, LLP..............    32
    Prepared statement...........................................    35
Marni Jameson Carey, Executive Director, Association of 
  Independent Doctors............................................    42
    Prepared statement...........................................    44
Laura LeBrun Hatcher, Board Vice President, Little Lobbyists.....    49
    Prepared statement...........................................    51

                           Submitted Material

H.R. 1790, the Fair Indexing for Health Care Affordability Act, 
  submitted by Ms. Eshoo\1\
H.R. 1796, the Health Care Enrollment Innovation Act, submitted 
  by Ms. Eshoo\1\
H.R. 1872, the Marketing and Outreach Restoration to Empower 
  (MORE) Health Education Act of 2021, submitted by Ms. Eshoo\1\
H.R. 1874, the Expand Navigators' Resources for Outreach, 
  Learning, and Longevity (ENROLL) Act of 2021, submitted by Ms. 
  Eshoo\1\
H.R. 1875, a bill to amend title XXVII of the Public Health 
  Service Act to eliminate the short-term limited duration 
  insurance exemption with respect to individual health insurance 
  coverage, submitted by Ms. Eshoo\1\
H.R. 1878, the State Health Care Premium Reduction Act of 2021, 
  submitted by Ms. Eshoo\1\
H.R. 1890, the Health Care Consumer Protection Act, submitted by 
  Ms. Eshoo\1\
H.R. 1896, the State Allowance for Variety of Exchanges (SAVE) 
  Act of 2021, submitted by Ms. Eshoo\1\
H.R. 340, the Incentivizing Medicaid Expansion Act of 2021, 
  submitted by Ms. Eshoo\1\

----------

\1\ The proposed legislation has been retained in committee files and 
is available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=111378.
H.R. 1738, the Stabilize Medicaid and CHIP Coverage Act, 
  submitted by Ms. Eshoo\1\
H.R. 1784, the Medicaid Report on Expansion of Access to Coverage 
  for Health Care (Medicaid REACH) Act, submitted by Ms. Eshoo\1\
H.R. 1025, the Kids' Access to Primary Care Act of 2021, 
  submitted by Ms. Eshoo\1\
H.R. 66, the Comprehensive Access to Robust Insurance Now 
  Guaranteed (CARING) for Kids Act, submitted by Ms. Eshoo\1\
H.R. 1791, the Children's Health Insurance Program Permanency 
  (CHIPP) Act, submitted by Ms. Eshoo\1\
H.R. 1888, the Improving Access to Indian Health Services Act, 
  submitted by Ms. Eshoo\1\
H.R. 1717, a bill to amend title XIX of the Social Security Act 
  to make permanent the protections under Medicaid for recipients 
  of home and community-based services against spousal 
  impoverishment, submitted by Ms. Eshoo\1\
H.R. 1880, a bill to amend the Deficit Reduction Act of 2005 to 
  make permanent the Money Follows the Person Rebalancing 
  Demonstration, submitted by Ms. Eshoo\1\
H.R. 1390, the Children's Health Insurance Program Pandemic 
  Enhancement and Relief (CHIPPER) Act, submitted by Ms. Eshoo\1\
Letter of March 22, 2021, from Alpha-1 Foundation, et al., to Mr. 
  Pallone, et al., submitted by Ms. Eshoo........................   108
Letter of March 22, 2021, from Brian Connell, Executive Director 
  of Federal Affairs, Leukemia & Lymphoma Society, to Mr. 
  Pallone, et al., submitted by Ms. Eshoo........................   110
Profile, ``Advocate Spotlight: Meet Katrina,'' Leukemia & 
  Lymphoma Society, submitted by Ms. Eshoo.......................   114
Statement of Sam Bloechl of Lemont, IL, March 23, 2021, submitted 
  by Ms. Eshoo...................................................   115
Letter of March 23, 2021, from Bill Sweeney, Senior Vice 
  President, Government Affairs, AARP, to Mr. Pallone, et al., 
  submitted by Ms. Eshoo.........................................   118
Summary, ``Covered California's Approach to Promoting the 
  American Rescue Plan: Target Groups and Strategic Approaches,'' 
  Covered California, March 18, 2021, submitted by Ms. Eshoo.....   121
Report, ``Covered California Announces American Rescue Plan 
  Roadmap to Lower Premiums and Help Millions Get Covered,'' 
  Covered California, March 18, 2021, submitted by Ms. Eshoo\1\
Statement of the American College of Physicians, March 23, 2021, 
  submitted by Ms. Eshoo.........................................   130
Letter of March 16, 2021, from the Academic Pediatric 
  Association, et al., to Ms. Schrier, et al., submitted by Ms. 
  Eshoo..........................................................   136
Statement of Laura Packard of Las Vegas, NV, March 23, 2021, 
  submitted by Ms. Eshoo.........................................   140
Letter of March 23, 2021, from Ann Greiner, President and Chief 
  Executive Officer, Primary Care Collaborative, to Mr. Pallone, 
  et al., submitted by Ms. Eshoo.................................   142
Statement of the Partnership to Empower Physician-Led Care by 
  Kristen McGovern, Executive Director, March 23, 2021, submitted 
  by Ms. Eshoo...................................................   146
House Energy and Commerce Committee Democratic Staff Report, 
  ``Shortchanged: How the Trump Administration's Expansion of 
  Junk Short-Term Health Insurance Plans is Putting Americans at 
  Risk,'' June 2020, submitted by Ms. Eshoo\1\
Letter of September 25, 2020, from Phillip A. Swagel, Director, 
  Congressional Budget Office, to Hon. Tammy Baldwin, U.S. 
  Senate, submitted by Ms. Eshoo.................................   150
Brief, ``Obamacare's Health Insurance Exchanges in 2021: 
  Increased Options, but Still Less Than Pre-ACA,'' by Edmund F. 
  Haislmaier and Abigail Slagle, Heritage Foundation, March 16, 
  2021, submitted by Ms. Eshoo...................................   159

----------

\1\ The proposed legislation and the Covered California and committee 
Democratic staff reports have been retained in committee files and are 
available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=111378.
Brief, ``Obamacare Has Doubled the Cost of Individual Health 
  Insurance,'' by Edmund F. Haislmaier and Abigail Slagle, 
  Heritage Foundation, March 21, 2021, submitted by Ms. Eshoo....   167
Report, ``Individual Health Insurance Markets Improving in States 
  that Fully Permit Short-Term Plans,'' by Brian Blase, Ph.D., 
  Galen Institute, February 2021, submitted by Ms. Eshoo\2\
Letter of March 23, 2021, from Andrew Lantz, Director of Federal 
  Policy, National Taxpayers Union, to Ms. Eshoo and Mr. Guthrie, 
  submitted by Ms. Eshoo.........................................   175
Article of March 3, 2021, ``More Money Without Reform for 
  Obamacare,'' by Chris Pope, RealClear Health, submitted by Ms. 
  Eshoo..........................................................   183
Summary, ``Questions and Answers about the Democrats' Proposal to 
  Expand Obamacare Subsidies,'' Galen Institute, submitted by Ms. 
  Eshoo..........................................................   186
Fact sheet, ``Protect Access to Affordable Coverage for 3 Million 
  Americans,'' Galen Institute, submitted by Ms. Eshoo...........   192

----------

\2\ The report has been retained in committee files and is available at 
https://docs.house.gov/meetings/IF/IF14/20210323/111378/HHRG-117-IF14-
20210323-SD014.pdf.

 
 BUILDING ON THE ACA: LEGISLATION TO EXPAND HEALTH COVERAGE AND LOWER 
                                 COSTS

                              ----------                              


                        TUESDAY, MARCH 23, 2021

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 11:00 a.m., via 
Cisco Webex online video conferencing, Hon. Anna G. Eshoo 
(chairwoman of the subcommittee) presiding.
    Members present: Representatives Eshoo, Butterfield, 
Matsui, Castor, Sarbanes, Welch, Schrader, Cardenas, Ruiz, 
Dingell, Kuster, Kelly, Barragan, Blunt Rochester, Craig, 
Schrier, Trahan, Fletcher, Pallone (ex officio), Guthrie 
(subcommittee ranking member), Burgess, Griffith, Bilirakis, 
Long, Bucshon, Hudson, Carter, Dunn, Curtis, Crenshaw, Joyce, 
and Rodgers (ex officio).
    Also present: Representatives Rush, Schakowsky, Veasey, and 
O'Halleran.
    Staff present: Jeffrey C. Carroll, Staff Director; Waverly 
Gordon, General Counsel; Tiffany Guarascio, Deputy Staff 
Director; Perry Hamilton, Clerk; Saha Khaterzai, Professional 
Staff Member; Mackenzie Kuhl, Digital Assistant; Una Lee, Chief 
Health Counsel; Meghan Mullon, Policy Analyst; Tim Robinson, 
Chief Counsel; Chloe Rodriguez, Clerk; Rick Van Buren, Health 
Counsel; C.J. Young, Deputy Communications Director; Sarah 
Burke, Minority Deputy Staff Director; Theresa Gambo, Minority 
Financial and Office Administrator; Grace Graham, Minority 
Chief Counsel, Health; Caleb Graff, Minority Deputy Chief 
Counsel, Health; Nate Hodson, Minority Staff Director; Peter 
Kielty, Minority General Counsel; Emily King, Minority Member 
Services Director; Clare Paoletta, Minority Policy Analyst, 
Health; Kristin Seum, Minority Counsel, Health; Kristen 
Shatynski, Minority Professional Staff Member, Health; Olivia 
Shields, Minority Communications Director; Michael Taggart, 
Minority Policy Director; and Everett Winnick, Minority 
Director of Information Technology.
    Ms. Eshoo. OK. Good morning, colleagues. The Subcommittee 
on Health will now come to order.
    Due to COVID-19, today's hearing is being held remotely. 
All Members and witnesses will be participating via 
videoconferencing.
    As part of our hearing, microphones will be set on mute to 
eliminate background noise, and Members and witnesses, remember 
to unmute your microphone each time you wish to speak.
    Documents for the record should be sent to Meghan Mullon at 
the email address we have provided to your staff. 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

    Ms. Eshoo. Senator Edward Kennedy wrote a letter to 
President Obama to be opened after his death, and in it he said 
that the cause of ensuring that, quote, ``the state of a 
family's health will never again depend on the amount of a 
family's wealth'' and was the ``great unfinished business of 
our society.''
    When President Biden signed the American Rescue Plan 
earlier this month, he took another step toward that unfinished 
cause. Covered California estimates that about 25 million 
Americans stand to benefit from the new and expanded subsidies 
to lower premium costs in the American Rescue Plan, including 3 
million Californians.
    For the millions of people who collected unemployment 
insurance at any time this year, they can now get covered by a 
health plan with a zero premium and added help to lower the 
cost of deductibles and copayments.
    After 4 years where millions of Americans who depended on 
the ACA lived in daily fear that they would lose their health 
insurance because of a decision by the former President, I have 
good news: Your ACA coverage is safe, and it is a lot more 
affordable.
    But the cause is still unfinished, especially in the 14 
States that have not yet expanded Medicaid. In those States, 
about 4.3 million Americans are locked out of health coverage, 
despite being poor, because their Governors or State 
legislatures have so far refused to expand Medicaid.
    Let's take Texas, for example. According to the nonpartisan 
Kaiser Family Foundation, if you are a parent in a family of 
three and make more than $3,700 a year, you would be making too 
much to be eligible for Medicaid.
    If you are an adult without kids in Georgia, North 
Carolina, Florida, Texas, or any of the other States that did 
not expand Medicaid, you are ineligible for Medicaid even if 
you have no job and no income.
    There is not any healthcare safety net for childless adults 
in those 14 States either.
    The American Rescue Plan offers those 14 States as much as 
$22.7 billion to correct this injustice. This Federal support 
is in addition to the guarantee that the Federal Government 
will pay for 90 percent of the cost of expanding Medicaid to 
this new population.
    Beyond Medicaid expansion, unfinished business remains. 
Today we will consider 18 bills, many of them bipartisan, to 
increase enrollment, lower costs, and improve coverage, 
especially for children and people with disabilities.
    To help us better understand how to finally achieve our 
North Star of universal healthcare, we will also hear testimony 
from experts on Medicaid and private insurance, as well as from 
the patient and provider perspective. And we all look forward 
to the testimony that we believe will be highly instructive.
    Senator Kennedy closed his letter to President Obama with 
the following, quote: ``What we face is, above all, a moral 
issue that at stake are not just the details of policy, but 
fundamental principles of social justice and the character of 
our country.''
    Today on the 11th anniversary of the passage of the 
Affordable Care Act, we will consider the details of the 
policies before us. But let's also work to restore the 
character of our country through this important work as well.
    [The prepared statement of Ms. Eshoo follows:]

                Prepared Statement of Hon. Anna G. Eshoo

    Senator Edward Kennedy wrote a letter to President Obama to 
be opened after his death and in it he said that the cause of 
ensuring that ``the state of a family's health will never again 
depend on the amount of a family's wealth'' was the ``great 
unfinished business of our society.''
    When President Biden signed the American Rescue Plan 
earlier this month, he took another step toward that unfinished 
cause.
    Covered California estimates that about 25 million 
Americans stand to benefit from the new and expanded subsidies 
to lower premium costs in the American Rescue Plan, including 3 
million Californians.
    For the millions of people who collected unemployment 
insurance at any time this year, they can now get covered by a 
health plan with a $0 premium and added help to lower the cost 
of deductibles and copayments.
    After four years where millions of Americans who depended 
on the ACA lived in daily fear that they'd lose their health 
insurance because of a decision by the former President, I have 
good news: Your ACA coverage is safe and it's a lot more 
affordable.
    But the cause is still unfinished, especially in the 14 
States that have not yet expanded Medicaid.
    In those States, about 4.3 million Americans are locked out 
of health coverage despite being poor because their Governors 
or State legislatures has so far refused to expand Medicaid.
    Let's take Texas for example. According to the nonpartisan 
Kaiser Family Foundation, if you're a parent in a family of 
three and make more than about $3,700 per year, you'd make too 
much to be eligible for Medicaid.
    If you're an adult without kids in Georgia, North Carolina, 
Florida, Texas, or any of the other States that did not expand 
Medicaid yet, you're ineligible for Medicaid even if you have 
no job or income. There isn't any healthcare safety net for 
childless adults in those 14 states.
    The American Rescue Plan offers those 14 States as much as 
$22.7 billion to correct this injustice. This Federal support 
is in addition to the guarantee that the Federal Government 
will pay for 90% of the cost of expanding Medicaid to this new 
population.
    Beyond Medicaid expansion, unfinished business remains.
    Today we'll consider 18 bills, many of them bipartisan, to 
increase enrollment, lower costs, and improve coverage, 
especially for children and people with disabilities.
    To help us better understand how to finally achieve our 
North Star of universal healthcare, we'll also hear testimony 
from experts on Medicaid and private insurance, as well as from 
the patient and provider perspective. I look forward to each of 
your instructive testimonies.
    Senator Ted Kennedy closed his letter to President Obama 
with the following: ``What we face is above all a moral issue; 
that at stake are not just the details of policy, but 
fundamental principles of social justice and the character of 
our country.''
    Today, on the eleventh anniversary of the passage of the 
Affordable Care Act, let's consider the details of the policy 
before us, but let's also restore the character of our country 
through this important work as well.

    Ms. Eshoo. The Chair now recognizes Mr. Guthrie, the 
ranking member of our subcommittee, for 5 minutes for his 
opening statement.
    And remember to unmute. It is great to see you, Brett.

 OPENING STATEMENT OF HON. BRETT GUTHRIE, A REPRESENTATIVE IN 
           CONGRESS FROM THE COMMONWEALTH OF KENTUCKY

    Mr. Guthrie. Great to see you. Thank you, Chair Eshoo, and 
thanks for holding this hearing.
    However, I do think we have other pressing or more pressing 
items that we should be looking at within our jurisdiction 
before looking at how to fix the Affordable Care Act.
    We have a crisis at the border where HHS Office is taking 
charge of taking care of unaccompanied children, and they are 
being overwhelmed. Some reports indicate there are over 15,000 
children in their control where there are only 13,000 licensed 
beds for them.
    We should also be looking at the impact of COVID-19 on 
mental health and substance abuse disorders, including programs 
this committee worked in the past, in CARA, 21st Century Cures, 
and the SUPPORT Act.
    We also need to be examining how to lower healthcare costs. 
This hearing's title does discuss lowering healthcare costs, 
but I am not sure the bills today do, but rather the bills 
continue to subsidize expensive insurance.
    The majority has called us here to look at ways to shore up 
the Affordable Care Act, which became law 11 years ago and is 
still not working. The ACA has increased premiums dramatically, 
and many insurers stopped offering coverage.
    In my home State, Kentucky was found to have the sixth-
largest rate increase in annual health insurance premiums at 27 
percent over a 6-year period. This is not sustainable for 
workers and families.
    Democrats have chosen to address it by pumping more money 
into the Affordable Care Act and limiting State flexibility 
instead of addressing what is the real problem: the high cost 
of healthcare.
    Even the generous subsidies that Congress just passed this 
morning are apparently not enough to make these insurance plans 
attractive, as we are back again to discuss more spending.
    By my account, on top of the $1.9 trillion that was just 
spent, today we are discussing at least another $45 billion or 
so based on scores I could find from the last Congress. 
Compared to $1.9 trillion, $45 billion may be small, but it is 
almost the entire annual budget of the National Institutes of 
Health.
    Before we authorize billions more on top, we need to first 
see how the funding from the $1.9 trillion law which has now 
been allocated--we need to see how it is being spent and where 
are the remaining gaps.
    We also need to be looking at innovative ways to lower 
healthcare costs. Today we are reviewing recycled language from 
six bills, two from the 2019 Energy and Commerce hearings. For 
example, the bill giving grants for State exchanges does not 
even update the date from January 1, 2019.
    So States like New Jersey that have already established an 
exchange since our last hearing could get funding from this 
grant.
    Additionally, I am concerned with banning short-term, 
limited-duration plans. CBO has estimated that, if the 
regulations are rolled back on these plans, 500,000 Americans 
will lose healthcare coverage. Instead of limiting plans, I 
think we need to allow States flexibility to best serve their 
residents.
    Of the 10 Medicaid bills, I specifically want to mention 
Money Follows the Person. This program is valuable for many 
individuals, and I am a champion of this program. Congress just 
extended MFP in December, which made important changes to the 
program. It is premature, in my opinion, to consider a 
permanent MFP extension before we know the impact of those 
changes.
    I also want to note that, while the Democrats have called 
this hearing to talk about building on the Affordable Care Act, 
over 100 Democrats, including the chairman of this committee 
and 15 other members of this committee, introduced legislation 
that would ban ACA plans and Medicaid coverage and replace it 
with a one-size-fits-all, government-run healthcare system for 
everyone.
    I am concerned that innovation would stop fully under a 
government-run healthcare insurance program and, according to 
the Heritage Foundation, would decrease the average annual 
American household disposable income by $5,600, or 11 percent.
    Let us not forget what we were told about the ACA: ``If you 
like your plan, you can keep it.'' Well, today we have bills 
before us that would do just the opposite, again, by limiting 
State flexibility and stopping short-term, limited-duration 
plans.
    But that would be nothing compared to the over 220 million 
Americans who would lose their health insurance under Medicare 
for All.
    I hope we will learn today about some of the unintended 
consequences of the legislation before us and change course to 
work together to come up with plans that will actually lower 
healthcare costs. Americans, not the government, should have 
the right to pick what health insurance and doctor is right for 
them.
    I thank you for the time, and I yield back.
    [The prepared statement of Mr. Guthrie follows:]

                Prepared Statement of Hon. Brett Guthrie

    Chair Eshoo, thank you for holding this hearing. It is 
another day in the Energy Commerce Committee where the 
Democrats continue to only bring up partisan bills. All while 
we have a border crisis on our hands and are still in a global 
pandemic.
    Obamacare:
    The ACA increased premiums dramatically and many insurers 
stopped offering coverage. Before the ACA, ----; in 2015, ----
--. Since the last time we met on these bills in 2019, however, 
actions by States and the Trump administration have led to 
insurers come back into markets and a stabilizing or even 
lowering of premiums. However, it is still too expensive and 
not working for patients and families across the country.
    This is evident by the need for my colleagues across the 
aisle to increase subsidies in the $1.9 trillion spending 
package. Besides the fact that Democrats continue to push the 
cost of ever rising healthcare costs on taxpayers, rather than 
address the cost of healthcare, these tax credits were not 
targeted.
    For example, a family with an income of XXX will get XX.
    Bill break down:
    Even the generous subsidies are not enough to make these 
plans attractive, apparently, as we are back again to discuss 
more spending and fixes. The 18 bills we are discussing today 
double down on this partisan approach to spend more money to 
subsidize ever-increasing healthcare costs. By my count, on top 
of the $1.9 trillion Democrats just spent, today we are 
discussing at least another $45 billion or so based on scores I 
could find from last Congress. And that doesn't even include 
all 18 bills. Compared to $1.9 trillion, $45 billion may sound 
small, but that is almost the entire annual budget of the 
National Institutes of Health.
    I don't have time to go through all the bills, but of the 
six that were actually part of two 2019 hearings in Energy and 
Commerce, the text is almost identical. The bill giving grants 
for State exchanges, for example, doesn't even update the date 
from Jan. 1, 2019 to next year--so States like New Jersey that 
have already established an exchange since our last hearing 
could get funding from this grant.
    States have continued to innovate in the last 2 years to 
try to do what they can with the limited flexibility they have 
under the Affordable Care Act to find alternative options for 
their citizens. I am glad Mr. Cameron is here today to tell us 
how he's worked to stabilize the Idaho insurance market, and 
make sure this committee is aware of how these bills will upset 
his good progress and end up with fewer people in Idaho having 
insurance.
    The 10 Medicaid bills are new, and we were not consulted at 
all. I specifically want to mention Money Follows the Person 
(MFP). This program is valuable for many individuals and I am a 
champion of this program. Congress just extended MFP in 
December, making important changes to the program. It is 
premature in my opinion to consider a permanent MFP extension 
before we know the impact of those changes. Especially when 
there are so many other items worthy of this committee's 
attention, such as:
     Crisis at the border, where the HHS office in 
charge of taking care of unaccompanied children are 
overwhelmed. Just this weekend another facility had to be 
opened, as some reports indicate there are over 15,000 children 
in their control while over 13,000 licensed beds for them.
     The impact of COVID-19 on mental health and 
substance use disorders, including if the programs this 
committee worked to pass in CARA and 21st Century Cures, passed 
in 2016, and the SUPPORT Act in 2018, have been responding to 
the surge in demand.
     Increase in healthcare costs. This hearing title 
discusses ``lowering costs,'' but I'm not sure the bills today 
do so, or just continue subsidizing expensive insurance. I am 
glad Ms. Carey is here to discuss some of the drivers of 
healthcare costs and what we can do about it.
    Medicare for All:
    I also want to note that while the Democrats have called 
this hearing to look at 18 bills and talk about building on the 
ACA, over 100 Democrats, including Chairman Pallone and 15 
other members of Energy and Commerce, introduced legislation 
that would ban ACA plans and Medicaid coverage, and replace it 
with one size fits all, government run healthcare for everyone.
    Let us not forget, what we were all told about the ACA--if 
you like your plan you can keep it.
    Well today we have bills before us that would do just the 
opposite by limiting and stopping short term duration plans, 
but that would be nothing compared to the ------of Americans 
that would lose their health insurance under Medicare for All.
    Conclusion
    I hope that Democrats will learn about some of the 
unintended consequences of the partisan legislation before us 
today and change course to work with us to lower healthcare 
costs while trusting Americans to make the right choice for 
themselves on what health insurance is right for them and what 
doctor to see.

    Ms. Eshoo. The gentleman yields back.
    The Chair now recognizes the chairman of the full 
committee, Mr. Pallone, for your 5 minutes for an opening 
statement.

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

    Mr. Pallone. Thank you, Chairwoman Eshoo.
    And this is a very important hearing. Today is the 11th 
anniversary of President Obama signing the Affordable Care Act 
into law, and the bottom line is, contrary to what our ranking 
member just said, is that the ACA has worked.
    Many millions of people have health insurance now who would 
not have had it without the ACA. I am amazed that with the 
Republican efforts to basically repeal it or basically cut it 
back that it is still around. It shows its resiliency. It shows 
how people really want it, despite all of the rhetoric on the 
Republican side, and particularly by President Trump, who has 
said it should be abolished.
    But I do want to say in response to Mr. Guthrie that, look, 
we do not want to cut healthcare for the sake of lowering cost. 
My concern has always been that, with these junk plans that did 
not provide essential services, people buy them thinking that 
they are going to have coverage when they do not.
    And so I would agree with you that when you provide--and I 
do not know if that is what you meant--but when you provide a 
lot of services--because our hallmark of the ACA has been that 
you have to have essential services--when you do that, it 
sometimes costs more.
    But the answer is not to take a meat ax and say, well, we 
will get rid of it and sell you a junk plan.
    I remember going before the Rules Committee, and I love 
Virginia Foxx. She is a friend, but you know, she basically 
said at one point that there were plans that were being sold 
that did not include hospitalization, and that that was OK if 
people wanted that.
    But to me, you know, if you buy a plan that does not have 
hospitalization, you do not have health insurance coverage. So, 
you know, keep in mind that the answer is to make things 
affordable, but not in a way that eliminates services like 
hospitalization and mental health and some of these other 
things that are what we get with the junk plans.
    In any case, earlier this month Democrats and President 
Biden signed into law the American Rescue Plan, which is the 
largest expansion of healthcare coverage since the passage of 
the ACA, and that builds on the ACA so that healthcare is more 
affordable and more accessible for Americans at a time when 
they are struggling financially and when coverage is so 
essential.
    The new law expands the ACA's tax subsidies, including for 
the first time to Americans with incomes above 400 percent of 
the Federal poverty line. Millions of Americans will gain 
healthcare coverage and see the cost of their monthly insurance 
premiums go down.
    Just as an example, a family of four with an annual income 
of $65,000 will save $2,800 each year. A family of four with an 
annual income of $100,000 will save $7,000 annually, and this 
is a huge benefit considering this item did not qualify for 
premium subsidies before the American Rescue Plan.
    It also provides an incentive for States, a new incentive 
for States, to expand Medicaid by increasing the Federal 
Medical Assistance Percentage, or FMAP, of new expansion States 
by 5 percentage points for 2 years.
    And finally, the American Rescue Plan takes steps to 
address disparities in coverage that have been laid bare by the 
COVID pandemic by creating a new State option to provide 
continuous Medicaid eligibility for 12 months post partum and 
provides billions in additional funding for home and community-
based services, or HCBS's.
    Now, you know, the 18 bills that we have before us today 
build on the accomplishments of the ACA and the American Rescue 
Plan and will make a real difference in people's lives, and 
these bills fix the 4 years of sabotage on our healthcare 
system from the previous Trump administration.
    We're going to talk about all of these, but I just wanted 
to mention initially because my time is going to run out 
Representative Castor's bill that will require short-term plans 
to comply with the ACA's consumer protections and offer 
comprehensive coverage.
    Last year our committee's investigation found that millions 
of Americans are enrolled in these short-term or junk plans 
that offer bare-bones coverage, discriminate against people 
with preexisting conditions, and leave patients saddled with 
thousands of dollars of medical debt. These junk plans have no 
place in our healthcare system as they are structured today, 
and that is why we have to ensure they are required to comply 
with the ACA's consumer protection.
    I am not going to go into the other bills, but I do want to 
stress again we want to bring costs down, but we also do not 
want to allow people to buy coverage that does not include 
essential benefits like hospitalization because, without that, 
you do not really have healthcare coverage.
    And many people buy these junk plans, and they are duped. 
They think it covers whatever condition they have and then find 
out later that it does not when it is too late.
    So with that, Madam Chair, thank you again. This is a very 
important hearing to say what we can do to make the ACA 
coverage even more expansive and less expensive in the long 
run.
    Thank you, Madam Chair.
    [The prepared statement of Mr. Pallone follows:]

             Prepared Statement of Hon. Frank Pallone, Jr.

    Today, on the 11th anniversary of President Obama signing 
the Affordable Care Act (ACA) into law, the committee is 
considering a slate of bills that reflect Democrats' continued 
commitment to make healthcare more affordable and accessible 
for all Americans.
    Earlier this month, Democrats passed and President Biden 
signed into law the American Rescue Plan Act of 2021, which is 
the largest expansion of healthcare coverage since the passage 
of the ACA. The landmark legislation builds on the ACA so that 
healthcare is more affordable and more accessible for Americans 
at a time when they are struggling financially and when 
coverage is so essential.
    The new law expands the ACA's tax subsidies, including for 
the first time to Americans with income above 400 percent of 
the Federal poverty line. Millions of Americans will gain 
healthcare coverage and see the cost of their monthly insurance 
premiums go down. Consider these examples. A family of four 
with an annual income of $65,000 will save $2,800 each year. A 
family of four with an annual income of $100,000 will save 
$7,000 annually--and this is a huge benefit considering this 
family did not qualify for premium subsidies before the 
American Rescue Plan.
    The new law also provides a new incentive for States to 
expand Medicaid by increasing the Federal Medical Assistance 
Percentage, or FMAP, of new expansion States by five percentage 
points for two years. Finally, the American Rescue Plan takes 
steps to address disparities in coverage that have been laid 
bare by the COVID-19 pandemic by creating a new 2tate option to 
provide continuous Medicaid eligibility for 12 months post 
partum and provides billions in additional funding for home- 
and community-based services, or HCBS.
    The American Rescue Plan only marks the beginning of our 
work to lower healthcare costs and further expand coverage. The 
18 bills before us today build on the accomplishments of the 
ACA and the American Rescue Plan Act and will make a real 
difference in people's lives. These bills also fix the four 
years of sabotage on our healthcare system from the previous 
Trump administration.
    We will be discussing Representative Castor's bill that 
will require short-term plans to comply with the ACA's consumer 
protections and offer comprehensive coverage. Last year, our 
committee's investigation found that millions of Americans are 
enrolled in these short-term or junk plans that offer bare 
bones coverage, discriminate against people with preexisting 
conditions and leave patients saddled with thousands of dollars 
in medical debt. These junk plans have no place in our 
healthcare system as they are structured today and that's why 
we must ensure they are required to comply with ACA's consumer 
protections.
    Other bills before us today would further expand coverage 
and reduce out-of-pocket costs for American families. 
Representative Craig's bill would provide $10 billion annually 
to States to set up their own reinsurance programs to help 
lower premiums. States may also use this funding to provide 
direct financial assistance to their State residents to lower 
their out-of-pocket costs. Representative Kim's bill would 
provide States the opportunity to create State-based Exchanges 
and tailor the program to meet the needs of their State 
residents.
    Representative Blunt Rochester's bill restores consumer 
outreach and enrollment funding and another bill introduced by 
Representative Castor would restore funding to the navigator 
program. These bills are important considering the Trump 
administration significantly scaled back this funding that 
helps make healthcare more accessible and affordable.
    Finally, we will be considering a number of bills today 
that will strengthen Medicaid and the Children's Health 
Insurance Program or CHIP. During this severe economic 
downturn, these programs are vital safety nets for low-income 
families. As of September 2020, Medicaid enrollment had 
increased by six million people to cover over 77 million 
Americans.
    Under Representative Dingell's bill, these individuals 
would be guaranteed continuity of coverage for 12 months, 
ensuring that they don't experience harmful disruptions in 
access to care. We will also discuss Representative Barragan's 
bill to permanently authorize funding for CHIP and provide 
States the option to increase Medicaid and CHIP eligibility 
levels for children, making it easier for lower-income families 
to access affordable health insurance. Representative Upton's 
bill would make permanent critical beneficiary protections for 
spouses of Medicaid HCBS recipients.
    These are just some of the bills that we have before us 
today. Collectively, they expand access to care, make 
healthcare more affordable, and help reduce racial and ethnic 
health coverage disparities. I look forward to the discussion, 
and I yield back.

    Ms. Eshoo. The gentleman yields back.
    The Chair now is pleased to recognize the ranking member of 
the full committee, Congresswoman Cathy McMorris Rodgers, for 
your 5 minutes for an opening statement.

      OPENING STATEMENT OF HON. CATHY McMORRIS RODGERS, A 
    REPRESENTATIVE IN CONGRESS FROM THE STATE OF WASHINGTON

    Mrs. Rodgers. Good morning, Madam Chair, and to all my 
colleagues, good morning.
    Mr. Guthrie discussed some of the concerns with the 18 
bills before us, and I am not going to talk further about those 
bills. These bills, unfortunately, divided Republicans and 
Democrats in 2019, and I am disappointed that we continue to 
focus on what is dividing us.
    Instead I want to talk about what we can accomplish in 
healthcare when we work together, and ask that we continue to 
build on our past bipartisan successes and lower healthcare 
costs I hear about every day from constituents in Eastern 
Washington.
    With the fast-paced, partisan, and polarized start to this 
year, I want to remind my colleagues that this committee worked 
together to lower healthcare costs for the American people last 
Congress. The December omnibus and COVID relief bill was large, 
and so you may have missed that it included the most 
significant legislation to reduce healthcare cost in over a 
decade.
    The December bill included solutions we worked together on 
to end surprise medical billing for patients, saving the 
government almost $20 billion in the process by lowering 
premiums.
    Provide long-term funding for public health, Medicare and 
Medicaid programs, and we fully offset that spending.
    Improved transparency so employers who provide health 
insurance for their employees have a right to find out the cost 
of what they are buying.
    Support for rural and underserved areas by increasing 
funding and providing more flexibility for hospitals in those 
areas.
    Provide funding so that Medicaid enrollees with life-
threatening conditions can participate in clinical trials.
    Address drug prices by requiring reporting to Health and 
Human Services.
    And closing loopholes that may delay competition, and many 
more.
    There are more opportunities for us to work together and 
build on the great work of last Congress. We can work together 
to modernize the Medicare Part D program, to reduce what 
seniors pay for prescription drugs out of their own pockets.
    We could also examine the drivers of healthcare 
consolidation, which is contributing to ever-increasing 
healthcare costs.
    I want to hear about how mental health and substance abuse 
disorder programs are working and how we can improve them, 
especially in light of the epidemics of despair made worse by 
COVID-19.
    We have also seen breakthrough innovation in the last year 
for COVID-19. Let's work together to find out what lessons we 
can take away from that and how to apply them to find cures for 
other diseases like ALS and Alzheimer's.
    Lastly, we must figure out how we can be better prepared 
against future pandemics.
    However, the bills today show us that the majority is 
choosing to go down a path for government-run healthcare rather 
than have these important discussions. Their end goal would 
include kicking every American off their health insurance plan 
of choice, whether it is employer-based, Medicare Advantage, or 
plans through labor unions.
    Americans would lose the few coverage choices they have 
left to make personal decisions about what is best for their 
family and be forced into a one-size-fits-all, government-run 
healthcare program.
    Just last week half of the Democratic members of this 
committee introduced Medicare for All, including Chairman 
Pallone. We apparently will be having a hearing on that 
legislation at some point, according to the press reports.
    And the bills today continue us down the path towards 
socialized medicine that Obamacare started, expanding the use 
of Federal taxpayer dollars to subsidize, and removing patient 
choice by promoting the insurance the Federal Government thinks 
is best for you.
    My hope is that we can get to work in a bipartisan way soon 
to lower cost, increase transparency, address the mental health 
crisis, enable innovation, and prevent pandemics.
    Addressing just one of those issues would take months of 
work, but I stand ready and hopeful that we can get started on 
that in April.
    And I yield back.
    [The prepared statement of Mrs. Rodgers follows:]

           Prepared Statement of Hon. Cathy McMorris Rodgers

    Thank you, Chair Eshoo.
    Mr. Guthrie discussed some of the concerns with the 18 
bills before us, and I do not want to talk about those bills 
further. These bills divided Republicans and Democrats in 2019, 
and I am disappointed we continue to focus on what divides us.
    Instead, I want to talk about what we can accomplish in 
healthcare when we work together.
    . . . and ask that we continue to build on our past 
bipartisan successes and lower high healthcare costs I hear 
about from my constituents at home.
    [Health Care Wins in December]
    With the fast paced, partisan start to the year, I want to 
remind my colleagues how this committee worked together to 
lower healthcare costs for the American people last Congress.
    The December omnibus and COVID relief bill was large, and 
so you may have missed that it included the most significant 
legislation to reduce healthcare costs in over a decade.
    The December bill included solutions we worked together on 
to:
    . . . end surprise medical billing for patients, saving the 
government almost $20 billion in the process by lowering 
premiums
    . . . provide long-term funding for Public Health, 
Medicare, and Medicaid programs, and we fully offset that 
spending.
    . . . improve transparency, so employers who provide health 
insurance for their employees have the right to find out the 
cost of what they are buying
    . . . support for rural and underserved areas by increasing 
funding and providing more flexibility for hospitals in those 
areas
    . . . provide funding so that Medicaid enrollees with life-
threatening conditions can participate in clinical trials
    . . . address drug prices by requiring reporting to HHS and 
closing loopholes that may delay competition
    . . . and many more.
    [Opportunities to work together]
    There are more opportunities for us to work together and 
build on the great work of last Congress.
    We can work together to modernize the Medicare Part D 
program to reduce what seniors pay for prescription drugs out 
of their own pocket.
    We could also examine the drivers of healthcare 
consolidation, which contributes to ever increasing healthcare 
costs.
    I want to hear about how the mental health and substance 
use disorder programs are working and how we can improve them, 
especially in light of the epidemics of despair made worse by 
COVID-19.
    We have also seen breakthrough innovation in the last year 
for COVID-19.
    Let's work together to find out what lessons we can take 
away from that and how to apply them to find cures for other 
diseases like ALS and Alzheimer's.
    . . . Lastly, we must figure out how we can be better 
prepared against future pandemics.
    [Today/More of the Same]
    However, the bills before us today show the majority is 
choosing to go down a path toward government run healthcare, 
rather than have these important discussions.
    Their end goal is clear: kicking every American off their 
health insurance plan of choice.
    Whether it's employer-based, Medicare Advantage, or plans 
through labor unions, American would lose the few coverage 
choices they have left to make personal decisions about what is 
best for their families.
    . . . and be forced into a one-size-fits-all government-run 
healthcare program.
    Just last week, half the Democratic members of this 
committee introduced the Medicare For All Act, including 
Chairman Pallone. We apparently will have a hearing on that 
legislation at some point, according to press reports.
    And the bills today continue us down the path towards 
socialized medicine that Obamacare started ...
    . . . expanding the use of Federal taxpayer dollars to 
subsidize and removing patient choice by promoting the 
insurance the Federal Government thinks is best for you.
    My hope is that we can get to work in a bipartisan way soon 
to lower costs, increase transparency, address the mental 
health crisis, enable innovation, and prevent pandemics.
    Addressing just one of those issues could take months of 
work, but I stand ready and hopeful that we can get started on 
that in April.

    Ms. Eshoo. The gentlewoman yields back.
    The Chair would like to remind Members that, pursuant to 
committee rules, all Members' written opening statements shall 
be made part of the record.
    I now would like to introduce our witnesses, and we are so 
fortunate to have each one of them with us today.
    First, Ms. Katie Keith, associate research professor at 
Georgetown University. Welcome and thank you to you.
    Mr. Dean Cameron, director of the Idaho Department of 
Insurance. Welcome back to the subcommittee, Mr. Cameron. We 
are happy to see you and have you with us.
    Ms. Cindy Mann, partner at Manatt, Phelps & Phillips, and 
former director of the Center for Medicaid and CHIP Services.
    Ms. Marni Jameson Carey, executive director, Association of 
Independent Doctors. Welcome to you, and thank you for being 
with us.
    And Ms. Laura LeBrun Hatcher, board vice president of 
Little Lobbyists, just a really extraordinary advocate.
    So welcome to each one of you. Thank you for being with us.
    And, Ms. Keith, you are now recognized for 5 minutes for 
your testimony, and please remember to unmute.

  STATEMENTS OF KATIE KEITH, ASSOCIATE RESEARCH PROFESSOR AND 
ADJUNCT PROFESSOR OF LAW, GEORGETOWN UNIVERSITY; DEAN CAMERON, 
 DIRECTOR, IDAHO DEPARTMENT OF INSURANCE; CINDY MANN, PARTNER, 
MANATT, PHELPS & PHILLIPS, LLP; MARNI JAMESON CAREY, EXECUTIVE 
DIRECTOR, ASSOCIATION OF INDEPENDENT DOCTORS; AND LAURA LeBRUN 
        HATCHER, BOARD VICE PRESIDENT, LITTLE LOBBYISTS

                    STATEMENT OF KATIE KEITH

    Ms. Keith. Thank you and good morning. Thank you, 
Chairwoman Eshoo, Ranking Member Guthrie, and members of the 
subcommittee.
    My name is Katie Keith, and I am a faculty member at 
Georgetown University, where I study private health insurance.
    I am also the author of the Following the ACA blog series 
for the Journal of Health Affairs, where I am responsible for 
tracking and chronicling ongoing implementation of the 
Affordable Care Act.
    I am especially honored to appear before you today on the 
11th anniversary of the law, in mere weeks after enactment of 
the historic American Rescue Plan.
    The Affordable Care Act has already extended coverage to 20 
million Americans, helped narrow racial and ethnic disparities 
in coverage, and served as a critical part of the safety net 
throughout the pandemic.
    We have seen enrollment through Medicaid and the 
marketplaces increase during the pandemic as demand has surged, 
and Congress leveraged existing Affordable Care Act standards 
to quickly mandate the coverage of COVID-19 testing and 
vaccines.
    On the law's 11th anniversary, it is more than safe to say 
that millions of families who would otherwise be uninsured have 
been able to enroll in Medicaid or the marketplace and get the 
coverage that they need for COVID-19 treatment, testing, and 
vaccines.
    Simply put, the Affordable Care Act has been there for 
millions of Americans when they needed it most. Enrollment is 
only expected to increase under the American Rescue Plan.
    As you all know, affordability has long been a challenge 
for many, even before the pandemic. This has been especially 
true for older middle-income Americans living in rural areas, 
where costs tend to be the highest.
    We all recognize that families who did not receive 
financial help before have had to make very difficult 
decisions, including remaining uninsured or enrolling in 
noncomprehensive coverage options.
    Sadly, the media has been filled with stories of families 
who enrolled in these noncomprehensive options only to be left 
with devastating medical bills when their plan did not cover 
the healthcare that they need.
    Fortunately, the American Rescue Plan puts that behind us. 
The new law significantly increases financial help for lower-
income people and, for the first time ever, extends financial 
help to more middle-income Americans. Of the 14.9 million 
uninsured people who qualify for subsidies, 3.6 million of them 
are newly eligible based on their income.
    Savings will vary, but many middle-income people who 
purchase their own health insurance will soon see significant 
premium relief.
    The American Rescue Plan also helps with high deductibles 
that many consumers have struggled with in recent years. More 
people will be able to afford a plan that is much more generous 
than in the past, which means lower deductibles and lower out-
of-pocket costs.
    Millions will be able to find a Silver Marketplace plan for 
$10 a month or less or opt into more generous Gold coverage 
with even higher cost-sharing protections.
    These reforms could not have come at a more important time, 
given the pandemic. Americans across the political spectrum 
want Congress to lower patient healthcare costs and protect 
people with preexisting conditions.
    The Affordable Care Act, as enhanced by the American Rescue 
Plan, does exactly that, and the legislation that you are 
considering today furthers those goals as well.
    The bills before you will increase awareness of this new 
financial help, will protect patients with preexisting 
conditions from plans that discriminate against them, and will 
help States experiment to further expand access to coverage, to 
lower healthcare costs, and further advance health equity.
    In closing, health insurance has always been about access 
to healthcare and financial security. Under the Affordable Care 
Act and the American Rescue Plan, millions of families have 
access to affordable, comprehensive coverage and the financial 
security that having high-quality health insurance brings.
    The time is now to continue building on these important 
reforms.
    Thank you for the opportunity to address you, and I very 
much look forward to your questions.
    [The prepared statement of Ms. Keith follows:]
    
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you very much for your important 
testimony.
    Next, Mr. Cameron, you are recognized for 5 minutes for 
your testimony, and as I said a few minutes ago, welcome back 
to the committee.
    Please unmute.

                   STATEMENT OF DEAN CAMERON

    Mr. Cameron. You bet. Thank you, Chairwoman Eshoo, and it 
is a pleasure to be back, and Ranking Member Guthrie and 
members of the subcommittee.
    My name is Dean Cameron. I am the director of the Idaho 
Department of Insurance.
    Thank you for this important hearing and this opportunity 
to testify and tell about Idaho's experience with the ACA and 
short-term plans, in particular.
    I firmly believe that the solutions to health insurance 
will be found at the State laboratories of creativity, and I 
completely support each State's right to try different 
approaches that meet their individual State's needs.
    A fundamental tenet to all insurance is the spreading of 
risk, the ability to share risk with each other. Idahoans, like 
many other States, are being priced out of the marketplace, in 
spite of even this latest improvement to the APTC.
    The ACA has become too expensive, and many do not qualify 
or can avail themselves of the subsidy. These are people like 
teachers and spouses of teachers who, because of the family 
glitch, do not qualify, or ranchers or farmers who, because of 
their unpredictable income, cannot avail themselves of the 
subsidy. They want coverage, but they simply cannot afford it.
    They are being forced to the unenviable position of either 
going without coverage or obtaining products such as those 
offered through Health Sharing Ministries or short-term plans.
    As prices for ACA plans continue to rise, more and more 
citizens are forced out of coverage, especially the young and 
the healthy, the healthy of all ages. And I can tell you story 
after story of older citizens who are being forced out of 
coverage.
    As more and more young and healthy citizens move out of 
coverage, prices continue to climb and more leave and the 
market is caught in a vicious cycle. Since 2015, Idaho 
consumers who are buying insurance on the individual market 
continue to decline.
    Now, this is at a time when our population growth is one of 
the highest in the country.
    So the question before Idaho and really before many States 
was, How do we provide quality yet affordable products to our 
citizens? And how do we improve the overall risk pool of the 
ACA, or how do we attract the young and the healthy back into 
the ACA market?
    Given the existing parameters of the ACA, Idaho decided to 
restrict the traditional short-term plans to 6 months while 
creating another product, an enhanced short-term plan for those 
with coverage longer than 6 months, which has all of the 
essential health benefits as required by the ACA.
    In fact, of the five plans created in Idaho by two 
different carriers, four of them have better actuarial values 
than the Bronze Plans, and two of them have better actuarial 
values than Silver Plans, and if sold during open enrollment 
are prohibited from preexisting condition clauses.
    Additionally, these plans could only be offered by carriers 
that are currently in the exchange alongside of ACA plans and, 
most importantly, in the same risk pool.
    By requiring enhanced plans to be part of the ACA pool, we 
protect the ACA plans and we lower the cost for those in the 
ACA marketplace while attracting young and healthy back into 
the marketplace.
    Madam Chairwoman and members of the subcommittee, in my 
opinion I would respectfully suggest the following regarding 
short-term plans.
    First, I would suggest to you that all STPs are not alike.
    Second STPs are not junk insurance just because someone 
dubbed them as such. As I have said before, I have STPs in my 
State which are better quality than some of the ACA plans.
    Third, I would respectfully suggest that STPs fill a need 
for those who are in between jobs, those who are in between 
coverage, or in Idaho's case, those who cannot afford ACA 
plans. They act as a bridge between those who miss open 
enrollment until the next open enrollment.
    Fourth--and this is rarely acknowledged--STPs assist in 
early diagnosis of serious health conditions, which ultimately 
save money to the entire system, including ACA plans. Without 
this product, consumers will be forced to go uninsured, which 
will cost us more as their conditions go undiagnosed and 
untreated.
    Lastly, I would respectfully indicate for you that I 
believe passage of H.R. 1875 would harm thousands of Idahoans 
and hundreds of thousands of Americans and would not--underline 
``would not''--benefit the ACA.
    In fact, passage of H.R. 1875, in my opinion, would 
potentially kick Americans off of their plan, increasing the 
number of uninsured, which would potentially lead to additional 
cost sharing and higher costs to those that are purchasing the 
ACA plan.
    Madam Chairman, I appreciate the opportunity to speak to 
you and would welcome questions and the opportunity to speak on 
the other bills.
    Thank you, Madam Chair.
    [The prepared statement of Mr. Cameron follows:]
    
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you, Mr. Cameron.
    Next, Ms. Mann, you are now recognized for 5 minutes for 
your testimony. And, again, thank you for being with us today, 
and please unmute.

                    STATEMENT OF CINDY MANN

    Ms. Mann. Thank you for inviting me today. It is a pleasure 
to be here, Chairman, and Ranking Member Guthrie.
    I am Cindy Mann, and I am a partner with Manatt Health, a 
division of Manatt, Phelps & Phillips, and I do a lot of work 
with States and with households, health systems, consumer 
organizations, foundations about delivering system payment 
reforms and focus particularly on the Medicaid and the CHIP 
programs.
    Previously, before coming to Manatt, I was a Deputy 
Administration of CMS and the Director of the Center for 
Medicaid and CHIP Services and was there during the 
implementation of the Affordable Care Act.
    I appreciate the opportunity to testify today.
    Many important changes to Medicaid were, of course, ushered 
in by the Affordable Care Act, but the most prominent and far-
reaching change is the one that sought to close a longstanding 
coverage gap in the program.
    Before the ACA, the public generally believed that Medicaid 
covered poor people, but in fact, until the ACA, Medicaid left 
out a large segment of poor adults.
    Who are they? Well, some of them are the children that 
Medicaid covers, but when they turn 18 in Medicaid parlance, 
they are considered childless adults.
    They are also the women who, when they become pregnant, 
they will be covered by Medicaid, but before their pregnancy 
they too are childless adults and were left out of coverage.
    And whatever their situations, most are working, many at 
multiple jobs scraping by to pay rent and feed their families.
    The ACA did not add a new group of strangers to the 
Medicaid program. It ended arbitrary coverage exclusions and, 
with the marketplace, created a continuum of coverage for those 
without access to affordable, job-based coverage.
    As was noted, Chairman Eshoo, the Supreme Court made the 
expansion voluntary with States, and not all States have taken 
up that really important option. In January 2014, when the 
coverage became effective from the ACA, we had 24 States that 
had expanded Medicaid.
    Today 36 States do so. Two additional States are poised to 
start coverage in July, leaving 12 States without expansion and 
over 4 million people without insurance as a result.
    After years of implementation, there is now a significant 
body of evidence on the success and impact of expansion. Pre-
COVID the expansion covered about 12 million newly eligible 
people. Uninsurance rates dropped in all States, but the 
decline was particularly steep in the expansion States: 69 
percent uninsurance rates in those States compared to 11.1 
percent in the nonexpansion States in 2019.
    But of course, it is not just about insurance. It is about 
the care, and studies have shown that people have gotten cancer 
treatments, preventive care, care management for chronic 
conditions.
    It has also helped people retain and gain jobs, and in the 
recession it has really helped significantly cushion the blow 
for million of workers who have lost their job.
    And notably, it has also reduced racial disparities in all 
States and then particularly, again, in the expansion States 
compared to the nonexpansion States.
    It has also helped the safety net. Rural hospitals, for 
example, have seen their uncompensated care costs drop by 43 
percent in expansion States compared to 16 percent for rural 
hospitals in nonexpansion States, and it has done most of this 
with little cost to States because of the generous match rate 
and offsetting savings.
    But the job is not done. In my minute or so remaining, let 
me just review a few ways in which Medicaid coverage can be 
strengthened.
    First of all, closing the coverage gap remains, of course, 
key unfinished business. The added support for expansion in the 
Recovery Plan is welcome and so timely, given the public health 
emergency.
    I do not know if you have all seen the news, but just last 
night an expansion bill passed in the House in the State of 
Wyoming.
    Doing a better job addressing racially driven inequities in 
coverage must also be front and center as we move forward, and 
again, the Recovery Plan took a really important step forward 
by extending the post partum period of coverage for pregnant 
women.
    The U.S., of course, is an outlier in terms of our share of 
Black women who are dying during or after giving birth, and 
post partum coverage extension is a critically important 
advance.
    Equity issues, of course, are not just limited to discrete 
issues. They must be looked at in every part of our delivery 
system and payment system. We have a bill introduced by members 
of this committee which would create parity in payment rates 
for primary care between Medicaid and Medicare, and that would 
help quite a bit.
    Other reforms would also significantly improve coverage and 
care, including 12 months' continuous coverage for adults and 
for children.
    And lastly, I want to note how important it is to give 
consideration to long-term services and support, like those 
that are so important for Ms. Hatcher's son--who is going to 
testify in a few minutes--her son Simon. Nearly a third of 
Medicaid expenditures are for home- and community-based 
services or nursing home care. Medicaid is the default payer, 
and we need a number of reforms in that area.
    We need to reimagine long-term care so that it provides 
safe and quality care for all who need it, preferably at home 
and in the community, and provides a living wage for those who 
provide the services.
    Serving more than 75 million people, nearly half of whom 
are children, Medicaid plays a central role in the healthcare 
system and in our communities. It deserves and it requires our 
support and attention.
    Thank you for allowing me to present testimony today, and I 
look forward to your questions.
    [The prepared statement of Ms. Mann follows:]
    
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    Ms. Eshoo. Thank you, Ms. Mann.
    Next, we have Ms. Carey, who is recognized for 5 minutes 
for your testimony.
    Please unmute, and know again how grateful we are for you 
to be with us today and your terrific work.

                STATEMENT OF MARNI JAMESON CAREY

    Ms. Carey. Thank you, Chairman Eshoo and Ranking Member 
Guthrie and members of the Subcommittee on Health, for the 
invitation to address you. It is truly a pleasure to be here on 
the anniversary of the Affordable Care Act.
    My name is Marni Jameson Carey. I am the executive director 
of the Association of Independent Doctors, a national nonprofit 
trade association with members in 44 States. At AID, we work to 
educate lawmakers, employers, patients, and taxpayers about why 
preserving independent doctors is so essential to lowering the 
cost of healthcare, improving access, and restoring the doctor-
patient relationship.
    Since AID was established, its mission has not changed. We 
strive to achieve systemwide price transparency, which would 
introduce competition into our price-opaque healthcare system.
    We aim to achieve site-neutral payments so the same medical 
service costs the same regardless of whether it is performed in 
an independent doctor's office or an outpatient hospital 
setting.
    And we work to stop the consolidation in healthcare, 
specifically the employment of physicians by hospitals and 
private equity groups, which drives up costs.
    I see the bills before this committee today as attempts to 
expand coverage and protect the vulnerable, which are such 
certainly worthy causes. However, I would like to address a 
root problem, a fundamental reason so many Americans still lack 
coverage and access.
    Healthcare costs are too much. At nearly 18 percent of our 
Nation's gross national product, Americans spend nearly 1 out 
of every 5 dollars they earn to pay for healthcare.
    The system we have is driving prices higher. Since the ACA 
went into effect, national spending has gone from $2.6 trillion 
to over $3.7 trillion. Our lack of coverage and the issues 
surrounding coverage are a direct byproduct of the high cost of 
healthcare.
    If healthcare were affordable, coverage would begin to take 
care of itself. And the cost matters, regardless of who is 
paying--regardless if it is the patient or the taxpayer or the 
government or the employer or the insurer. We can lower prices 
by achieving price transparency, realizing site-neutral 
payments, and stopping consolidation.
    Before I became executive director for AID, I worked as a 
health reporter, writing for the Los Angeles Times and the 
Orlando Sentinel. As the ACA rolled out, media reports were 
full of statistics about how many Americans would gain or lose 
coverage as a result of insurance exchanges, mandates, and 
Medicaid expansion.
    In fact, that remains much of the talk here today. Covered 
lines became the story largely because hospitals and insurers 
did a great job of turning the public's attention toward the 
issue of coverage and away from the matter of cost.
    Sadly to some, cutting cost is less appealing than 
guaranteeing revenue streams. Lowering cost is what I would 
like the subcommittee to focus on today. The path forward 
begins with systemwide healthcare price transparency.
    For too long hospitals and insurance companies have 
profited excessively from keeping their patients and prices in 
the dark. Most patients have no idea when they get their care 
what the price will be until they get their bill.
    This matters especially with those who have high-deductible 
plans. However, if consumers could see the price of their care 
beforehand and shop and compare prices, more would choose 
lower-priced providers. Price competition would enter the 
market, and prices would come down.
    Patients would see the wide price variations. For instance, 
the price of having a C-section at one hospital in California 
could cost $6,000 or $60,000, depending on their insurance.
    Price transparency would also expose facility fees, which 
hospitals pack onto their employee doctor services that adds 
zero value but that can drive up costs three to five times.
    As long as these prices are hidden, hospitals get away with 
these extra charges. When they no longer can, they will lose 
much of their financial incentive for hiring doctors, and when 
they do, we can show, if not unwind, the consolidation trend in 
healthcare, which economists agree is a leading driver behind 
skyrocketing healthcare costs.
    Sorry. Am I still going here?
    We have made progress. In January, the Department of Health 
and Human Services' hospital price transparency rule went into 
effect, requiring hospitals to show all their prices online.
    Only hospitals are not complying. Just yesterday the Wall 
Street Journal published an article stating that their 
investigators visited over 3,000 hospital websites and found 
most had imbedded codes that worked to block access to their 
newly posted prices.
    This is a golden moment for the Biden administration and 
for this Congress to build on the price transparency 
initiative, which has its roots in the Affordable Care Act and 
which puts consumers in charge of their healthcare spending.
    A recent National Merit survey found that 91 percent of 
Americans believe that hospitals should be legally required to 
post all of their prices online and in an easy-to-access 
format.
    Price transparency is not a red or blue issue. It is an 
American issue. It is a unifying issue, and it would cost 
taxpayers nothing.
    As we acknowledge the anniversary of the Affordable Care 
Act and a new era in Washington, I urge the subcommittee to 
work to enact legislation that would reinforce systemwide price 
transparency, encourage competition, and discourage healthcare 
consolidation, all of which would drive down the cost of 
healthcare and make coverage truly accessible and affordable 
for all Americans.
    Thank you again for this opportunity and for your service 
to our country.
    [The prepared statement of Ms. Jameson Carey follows:]

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    Ms. Eshoo. Thank you.
    And last but not least, Ms. Hatcher, you are recognized for 
5 minutes, and please remember to unmute. Wonderful to have you 
with us.

               STATEMENT OF LAURA LeBRUN HATCHER

    Ms. Hatcher. Thank you so much.
    Greetings, Chairwoman Eshoo and Chairman Pallone, Ranking 
Members Rodgers and Guthrie, and members of the committee. 
Thank you for inviting me here today to share my family's story 
with you.
    My son Simon has the best laugh you have ever heard. He 
loves to watch the Muppets and play the drums, sometimes at the 
same time.
    Simon was born in 2006, before the Affordable Care Act 
became law. He had a brain bleed in utero, and when he was just 
2 weeks old and in need of emergency brain surgery I learned 
about the limitations of our private health insurance, about 
lifetime caps on care, and the danger of losing coverage 
because of preexisting conditions my child was born with.
    Through Simon's early years, his diagnoses piled up--
hydrocephalus, cerebral palsy, epilepsy, autism, a genetic 
disorder--and so did our medical bills with each ride in an 
ambulance and each stay in the pediatric intensive care unit.
    My anxiety increased. I was afraid for my son, and I was 
afraid of losing his health insurance. I was terrified of 
reaching his rapidly approaching lifetime cap on care, and I 
had no idea what we would do when we hit it.
    So it felt like a miracle when the Affordable Care Act 
passed. I no longer had to worry about his health insurance 
dropping him because he needed a high level of care, and for 
the next 7 years as Simon grew up I grew more confident in my 
ability to care for my medically complex child, to get him what 
he needed to survive and to thrive.
    Then in 2017 that confidence was shattered when the 
Republican-led House of Representatives voted to repeal the 
healthcare protection that my child's life depended on.
    At first, I was devastated, and then I found other families 
like mine. We are called the Little Lobbyists, named after an 
article about a 6-year-old boy called Timmy who came to Capitol 
Hill to ask Congress to save his healthcare.
    Simon and I joined Timmy, Xiomara, Abby, Emma, Joe, Teddy, 
Claire, and so many other amazing kids with complex medical 
needs and disabilities and their families, and together we 
advocate for the healthcare, education, inclusion our families 
need to survive and thrive.
    And that is why I am here today. Though there is still a 
case in the Supreme Court threatening the ACA, it seems that 
for now ACA protections which we worked so hard to save have 
survived.
    As our country begins to recover from this deadly pandemic 
and the horrific, disproportionate toll it has taken on 
marginalized communities, especially disabled Black, Brown, and 
indigenous peoples, it is time for us to work together to help 
all of our families thrive.
    So let me tell you a little bit more about my family. In 
2019, after being on a waiting list for 9 years, Simon 
qualified for a Medicaid waiver, thanks to Medicaid expansion 
in my State. We finally have coverage for the things that our 
insurance would not fully cover, like medication to prevent 
Simon's seizures, a pulse oximeter he needs to sleep safely, 
and a walker that he uses to get around.
    Simon also has access to home- and community-based 
services. At 14, with the help of a direct support 
professional, he was able to get his first taste of 
independence.
    In addition to being Simon's mom, I am a self-employed 
graphic designer. My husband Brian is also a designer. Recently 
Brian lost his job and with it our employer-sponsored health 
insurance. But thanks to the Affordable Care Act and a 
navigator, who helped us avoid treacherous junk insurance 
plans, we were able to purchase quality health coverage for our 
family through the exchanges.
    We have been able to turn an unforeseen hardship into an 
opportunity for Brian to join me in building our family 
business.
    But COVID has been tough on our business. Projects have 
been canceled or postponed, and it has also been tough on 
Simon. Online school has been hard, but he cannot safely return 
to the classroom until he has access to a vaccine.
    He also lost his direct support professional because there 
was not enough funding for Medicaid services for the PPE and 
support that his staff needed. Fortunately, Congress offered us 
a lifeline with the American Rescue Plan, and I want to 
personally thank you for that.
    You voted to support funding for Medicaid home and 
community services that people with disabilities like my son 
need to stay in their communities and out of deadly 
institutions.
    You voted to encourage States that have not yet expanded 
Medicaid to do so, so more people like Simon can access the 
lifesaving care that they need.
    In addition to support for small businesses like mine, 
Congress built on the ACA. By expanding subsidies to eliminate 
the cliff that my family fell off of, I am able to think about 
the future with the confidence of knowing that we will not pay 
more than 8.7 percent of our income on our health coverage even 
if our business grows, as I really hope it does.
    I am asking you to make these provisions permanent. My 
family and so many others need the security that comes with 
affordable, quality healthcare. Thanks to the ACA and to the 
American Rescue Plan, I am able to sleep a little better and 
continue dreaming my American dream where my family succeeds 
with a small business and my son with complex medical needs and 
disabilities survives and thrives in his community, in this 
country where we all belong.
    Thank you.
    [The prepared statement of Ms. LeBrun Hatcher follows:]
    
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    Ms. Eshoo. Thank you very much. And thank you for all of 
the advocacy. It is really something to behold, and I think if 
someone had said to you in the beginning this is what you will 
be a part of and that the organization would grow and be as 
effective, you would have said, ``No, we are not, we'll never 
be able to do that.''
    But you have, and it has been so important for so many.
    I will now move to Member questions, and the Chair 
recognizes herself for 5 minutes for questions.
    You know, there has been a reference legitimately to the 
American Rescue Plan and its subsidies, how they are going to 
benefit millions of people. I think that we have an issue here 
because the CBO estimates that only 10 percent of those 
uninsured and eligible for the new subsidies are going to 
enroll and only 20 percent of those currently insured but 
unsubsidized will sign up for the new benefits because of a 
lack of awareness.
    So I think whoever would like to take this, probably Cindy 
Mann or Katie Keith or both: What do you advise us and the 
administration to do?
    If people do not know, they are not going to take advantage 
of what we are working so hard to give them, you know, in terms 
of this coverage.
    My goal, the goal of so many, our North Star, has been 
universal healthcare, and what we have in the American Rescue 
Plan, in my view, advances that, but people have to know.
    My other question is to Mr. Cameron. You are obviously a 
fan of the plans that you have spoken about, but you know, for 
these short-term plans what really bothers me is that many of 
them are the king of surprise medical billing.
    The Congress addressed that, thank goodness, on a 
bipartisan basis, but they imposed burdensome post claims, 
review processes to avoid paying for surgeries, for emergency 
room visits, for cancer treatments. They used the fine print of 
their coverage restrictions or enrollees' medical history to 
deny claims.
    So there are problems with some of these short-term plans, 
and it is not to pick on anyone. It is to see what is wrong to 
be made right.
    And we had a hell of a time addressing surprise billing, 
and we did. It is costly and, I think, really wrong.
    So first to Cindy Mann and to Katie Keith: What do you 
recommend that we do so that people will, in fact, take 
advantage of what we are working so hard to provide them?
    And, Mr. Cameron, maybe you want to comment on what I just 
outlined, and that H.R. 1875 closes the loophole that allows 
these short-term plans to avoid the ACA rules, to finally put 
an end to preexisting condition discrimination.
    You are talking about ones that you like and do some of the 
good things, but that is not the case across the board.
    So let's start. I have a minute and 38 seconds for three 
people to answer my questions.
    Ms. Mann. This is Cindy Mann. I will jump in but also be 
really quick.
    It is a really important point you have brought up. People 
have to know what the benefits are. People have to know what 
the rules are. People also need help applying, and we have 
learned in the past, there were robust navigation and outreach 
efforts, but they have dried up a lot over the last 4 years.
    Ms. Eshoo. I did not hear you. They what?
    Ms. Mann. I said they dried up. They were cut 
substantially, and so this is the time, particularly because of 
the pandemic, where we need to increase that outreach and 
navigation.
    You are covered in California. The marketplace in 
California had documented how important that marketing is to 
make sure people understand these rules and what has changed.
    Also it is going to be really important to try and make 
those changes permanent so people will have confidence that 
they will still be there.
    Ms. Eshoo. Mr. Cameron, do you want to comment?
    Mr. Cameron. I thought you had one other person in front of 
me, but to your question----
    Ms. Eshoo. Well, I only have 26 seconds now. So that is why 
I am shifting.
    Mr. Cameron. First of all, I am a fan of choice. I am not 
necessarily a fan of all STP plans, and I will tell you that 
many States have adopted regulations that are trying to address 
the issues with the bad actors. Like in everything, there are 
bad actors and there are good actors, and we have addressed 
those.
    We have limited preexisting condition clauses for all of 
the plans. They have in some cases the same approach or clauses 
as the ACA plan. We go after them in the fine print, and we 
help consumers to be able to get the coverage that they need.
    I would also just quickly say that many of those that will 
not take advantage of the subsidy that you mentioned are those 
that are healthy and the plans are still too expensive.
    Ms. Eshoo. All right. My time is expired.
    I now will recognize the ranking member of our 
subcommittee, Mr. Guthrie, for his 5 minutes of questions.
    Mr. Guthrie. Thanks. I appreciate that very much.
    Ms. Carey, I guess we are talking about where the 
Affordable Care Act has not been successful is in controlling 
cost of healthcare. As you mentioned, over a trillion dollars 
have increased in healthcare spending since the Affordable Care 
Act was passed 11 years ago.
    And testimony has been given today that the ACA and we hear 
the American Rescue Plan have made coverage affordable by 
subsidizing ever-increasing costs, and this continued 
increasing subsidies to chase ever-increasing costs is just not 
sustainable, and particularly those who are just above the 
threshold to get any kind of subsidies continue to get squeezed 
by the ever-increasing cost.
    So my point is that we have failed at controlling 
healthcare costs or getting a handle on healthcare costs, and 
we need to focus on healthcare costs or the system is going to 
implode.
    And so your research, Ms. Carey, has been on the Federal 
Government and its role in driving healthcare costs, 
particularly structural regulations of Medicare. Could you 
explain further?
    I know you did in your opening statement, but could you 
explain further how we can deal with healthcare costs, which 
would hopefully make insurance--if we deal with the costs, it 
makes insurance more affordable. We are going to make 
insurances unaffordable for everybody if we do not deal with 
costs.
    Ms. Carey. That is right. We all pay for healthcare whether 
we are paying as the patient or paying as the taxpayer or 
paying through premiums. So we have to bring down the whole 
burden across the board.
    And there are many systems in place right now that are 
working to drive up the cost, and hospitals when they purchase 
medical groups, they are able to layer in facility fees that 
independent doctors do not charge, and that compounds.
    So if you have a primary care doctor who refers you to an 
orthopedist who refers you to an MRI or refers you to an 
outpatient surgical center, all of them layer in facility fees, 
which drive up the cost of care five times or more.
    So we need to unwind that and bring those costs down and 
expose them to price transparency. When patients begin to see 
the huge variance in price and that you can get a colonoscopy 
for $750 and across the street for $4,000, and you look for the 
quality and you get the best value. Competition will enter the 
system, and the costs will come down, and that will [inaudible] 
take care of itself.
    Mr. Guthrie. Thank you for that.
    And, Ms. Mann, in GAO's report on express lane eligibility, 
ELE, GAO found that CMS has issued guidance on how to determine 
ELE errors and calculate such payments if those errors occur.
    If the ELE option is continued, it will be particularly 
important that CMS issue such guidance, as questions have been 
raised by States and others regarding how ELE errors should be 
defined.
    Has CMS issued such guidance?
    Ms. Mann. There is a lot of guidance around error rates and 
how those are calculated. Some of that guidance would pertain 
to the express lane eligibility that you speak of.
    There are only a couple handful of States, about nine 
States, that do express lane eligibility, and both the GAO and 
OIG found that it has been an effective program, albeit a 
limited-scope program to be able to promote enrollment.
    But certainly CMS can continue to look at questions around 
it and issue guidance as needed.
    Mr. Guthrie. So more guidance is needed, it appears?
    Ms. Mann. Well, the findings from the OIG and from the GAO, 
the GAO did suggest that there be more guidance. OIG indicated 
that it did not see any particular evidence of erroneous 
determinations.
    So that was a while ago. Those reports were several years 
ago. So it is always good for CMS to continue to look at all 
facets of the program and identify whether any particular 
[inaudible] is needed to assure program integrity.
    Mr. Guthrie. Hey, thank you very much for that.
    And, Mr. Cameron, I know Idaho is one of 27 States with 
short-term plans, and short-term plans are not for everyone. 
They typically are a gap when people need coverage and they 
need affordability.
    So would you talk in the 40 seconds left about States' 
ability to regulate these plans and who these plans are a value 
for, if they have value for certain groups of people?
    Mr. Cameron. Absolutely. Certainly they have value for 
those that are in between jobs or those that are forced out 
until the next open enrollment period. Many States have also 
started regulating these plans a little more intently.
    Some States, five States, have banned them. Twenty States 
have limited what these plans can have in them, limited their 
length of time, and even those that allowed, like Idaho, 
allowed them to exist longer than six months have instituted 
requirements on preexisting conditions and on essential health 
benefits.
    We are really trying to attract the young and the healthy 
back into the marketplace so that it will help hold down costs 
for everyone, including those that are buying coverage through 
the ACA.
    Mr. Guthrie. Thank you.
    My time has expired, and I yield back. Thank you, Madam 
Chair.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize the chairman of the full 
committee, Mr. Pallone, for your 5 minutes of questions.
    Mr. Pallone. Thank you, Chairwoman Eshoo.
    You know, it bothers me because we keep hearing about this 
idea of choice, and of course, you do not have to choose the 
Affordable Care Act. You do not even have to have health 
insurance at all if you do not want to. So you ultimately have 
a choice of what you want to do.
    But I think that what bothers me is, you know, you say you 
have a choice, but when you buy these junk plans, people do not 
realize that they do not cover things.
    And so, you know, I used the extreme example which was sold 
before the ACA--I do not know if it is sold anymore--where 
people would buy plans that did not have hospitalization. They 
go to the hospital, and then they are shocked to find out it 
does not cover hospitalization because they cannot believe a 
plan is sold that does not cover hospitalization.
    Nobody believes that when they buy a plan it is not going 
to, you know, cover mental health. It is not going to cover 
maternal health. They just assume it does.
    And you can say, well, they are stupid and that is their 
own problem, but you know, this is the reality that you cannot 
have these false choices.
    The same thing is with innovation. Of course, we are all 
for innovation and we want to encourage innovation, but 
everybody wants the new thing. They want the new machine. They 
want the new way of diagnostic care.
    Well, a lot of times those things drive up the cost, but 
everybody wants them, and so I kind of want to debunk this 
thing that you can squeeze a lot more out of this system and 
still do more. I do not really think that is true.
    If you squeeze the system, often what happens is you do not 
have benefits. You do not have new techniques. You are not 
covered, and you know, it may be that you can squeeze a little 
more out of the system and save money, but that is often not 
the case.
    So with that I really want to go to Ms. Keith. I want to 
ask you about these short-term or junk plans with the 3 minutes 
we have left.
    These junk plans often exclude coverage for prescription 
drugs, mental health, substance use disorders, and in some 
cases basic preventative services. Is that correct?
    Ms. Keith. That is correct, yes.
    Mr. Pallone. And I understand that these junk plans impose 
annual and lifetime limits. Is that correct?
    Ms. Keith. That is correct.
    Mr. Pallone. And is it correct that these junk plans also 
deny coverage altogether for individuals sometimes with 
preexisting conditions?
    Ms. Keith. That is correct, yes.
    Mr. Pallone. So my Republican colleagues claim that these 
short-term or junk plans provide Americans with choice. That is 
what I mentioned, but is this choice to buy bare-bones coverage 
beneficial for consumers?
    Can you describe why an individual who is healthy when they 
sign up for one of these plans can still be subject to hundreds 
of thousands in medical bills?
    Ms. Keith. Thank you for that question.
    So there are many reasons why someone who might be healthy 
enrolled and then comes to need healthcare. They might have an 
accident. They might be injured. They might get pregnant. They 
might be diagnosed with something.
    And when you happen to be enrolled in one of these short-
term plans or other noncomprehensive options, you end up with 
high medical bills because of the significant gaps in these 
products. They simply do not cover the benefit categories that 
you just mentioned that most people expect to be covered. 
Prescription drugs is a huge one.
    They often have very high out-of-pocket costs, so up to 
$30,000. That is compared to about $8,000 with Affordable Care 
Act plans, and many exclude coverage for preexisting conditions 
in addition to the other benefits and services that they often 
exclude.
    Those are just some of the ways that I think enrollees in 
short-term plans can be very surprised and end up with 
devastating medical bills as a result.
    Mr. Pallone. And, Ms. Keith, our committee did an 
investigation, and they found that these short-term or junk 
plans subject consumers to invasive and burdensome process to 
avoid paying for medical claims, and consumers are denied 
coverage for lifesaving and necessary treatments and left with 
thousands of dollars in medical bills.
    You see, the problem is you can talk about choice and you 
can say, ``Oh, everybody should have a choice,'' but 
unfortunately a lot of people just do not understand when they 
sign up for these things.
    You know, no one would ever believe that they have health 
insurance that does not cover hospitalization. Most people 
would never believe that they have health insurance that does 
not cover maternal healthcare, right?
    I mean, who would think that you would sell that kind of a 
plan?
    And this is my experience, and this is what happens, and 
this is what the committee found, that oftentimes--and then 
what happens is the plans try to get around all of this, and 
people end up bankrupt.
    You know, I just want to stress that because I think it is 
so important, you know. I know you can always say, look, it 
does not matter. You know, buyer beware. But they do not read 
the fine print when they sign that. They are just not aware.
    So thank you, again. I appreciate it.
    And with that, Madam Chair, I yield back.
    Ms. Eshoo. The gentleman yields back.
    The Chair recognizes the ranking member of the full 
committee, Mrs. Rodgers, for your 5 minutes of questions.
    Mrs. Rodgers. Thank you, Madam Chair.
    Thank you to all of the witnesses for being here.
    You know, across the country States run their own 
exchanges, and we have seen in those State-run exchanges an 
enrollment increase for the most part, although Washington 
State has actually seen a decline both in 2019 and 2020.
    And it highlights the need for more affordable options. So 
Mr. Cameron, my neighbor--my district actually borders Idaho--I 
was excited to learn about the innovative model that you have 
come up with in Idaho.
    And you have clearly worked very hard to try to find the 
options that people need so that they have health insurance and 
they have access to that healthcare when they need it.
    I would like to start out by just asking what advice do you 
have for us, as we are continuing to try to make healthcare 
affordable.
    And in your opinion, is there anything stopping Washington 
from implementing a plan like yours?
    Mr. Cameron. Well, thank you, Congresswoman, and thank you 
for the compliment, and I am glad to be here.
    First of all, our plan, our approach could be adopted by 
other States provided some of the bills that are introduced 
today do not pass, which really cut the legs out of anybody 
buying a plan, regardless of whether it is a good plan or a bad 
plan, if it is outside of the ACA.
    You know, the implication that you are somehow better 
without coverage than you would be with coverage that is 
inferior, I just do not agree with that.
    And we have worked long and hard in Idaho and many other 
States to try and put appropriate standards and guidelines 
around what should be short-term plans and to avoid the fine 
print.
    Mrs. Rodgers. OK. Thank you.
    Mr. Cameron. Sorry.
    Mrs. Rodgers. Thank you. I want to move on to a couple 
other questions too.
    Do any of the bills before the committee today, in your 
opinion, lower the cost of healthcare?
    Mr. Cameron. You know, the only bill I think that is in 
front of the committee that has even a remote chance is the one 
that funds reinsurance pools, but then only if it is modified 
and adjusted to do high-risk reinsurance pools that are 
invisible reinsurance pools.
    Mrs. Rodgers. OK. Thank you.
    Ms. Carey, do you believe any of these bills before the 
committee will help lower the cost of healthcare?
    Ms. Carey. I did not see any evidence of that.
    Mrs. Rodgers. OK. You know, I really think that this 
hearing is a missed opportunity to build on our work together 
to actually try to lower the cost of healthcare, not to shift 
those costs to the taxpayer.
    I am excited about the potential of transparency to lower 
cost, but I would also like to hear about how it would help 
patients.
    Ms. Carey, can you give us some examples of how 
transparency within healthcare would help patients pay less for 
their healthcare?
    Ms. Carey. It would help in so many ways. First of all, it 
would put the power in the patient's hands and not into the 
insurer's hands and into the government's hands. It would help 
them drive as consumers and improve every market when they have 
price competition and price transparency.
    Markets compete, quality gets better, and prices come down. 
We have seen it in retail. We have seen it in airlines. And if 
consumers can get on their phone an app that compares what it 
is like to have a hernia surgery or how much it costs across 
systems systemwide and they pick the high-value, low-cost 
provider, others are going to have to compete, and that is 
going to empower patients, bring costs down, and really make 
healthcare affordable and accessible.
    Mrs. Rodgers. So as a followup, what advice would you have 
for a patient needing to get an MRI, for an example, that has a 
high deductible?
    Ms. Carey. I would go to anyplace that posts their prices. 
Green Imaging has price transparency, has an imaging center 
across the country. Go to a surgical center, like Oklahoma 
Surgery Center, and look up what they charge for a knee 
replacement, for example. It is $15,500, where the average cost 
for a total knee replacement is $57,000 in this country.
    And you go to your hospital and you say, ``Look. I can get 
an MRI for $350 over here. I can get my knee replaced for 
15,500 over here. Can you match that?''
    That is what I would tell the American consumer, to hold 
the hospitals accountable to the price that you should be 
paying, not to the prices that they want to charge you.
    Mrs. Rodgers. Would you speak to the concern about quality, 
as you are making that decision?
    Ms. Carey. Quality of care also takes care of itself when 
patients have transparency to the marketplace. A great example 
is Lasix surgery, which has only come down in price because 
these ophthalmologists are competing and the quality is being 
reported online in real time.
    The same is with the plastic surgeons who typically do not 
get involved with insurance. They get private pay, and their 
prices come down and their quality has gone up.
    It works in the market, and it can work systemwide.
    Mrs. Rodgers. Thank you. I appreciate you being with us 
today.
    Ms. Carey. My pleasure.
    Mrs. Rodgers. I yield back, Madam Chair.
    Ms. Eshoo. The gentlewoman yields back.
    A pleasure to recognize the gentleman from North Carolina, 
Mr. Butterfield.
    Mr. Butterfield. Thank you very much, Madam Chair. It is 
good to see all of you this morning. Actually it is afternoon 
now.
    But it is also good to see the witnesses, and thank you for 
your testimony.
    Let me spend my few minutes with Cindy Mann, if I may.
    Ms. Mann, just 12 States, including my home State of North 
Carolina, have failed to expand Medicaid. We have talked about 
this now for 11 years. They have failed to expand Medicaid 
despite the Federal Government picking up the majority of the 
cost.
    The American Rescue Plan included a robust financial 
incentive for these States. States that expand under this new 
incentive can use those funds to combat the pandemic. They can 
expand coverage. They can bolster their programs.
    For example, it would cost North Carolina $490 million to 
expand the Medicaid program, but North Carolina would receive 
$1.7 billion in new Federal funding if it expanded under the 
American Rescue Plan.
    Do the math. North Carolina could reinvest the remaining 
$1.2 billion of new Federal funds in critical State programs 
and in communities like I represent.
    The question, Ms. Mann, if you believe that States like my 
State should expand Medicaid because it is the right thing to 
do. I believe that 600,000 North Carolinians who would gain 
coverage and access to quality healthcare under expansion are 
reasons enough.
    But Republicans who control our State legislature have thus 
far disagreed with me. Given that, can you discuss the economic 
benefits of Medicaid expansion with States and communities?
    We have heard it before, but we need to hear it again.
    Ms. Mann. I would be glad to. Thank you for the question, 
and thank you for your support for getting expansion in place 
in North Carolina. It represents about 10 percent of all the 
people in this country that are in the coverage gap, your 
residents in North Carolina.
    You are absolutely right, Congressman. It is a real value 
to the States. There has been an increase in Medicaid 
expenditures as a result of the expansion, but it has been 
because we have been covering more people, and the vast 
majority of those additional costs have been borne by the 
Federal Government.
    States have enjoyed generous match rates, and they have 
also been able to offset other costs that they have been 
spending with State-only dollars with the value of having 
Medicaid matching apply.
    So it has been enormously helpful to States. I need to 
remind everybody, of course, that we have Medicaid expansion in 
36 States. There are States with Republican legislators and 
Democratic legislatures, Republican Governors and Democratic 
Governors.
    No State that has adopted an expansion has decided to drop 
it, and that is, of course, in part because the State is 
providing care for their residents, it is providing reduction 
in uncompensated care for providers who serve them, but also 
because it has been a real benefit fiscally for States to be 
able to provide that care in bringing Federal dollars to share 
in the cost.
    Mr. Butterfield. You talk about these expansion States and 
how they have benefitted. Can you give me just a very simple, 
plain example of how expansion can benefit the State other than 
providing care to the patient and improving the economy? Are 
there some other collateral benefits?
    Ms. Mann. Sure. So a couple, let me mention a couple. One 
is virtually every State right now, expansion or nonexpansion, 
spends some of their own dollars--whether it is on mental 
health services, substance abuse disorder services--they are 
spending State-only dollars.
    And yet, with the Medicaid expansion funding, a much 
broader group of beneficiaries who can now enroll in the 
Medicaid program, that brings in Federal dollars where the 
State has been shouldering those expenses with State-only 
dollars.
    Medicaid has been an incredibly strong factor in terms of 
addressing the opioid crisis, for example, bringing down deaths 
and destruction in communities across the country.
    The other way in which Medicaid provides fiscal benefits to 
States is because the Federal dollars coming in provide 
additional economic activity in the State, and so there is a 
boon in that way as well.
    And for some States where they have imposed fees on health 
providers and health plans, often those fees are based on how 
many lives are covered. So to the extent that plans or 
hospitals are serving more people, they may be paying more 
revenues into the State.
    Mr. Butterfield. Thank you. Thank you, Ms. Mann, and I pray 
that we see the day very soon when these 12 States will expand 
Medicaid.
    Ms. Mann. I am hopeful. It is a very exciting incentive 
that you all have made available.
    Mr. Butterfield. Thank you.
    I yield back, Madam Chair.
    Ms. Eshoo. The gentleman yields back.
    There is hope on the horizon. I mean, two deeply red 
States, Wyoming and Alabama, are considering expansion. So 
there is hope out there. There is some movement.
    The Chair now recognizes Dr. Burgess. Are you there, Dr. 
Burgess? I do not see you.
    Not there. We will circle back to him.
    And I will recognize the gentleman from Virginia, Mr. 
Griffith, for his 5 minutes of questions.
    Mr. Griffith. Thank you very much, Madam Chair.
    A note to Ms. Jameson. I instinctively like what you are 
saying about transparency, but there are hospitals who say that 
they would have a hard time being able to stay open in rural 
areas if the transparency that you propose is mandated.
    What is your response to that argument?
    Ms. Carey. We need hospitals, and we need them to stay 
open, but we do not need them owning all of the physicians in a 
community and all of the imaging centers, and we need them to 
unwind themselves of some of the consolidation and focus on 
their internal hospitalization needs.
    So I find a lot of hospitals spending a lot of money that 
they are not paying in property taxes, for instance, because 62 
percent of our hospitals are not-for-profit or they pay no 
taxes.
    These are monies that are supposed to get plowed back into 
the community in the way of charitable patient care, but 
instead they are turning it into infrastructure.
    So I would like to see a little realignment of the funds, 
have them spending less money on acquiring things, less money 
on building things, and more on giving back to the patient and 
getting their costs truly in line with delivering patient care.
    Mr. Griffith. I look forward to figuring out how we get 
that balance down because I am worried about our rural 
hospitals as well. But I want people to know that you can lower 
costs on things like eye surgery.
    You mentioned Lasik, and when I was in the State 
legislature, I worked with a group that was working on 
cataract, a stand-alone surgical center for cataracts and 
glaucoma. As soon as they got the permission to open, the 
prices in the community dropped substantially--all providers, 
including the hospital.
    All right. Mr. Cameron, does Idaho have network adequacy 
standards to ensure health plans in your State provide 
sufficient in-network access to primary and specialty 
providers?
    Mr. Cameron. Yes, we do. We have six carriers in our 
exchange--which most other States cannot brag of that--and we 
do have network adequacy standards that we require that they 
meet.
    Mr. Griffith. And how do you balance network adequacy with 
the insurer's ability to negotiate lower cost or exclude lower-
caliber providers?
    Mr. Cameron. Well, obviously, they have the ability to 
establish those contracts. As seen, at times it required 
negotiation and conversation with our department and the 
provider or our department and the insurance carrier to make 
sure that it has taken place.
    Mr. Griffith. Do you think folks at CMS in Baltimore or 
Washington, DC, would understand the nuances of Idaho's health 
insurance market to be able to write rules addressing your 
network adequacy standards?
    Mr. Cameron. Absolutely not.
    Mr. Griffith. And how about your rate review 
determinations? And explain if you can.
    Mr. Cameron. Yes. We have a very extensive process in which 
the carriers are required to submit their rates. We review 
every policy, every wording of every policy, and we review how 
they calculated the rates.
    We have actuaries on staff that review them, and we push 
back at times. We have a high-risk reinsurance pool that helps 
us, and we argue that rates should be lower because of that, 
and so we have done a pretty good job over the last 4 years of 
trying to control those rates in spite that their costs, 
particularly for 5 years, were really exorbitant.
    Mr. Griffith. What do you think the confusion caused by 
perhaps having folks at CMS in Baltimore and Washington trying 
to make all of these rules and decisions--what do you think 
that confusion would do to competition?
    And would it encourage or discourage insurance carriers to 
offer plans in Idaho?
    Mr. Cameron. We think it would discourage them. We think it 
would create, you know--I do not know what the right word is--a 
vacuum where carriers would not be able to offer and meet those 
demands.
    We think consumers would be less protected and would not 
know who to turn to. So when we hear about folks that have 
bought plans that are not appropriate, we hear those on ACA 
plans. We get complaints all the time on folks that have bought 
ACA plans and they thought something was covered and it was 
not.
    And if they had to report to Washington, that would be 
devastating to them.
    Mr. Griffith. If Medicare for All that was introduced last 
week were to pass, the bill would eliminate Medicaid as well as 
the private market. Approximately how many people in your State 
would lose their current insurance plans? Do you know?
    Mr. Cameron. It would be about 1.4 million which would lose 
their coverage, which is about what we have covered. We have 
1.8 million, is our population.
    Mr. Griffith. All right. Thank you very much.
    I yield back, Madam Chair.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize the gentlewoman from 
California, Ms. Matsui.
    Ms. Matsui. Thank you very much.
    Ms. Eshoo. Nice to see you.
    Ms. Matsui. Thank you. You too. Thank you very much, Madam 
Chair, for calling this very important hearing, and happy 
anniversary, too, for ACA.
    From the young and uninsured to the middle-income off-
exchange couple, an estimated 25 million Americans stand to 
benefit from the health coverage expansion in the American 
Rescue Plan.
    However, as the chairwoman outlined, the Congressional 
Budget Office estimates that only a small percentage of the 
uninsured or unsubsidized will sign up for the new benefits. 
Ms. Keith, Covered California is encouraging its 11 health 
carriers to invest in marketing and outreach to find off-
exchange consumers to let them know that they are now eligible 
for financial help.
    Is this something that the Biden administration could do as 
well?
    Ms. Keith. Thank you, Congresswoman, for that question.
    So I would first say that I think the CBO's estimates are 
low on this point, in part, because the enhancements are only 
temporary. So if and when those enhancements were made 
permanent, I think we would see those numbers increase 
significantly. So I do want to make that point.
    In terms of what Covered California is doing, I think 
Covered California has really led the way in investments in 
marketing and outreach. They have put together entire reports 
about how that has helped keep premiums down in our State and 
really brought in healthier and younger people.
    So far, the Biden administration has allocated about $50 
million to advertise the current special enrollment period 
that's running through Healthcare.gov.
    I think an even greater investment is needed, and certainly 
I think to undo some of the harm that we have seen over the 
past 4 years. Many uninsured people are unaware of the 
Affordable Care Act.
    I think the same is going to be true of this new financial 
help that is available, and I think it is on all of us to make 
sure that people understand their options.
    Ms. Matsui. Well, thank you very much.
    And in California we really build up the plan to maximize 
enrollment and based upon marketing principles. So we hope to 
encourage the administration to do the same too.
    From PPE and testing to treatment and vaccinations, 
inequitable access has been really a defining characteristic of 
the COVID-19 pandemic, an enduring problem in this healthcare 
system.
    The ACA's Medicaid expansion helped reduce longstanding 
racial disparities in health coverage, but we know that 
coverage alone is not enough to eliminate these disparities. 
This is one reason why the American Rescue Plan injects new 
resources to States, localities, and directly to families.
    Ms. Mann, can you provide an example of how some States are 
working to address social determinants through their Medicaid 
programs?
    Ms. Mann. Certainly, and thank you for that question.
    Let me start with your home State, which is the State of 
California, which has been operating under a Medicaid waiver 
and has had something in place, pilots around the States called 
Whole Person Pilots.
    Ms. Matsui. Yes.
    Ms. Mann. Whole Person Care Pilots that have invested in 
social determinants of care, has addressed homelessness, has 
addressed housing insecurity issues, has addressed hunger and 
violence, and other needs that people have.
    And they are now looking, the State of California is now 
looking to make that program statewide and make sure that whole 
care is provide, meaning that we do not release people from a 
hospital if they are homeless. That is not good care. That is 
not smart care. That is not cost-effective care.
    So increasingly we are seeing States do that. North 
Carolina is a State that is just about to embark on major 
system transportation in its Medicaid program where buying 
health is the mantra, and that is health needs with excellent 
medical care, but also really thinking about those health-
related issues that can drive bad health and healthcare costs.
    So we have seen an enormous number of States really move 
ahead, particularly in COVID times, realizing the link between 
social barriers of health and delivery of healthcare is so 
important if we are going to get good results.
    Ms. Matsui. So you would recommend that Congress support 
these types of programs moving forward?
    Ms. Mann. I think that it is really important to support 
it, and there are a number of ways it can be supported. Part of 
it is in our healthcare system itself, making sure that 
payers--Medicaid, Medicare--commercial payers, recognize some 
of these services.
    But also we need other investments. We need more affordable 
housing.
    Ms. Matsui. Right.
    Ms. Mann. We need investments that increase SNAP benefits. 
They are all important ingredients to really making sure that 
the whole person is cared for and that people actually can get 
healthier as they move through the system.
    Ms. Matsui. Well, thank you very much, and I agree with 
you.
    And I yield back.
    Ms. Mann. Thank you.
    Ms. Eshoo. The gentlewoman yields back.
    It is a pleasure to recognize the gentleman from Florida, 
Mr. Bilirakis, for your 5 minutes of questions.
    Mr. Bilirakis. Thank you, Madam Chair. I appreciate it very 
much. Thanks for holding this hearing.
    The first question is for Mr. Cameron.
    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 did not enroll.
    However, in the decade since its enactment, insurance costs 
continue to rise. Why is that?
    Mr. Cameron. Well, I think it is a number of reasons. Thank 
you for the question.
    It is because those that are healthy are pushed out. Those 
that do not qualify for a subsidy are forced out. So if you are 
a schoolteacher and your employer offers you coverage but it 
does not pay for the coverage on your spouse and your kids, you 
do not get a subsidy.
    If you are a rancher or a farmer, you do not qualify for a 
subsidy because your incomes are too unpredictable. All of 
those things, that family glitch and the unpredictable nature, 
have forced the young and healthy out while costs have 
continued to rise.
    And so what you have in our marketplace, what we have 
essentially is those people who absolutely need coverage or who 
are subsidized. About 85 percent of our folks, maybe even 90 
percent of our folks receive a subsidy, and it has to be a 
significant subsidy. If it is just a $50 subsidy on a $1,000 
premium, it does not get people to buy.
    Mr. Bilirakis. Thank you.
    A second question for you, sir. CMS released a report in 
August of 2019 on individual insurance market enrollment 
trends. Data show that between the years 2016 and 2018, 
unsubsidized enrollment declined by approximately 40 percent.
    If the ACA has fulfilled its promise to provide affordable 
health coverage to all, why has this decline occurred?
    And is it an absolute affordability issue? And if so, how 
has Idaho, your State of Idaho, responded to increased 
enrollment and its risk pool?
    Mr. Cameron. Yes, thank you very much for the question.
    First of all, it absolutely has happened. We have seen it 
happen in our State, and essentially people are being forced 
out of the marketplace. They are unable to afford those prices.
    And so if you are not getting a subsidy, you do not have 
any choice. Your choices are going without coverage or going to 
a Health Sharing Ministry Plan or going to a short-term plan.
    And so what we did in Idaho is we said, OK, if this is 
where people are being driven, how do we improve the 
marketplace? How do we help the ACA plans?
    And so we said, OK, if you are going to offer long-range, 
short-term plans, you have to meet the conditions of the ACA. 
You have to have all of the essential health benefits. You have 
to not have preexisting condition clauses if you are selling at 
the same time on the exchange, and you have to be part of the 
same risk pool.
    So we tie the rates together. So if the rate increases 
occur to one, it occurs to both of them. So they are all 
sharing the same risk pool.
    And in my mind that is what the ACA was intended to do, was 
to do that, but then the rule and subsequent decisions forced 
individuals out and have made prices higher. So if you are not 
getting the subsidy, if you are in the family glitch, you are 
not getting the benefit of you being in the risk pool.
    Mr. Bilirakis. Thank you very much.
    The next question is for Ms. Carey.
    How are hospitals complying with the price transparency 
rule issued by the previous administration? I think you 
addressed that.
    Where do the biggest issues persist in achieving true 
transparency, and how can Congress address this?
    Ms. Carey. Thank you, Congressman, for the question.
    Congress can address this by putting a law in place that 
further reinforces the rule and going further in requiring 
hospitals to show not only their discounted cash prices, but 
all of their secret negotiated rates with all of their 
contracted payers.
    And insurance companies are supposed to follow a rule that 
lands January 1, 2022. We need Congress to make sure and HHS to 
make sure these rules get put in place and get recognized and 
are enforced.
    Hospitals are not complying with the rule as it stands. We 
see a lot of good investigative media coverage exposing that. 
They really need to be held accountable. We really need 
machine-readable formats so data innovators can aggregate the 
data so we can start to shop for prices the way we shop for 
airline tickets, and the competition will kick in and the 
prices will come down.
    Mr. Bilirakis. Thank you.
    And, Madam Chair, in the interest of time, I will go ahead 
and yield back the rest of my time.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize the gentlewoman from Florida, 
Ms. Castor, for your 5 minutes of questions.
    Ms. Castor. Well, thank you, Madam Chair. Thanks for having 
this very important hearing on how we expand coverage and lower 
healthcare costs, including two of my bills.
    But first, happy 11th year anniversary to the Affordable 
Care Act. It has provided affordable coverage and health 
coverage for families, and on behalf of the over 2 million 
Floridians who go shopping on the healthcare marketplace, and 
that is where they get their affordable coverage, thank you, 
thank you.
    On behalf of the seniors in Florida who have stronger 
Medicare, thanks, on behalf of all of the young people who have 
been able to stay on their parents' insurance.
    And by the way, when you are talking about choice, here in 
the Tampa Bay area if you go shopping in the ACA marketplace, 
there are over 100 private plans that you have to choose from. 
So I think that highlights the importance of navigators.
    But now, thanks, colleagues and the American Rescue Plan, 
we have made ACA coverage even more affordable. One estimate in 
the Sunshine State is we have over 300,000 families that are 
newly eligible for expanded tax credits. So that is going to 
make a real difference.
    And of course, we still have the issue of expanding 
Medicaid in Florida. If we were to do that, not only would we 
bring billions of dollars of our tax money back to the State 
and expand economic activity, as Cindy Mann has said, but this 
would make a real difference in the lives of so many 
Floridians.
    So hopefully they will hear what Congressman Butterfield 
said. Do the math. This is a benefit.
    And I want to thank Representative Veasey, who has worked 
on this with me, and his terrific Incentivizing Medicaid 
Expansion Act, and Representative Schrier, Dr. Schrier, thank 
you for your work on the KIDS Act. That is the primary care 
that will boost the Medicaid reimbursement rates as well.
    But I want to spend my time on navigators and the 
outrageous junk plans. One of my bills is the Expand 
Navigators' Resources for Outreach, Learning, and Longevity 
Act, or the ENROLL Act. It will provide continuity for families 
and navigators.
    And I would like to ask Ms. Hatcher first of all, you said 
that you used the navigator to help you shop for coverage in 
the ACA marketplace. How did the navigator help you find 
coverage that was right for your family?
    Ms. Hatcher. Thank you for the question.
    The navigator was actually quite indispensable. You know, 
shopping for healthcare is overwhelming under the best 
circumstances. There are lots of different options, and trying 
to figure out what will be the right fit for your family is a 
challenge, especially when you do not have the backing of an HR 
department.
    So the navigator kind of functions as your own HR 
professional. She or he lets you know what your options are. 
You can talk through different plans. They help you determine 
what your subsidies may or may not be.
    So it has been truly indispensable, and they also help you 
be sure that the coverage that you think you are getting is 
what you are getting.
    What we learned through the ACA is that we were actually 
able to purchase better insurance than what had been offered 
through my husband's employer-sponsored care. We had more 
options. We were able to choose a plan with a company that we 
trusted, and it was actually a very, very good experience, very 
positive.
    Ms. Castor. Thank you.
    Now on junk plans, Ms. Keith, thank you for your 
outstanding testimony. I am so concerned about these junk plans 
and the fact that so many of these companies take advantage of 
our neighbors.
    In fact, I just got word this morning when I was asking for 
that update on how many plans were in this local area. They 
shared a story that just last week a couple was dropped without 
notice. They had one of these junk plans and was dropped 
without notice. They did not find out about this until they 
went for a CAT scan.
    They did not have coverage because this short-term plan, 
they hightailed it out of there, and they had to pay out of 
pocket for the CAT scan.
    And we just cannot have folks suffering like this anymore. 
We know that a lot of these plans have these fraudulent 
marketing tactics, too, but talk to us, too, about some of the 
back-end tactics that these plans engage in to avoid paying 
medical bills.
    Ms. Keith. Thank you for that very important question.
    So some of the back-end tactics, many of these companies 
engage in what we call rescission. So as soon as someone 
actually needs healthcare--and maybe this applies to the couple 
that you are talking about in Florida--as soon as they need 
healthcare, the insurance company will pull their application, 
will ask for medical records going back 3, 5, 7 years and comb 
through all of that information looking for a reason to tie the 
healthcare that they need either to a preexisting condition or 
some reason why they should not have issued the policy in the 
first place.
    That gives the company grounds to pull back, to rescind, to 
cancel the policy, leaving the person without any type of 
coverage at all and fully responsible for their medical bill. 
It is one of the biggest abuses that we have seen.
    Ms. Eshoo. Your time has expired. Thank you, Ms. Castor.
    The Chair is pleased to recognize the gentleman from 
Missouri, Mr. Long, for your 5 minutes of questions. It is good 
to see you.
    Mr. Long. Thank you, Madam Chair.
    And I hate to go over plowed ground, but whenever the ACA 
was about to come into effect, we had discussions about the 
navigator, and if memory serves, you could not be a navigator 
if you knew anything about insurance. If you had any nexus to 
insurance, you were disqualified from being a navigator.
    So to me that was kind of like if your car needed repair, 
you can take it to someone, anyone but an automobile mechanic.
    So with that being said, Director Cameron, here is my 
question for you. You talk about the importance of getting 
people into the marketplace to stabilize and lower premiums. 
The ACA Navigator Program has consistently underperformed in 
its enrollment goal.
    In 2017 and 2018, navigators enrolled only 1 percent of 
total enrollees and had comparable outcomes for 2018 and 2019. 
Agents and brokers, which are licensed and trained to educate 
the people on insurance, can be much more effective and cost 
efficient in assisting people obtaining coverage.
    CMS noted that in 2018 agents and brokers were responsible 
for 42 percent of enrollees at an average cost of $2.40 per 
enrollee.
    Can you discuss how effective the Navigator Program has 
been, and do you think we should be providing an additional 
$100 million to the program collected from exchange user fees?
    Mr. Cameron. Thank you, Congressman, for that question.
    No, I do not. In our State, we have used some navigators, 
but the bulk, about 80 percent of our folks that are enrolled, 
use an agent who actually is, as you said, licensed and 
trained. They have to go through an extra training program to 
work through our State-based exchange so that we make sure that 
they are covering all of the facets appropriately.
    And that is how the majority of Idaho citizens obtain their 
individual coverage, and frankly, that is the safest. That is 
the safest way. They are responsible for what they helped 
individuals purchase. And so we think, rather than spend that 
money that way, that it would be better to more embrace the 
agent community and the agent population.
    Mr. Long. Do you think navigators should be able to 
consider short-term, limited-duration plans when assisting a 
potential enrollee?
    Mr. Cameron. I do not believe a navigator would have the 
expertise to be able to distinguish between a good short-term 
plan and one that maybe is not as good. So I would have some 
heartburn with that.
    Obviously, if they became licensed and were trained, even 
though they are operating as a navigator--but if they are 
licensed and have all the same or similar training as an agent, 
then perhaps they could.
    Mr. Long. What are some of the headwinds and challenges 
that agents and brokers in your State face helping people 
obtain coverage in the ACA marketplace?
    Mr. Cameron. Yes. Perhaps the most difficult one is ones 
that I have already mentioned. They have folks that want 
coverage, that know the importance of coverage, like the 63- 
and 62-year-old from Twin Falls, Idaho, who wants coverage, but 
prices got too high, $1,500 a month. So they are forced out of 
coverage.
    They actually went to the traditional-style short-term 
plans, which are not the better ones, and they are hopping from 
one company to another company until they turn 65. And in the 
meantime, that is hurting the overall risk pool.
    Or we have individuals that, because they are, you know, 
like I said, a spouse or schoolteacher, they cannot afford the 
dependent coverage on the school district's plan, and so they 
are forced to go without coverage, and if they are basically 
healthy, then they are choosing to take that risk on 
themselves.
    We believe that the appropriate use of short-term plans as 
in-between coverages is appropriate. It saves lives. It saves 
with early diagnosis and early treatment of conditions, and 
they have the opportunity then at the open enrollment then to 
move over to an ACA plan.
    Mr. Long. Well, I know that since 2013 premiums in 
individual markets have tripled, just since 2013 here in 
Missouri. So we are going to have to figure out some kind of 
way to consider lowering premiums for the Affordable Care Act 
plans beyond just throwing more money at this problem.
    And my wife's car is having some issues, and so I am going 
to head out now and yield back because I need to head over here 
to the dry cleaners and see if they can fix her car.
    I yield back.
    Ms. Eshoo. I am sorry. I did not follow my own rules about 
unmuting.
    The Chair now, let's see, recognizes Mr. Schrader of Oregon 
for your 5 minutes of questions.
    Mr. Schrader. Thank you, Madam Chair.
    The Affordable Care Act has been an unqualified success for 
millions and millions of Americans. Having said that, there are 
still a few that unfortunately do not have access, those in 
those States that decided not to do the Medicare expansion, 
which I find unbelievable.
    When I was budget chair in Oregon, it was a no-brainer. If 
the Feds are going to, you know, pay 95 or 90 percent of the 
bill paid on healthcare, it would save my State money in the 
long run.
    So, hopefully, listening to the testimony States are 
gradually figuring out that they really need to do that.
    The other problem that was not anticipated in the 
Affordable Care Act is the problems with upper-middle-class 
individuals that do not qualify for subsidies, and Mr. Cameron 
has talked about that. Actually you all have at that.
    And I guess one of the cost-containment options that you 
did think was reasonable, Mr. Cameron, was the reinsurance or 
risk pools. Could you comment on that? I mean, there is 
evidence that it can reduce premiums by almost 17 percent. 
Could you comment on that briefly?
    Mr. Cameron. Thank you, Congressman, for the question.
    In Idaho, we have a high-risk invisible reinsurance pool. 
So what happens, we actually take some of our premium tax 
dollars as well as some other funds that we were able to cobble 
together. Carriers, insurance carriers, buy the reinsurance. So 
they have to determine whether they are going to seed the risk, 
and we help cover those most expensive treatment items with 
about 50 percent coinsurance, if you will, to the insurance 
company.
    The consumer does not know that their condition is being 
reinsured. So they are protected. At the same time it has 
helped lower cost over time.
    We have not seen quite the level that you mentioned, 
although we are a small State with a small pool of money, and 
so we are only covering those high-risk items for which we can 
afford. The larger the pool, the more we could afford to cover, 
but I think that has----
    Mr. Schrader. Very good.
    Mr. Cameron. I think the bill would need some amending.
    Mr. Schrader. Very good, very good. But I have heard both 
Democrats and Republicans talk about risk pools, reinsurance 
program. So there seems like an area of commonality.
    You also talk a little bit about the short-term plans. On 
one hand, some can be taking advantage. We have heard about the 
bad actors, but there are some good actors. It has a role. I 
actually like what you say about bridging insurance, longer-
term insurance.
    And you commented that in Idaho they had to meet at least 
the essential benefits that were in the Affordable Care Act. Is 
that correct?
    Mr. Cameron. Yes, that is correct. We actually went and 
drafted a bill, worked with the legislature, and allowed us to 
devise what we are calling the enhanced short-term plans. We 
would prefer not to call them short-term plans, but that was 
the opportunity we could move forward with.
    Mr. Schrader. Well, it would seem to me the goal of the 
Affordable Care Act was to make sure that you could not 
shortchange--all of the comments we have heard here today, you 
know, individuals who are not reading the fine print--and as 
long as you had the essential healthcare benefits in either 
short-term plan or an association plan.
    I mean, you know, if we had association plans that were 
required and you had essential benefits that were similar to 
the ACA, I think that would also be an area of commonality.
    Another point that my colleagues on the other side of the 
aisle bring up all the time are health savings accounts and 
flexible savings accounts. Is there a role for that, Mr. 
Cameron, in helping people that do not get the subsidies for 
healthcare?
    Mr. Cameron. Absolutely. We are big fans of using the 
health savings accounts, particularly amongst those that are 
healthy. Those are some of the ideas that need to be discussed 
as we bring or draw back the healthy of all ages back into the 
marketplace.
    People do not like buying insurance if they do not feel 
like they are going to need it or utilize it, and so then they 
end up with a situation where they are going bare and all of a 
sudden find out they do not have coverage. So we think that 
there ought to be some options and choices within the ACA that 
would openly allow health savings accounts so that those that 
are healthy can buy less expensive coverage and set other money 
aside in their health savings account.
    Mr. Schrader. Well, it seems to me there is a marriage here 
between making sure low-income folks get the cost-sharing 
subsidies they need, get the Medicaid coverage or subsidies in 
the Affordable Care Act, and then there is, you know, an 
opportunity at the higher end of the income spectrum to make 
sure they also can afford healthcare.
    That really is our goal here, making sure everyone has 
affordable healthcare.
    So I appreciate everyone's testimony. It has been very 
helpful, and I think this is an area we can get together and 
work on.
    And I yield back, Madam Chair.
    Ms. Eshoo. The gentleman yields back.
    The Chair recognizes the gentleman from Florida, Mr. Dunn, 
for your 5 minutes of questions.
    Mr. Dunn. Thank you very much, Madam Chair.
    Let me start by associating myself with Representative 
Schrader's remarks.
    I am pleased to be discussing ideas to lower healthcare 
costs for the American people. As we all know, healthcare 
coverage does not always equal access to affordable, quality 
healthcare. We are not better off if more people technically 
have coverage by insurance but still face sky-high deductibles 
and exorbitant prices.
    I believe that price transparency throughout the healthcare 
system will empower patients to choose their care and 
ultimately lead to lower cost.
    Patients should be able to know how much a visit will cost 
before they show up, and they should know how that cost might 
vary at other hospitals, clinics, and offices.
    The physician-patient relationship also needs to be 
preserved. It is the pillar of a patient's trust in the 
healthcare system. Medical choices should be made by patients, 
doctors, and families, not bureaucrats. Physicians have the 
knowledge and the best interest of their patients at heart.
    And we should be wary of any actions by insurance plans to 
restrict choices and insert themselves into what should be 
doctor-patient decisions.
    As we think about transparency, preserving the doctor-
patient relationship, and lowering cost, we must focus on 
policy that drives value in the healthcare system. We can do 
this with policy incentives that encourage efficient, evidence-
based, integrated care that considers the whole patient.
    We can and we must modernize our healthcare. We think we 
can improve healthcare outcomes while we lower healthcare 
costs.
    So Ms. Jameson Carey, you are a proponent of healthcare 
price transparency to lower healthcare costs. What is the role 
of the physician when helping patients navigate the system? And 
how can physicians increase price transparency?
    Ms. Carey?
    Ms. Carey. Thank you for the question, Congressman.
    Doctors want to show their prices. Doctors are on patients' 
sides. They are not on the side of insurance companies 
necessarily. They want to know prices. They want to be able to 
tell their patients how much things cost, and sometimes they do 
not even know.
    Doctors come to me all the time saying, ``I just want to 
restore the doctor-patient relationship and get the hospital 
administrators, the government, and the insurance companies out 
of the exam room. But I spend the first 10 minutes of my visit 
with the patient answering questions to qualify for certain 
reimbursements or certain coverages, and it is a waste of time, 
and I need to get back to helping out my patient.''
    Unfortunately, doctors are very nervous about posting their 
prices because there are two upper questions for them. They all 
want their prices out there, but they are afraid if they put 
their cash prices out there that insurance plans will cancel 
them because their cash prices will look so much better than 
their contracted rates with insurers.
    I have also talked to doctors who put their prices up and 
the hospital tells them to take the prices down or they will 
lose their privileges because it's threatening to the hospital 
who charges four times more.
    So we need this to be open. We need to shine some sunshine 
on this situation. We need doctors to be free to post their 
prices and not to get the reprimands and return the 
relationship between the doctor and the patient, as you so 
eloquently pointed out.
    Mr. Dunn. So I agree. I mean, in my practice we actually 
were forbidden from revealing prices publicly because that was 
equivalent, in the insurance company's view, of sharing, price 
fixing with other physicians across town. It was a crazy 
situation.
    And the same is true, by the way, of other services. 
Radiology stands out in my mind. I was a patient this past 
year.
    And I want to talk to you, by the way, offline about this 
later, Ms. Carey.
    So do doctors in your association, Ms. Carey, have adequate 
access to price information across the system? It is funny. You 
alluded to many who do not know the cost of the very services 
that they order, you know, for their patients. So is there 
something that we can do to help them know that?
    Ms. Carey. Well, I think if you made it easier for everyone 
to have their prices transparent, they would really appreciate 
that because they refer a patient to a MRI and they do not 
always know how much that is going to cost them, and they would 
like to be good stewards of their patients' finances and they 
do not have enough access to prices themselves. They almost 
have the same access the rest of us have.
    So they are operating in the dark. So, if we get more 
sunshine and more transparency, they are going to be able to 
steer their patients to the best value providers.
    Also, if they remain independent, they are not required to 
forward all of their patients into the health system where 
costs are the highest. So employee physicians must refer into--
--
    Mr. Dunn. We are running out of time, but I want to talk to 
you later, your association later, and I cannot agree with you 
more.
    We were literally forced to turn patients back into a 
system that outrageously overcharges them, and I have great 
examples of that.
    Thank you, Madam Chair. I yield back.
    Ms. Eshoo. Thank you. The gentleman yields back.
    It is a pleasure to recognize the gentleman from 
California, Dr. Ruiz, for your 5 minutes of questions.
    Mr. Ruiz. Thank you, Madam Chair.
    Today we celebrate 11 years since the Affordable Care Act 
became the law of the land. This historic, lifesaving piece of 
legislation has helped millions of Americans access healthcare, 
and as this past year has made clearer than ever, having an 
affordable option that is not tied to employment is critical to 
the millions of families that rely on the marketplace or 
Medicaid for their healthcare.
    Of course, there is still more that needs to be done, which 
is why we are having this hearing today and why it was so 
important that the American Rescue Plan was just signed into 
law to expand coverage and reduce the cost of healthcare for 
millions of Americans.
    As I have been on the ground administering vaccines to 
underserved communities in my district, I can say unequivocally 
that now, during this public health emergency, is precisely the 
time to expand healthcare.
    Access to healthcare is a human right, not a privilege for 
just a select segment of the population. Whether or not someone 
has access to affordable healthcare should not depend on their 
ZIP code or how much money they make or how healthy they are, 
which is why we must keep working to reduce gross health 
disparities, achieve health equity, and create an America where 
every person has access to quality, affordable healthcare.
    And on the topic of health equity, today I would like to 
focus on an area of health equity that does not get as much 
attention as it should: the Indian Health Service.
    Today we are considering my bill, H.R. 1888, the Increasing 
Access to Indian Health Service Act, which extends 100 percent 
Federal Medical Assistance Percentage, the FMAP, to urban 
Indian organizations and allows Tribal health programs to 
receive reimbursements for services provided outside of the 
four walls of their clinic.
    IHS provides healthcare to 2.2 million American Indian and 
Alaskan Natives every year. Across the United States, 41 urban 
Indian health programs provided medical services to over 65,000 
people per year. Even though they are a vital part of the 
Indian Health Service provider network, they only receive about 
1 percent of the annual IHS budget.
    Furthermore, urban Indian health programs are the only IHS 
facilities that do not receive 100 percent FMAP for Medicaid 
services. Under the American Rescue Plan, I successfully 
advocated for the next 2 years urban Indian health programs 
will receive 100 percent FMAP, but this is merely a temporary 
policy. We need a permanent fix.
    Ms. Mann, what is the current FMAP for the urban Indian 
health programs?
    Ms. Mann. The services that are provided through the 
Medicaid program would be at the State's regular Medicaid 
match, Congressman. So in California that would be 50 percent, 
and so a very significant difference from what the American 
Rescue Plan has provided and what your bill would provide on a 
more permanent basis.
    And you are absolutely right. It is the one portion of that 
delivery system which is left out of the 100 percent match and 
really important----
    Mr. Ruiz. And is there any policy basis for this disparity 
in how the Federal Government funds services received for 
different Indian health providers?
    Ms. Mann. I believe it is, like the Medicaid expansion, it 
is sort of an accident of history, right, in terms of who 
[inaudible]. So I would defer to you to have a better sense of 
that.
    Mr. Ruiz. A 100 percent FMAP----
    Ms. Mann. But there is no sound policy basis that I know 
of, Congressman.
    Mr. Ruiz. Thank you. Thank you.
    A 100 percent FMAP for UIOs means the Federal Government 
would cover a greater portion of Medicaid care. Is it fair to 
assume that this could help incentivize States to increase a 
pay raise to these financially strained providers?
    Ms. Mann. I think it can. I think it can help them increase 
pay for staff. It can help them provide their navigation help. 
It can help them address things like emotional determinants. It 
can really provide a more robust platform of providing care and 
assistance to people.
    Mr. Ruiz. Thank you.
    It is critical that we pass my legislation to ensure this 
long-overdue policy is implemented permanently.
    Finally, Ms. Mann, I would like to ask you about the other 
provisions of H.R. 1888 that would permanently allow IHS 
clinics to receive Medicaid reimbursement for services provided 
outside of their clinic.
    The administration recently extended a grace period that 
allows for this type of reimbursement through the end of fiscal 
year 2021. My understanding is that there is nothing in 
statutes or regulations that guarantees that this ability to 
bill Medicaid for these services will extend beyond that date.
    Ms. Mann, would it be beneficial to ensure that Tribal 
healthcare providers can maintain this reimbursement for care 
outside of the four walls of their clinic beyond 2021?
    Ms. Mann. Absolutely, and there have been steps taken under 
the Obama administration that were taken to be able to extend 
that 100 percent FMAP for contracted providers, but it has not 
been as evenhandedly provided for as your legislation would do.
    And I think there has been a lot of temporary flexibilities 
that have been granted during the pandemic that States and the 
Federal Government and healthcare providers need to look 
carefully at and determine which ones ought to be made 
permanent.
    Mr. Ruiz. Thank you. I yield back.
    Ms. Eshoo. The gentleman's time has expired.
    The Chair is pleased to recognize the gentleman from Utah, 
Mr. Curtis, for your 5 minutes of questions.
    Mr. Curtis. Thank you, Madam Chair.
    I am so grateful for all of our witnesses today. I am 
finding myself wishing I had an hour with each one of them. 
Thank you for your thoughtful testimonies.
    A quick thought, not a question, Ms. Jameson Carey. I 
actually had four surgeries last year, and I can speak 
firsthand to the confusion of pricing.
    And one of the points that I do not think was made but I 
would like to throw in here is this confusion and the multiple 
bills that come after surgery make it very, very difficult for 
the average consumer to get insurance reimbursement. And I 
would just like to kind of throw that in to validate your 
point, in addition to what you have said.
    Mr. Cameron, we have a couple of connections. We share a 
border. I am from Utah. I noticed in your bio you are third-
generation insurance agent. My father was an independent 
insurance agent, and his father was an independent insurance 
agent, and I broke that third-generation link. In hindsight 
maybe I should have gone into insurance.
    But I remember my father taught me a couple of lessons when 
I was very young about insurance that I feel like we have 
forgotten in today's world.
    The first was that you only buy insurance for things that 
you cannot afford to pay for, and I feel like in today's world 
we want insurance to cover dollar one, and we could reduce the 
cost of insurance, I think, if we could remember that.
    The second thing he taught me was to never get a traffic 
ticket because it makes your insurance go up, and it is a very 
simple example, but I think we also forget sometimes what we do 
that causes the cost of insurance to go up.
    Now, a question for you, Mr. Cameron. In the last Congress 
I had a bill. It was called the American Health Share Plans 
Act, and in essence what it did is it would permit member 
companies--Costco is maybe a good example that would come to 
mind for everybody, or similar companies like that with 
membership--to sponsor healthcare plans, particularly across 
straight lines. In Costco's case, they have 84,000 members.
    Have you heard of that plan? And do you see how plans like 
that, large and small, might be able to help us reduce the cost 
of health insurance?
    Mr. Cameron. Certainly, and thank you for the question, and 
thank you for being a good neighbor.
    First, we have worked very carefully with association 
plans. We have also worked with our legislature on a bill for 
selling across State lines. It can be done.
    The biggest fear about selling across State lines is, where 
does the consumer go when they have bought a plan that is not 
licensed in Idaho? Where do they go? And so we were able to 
address that with collaboration of other States that are 
struggling. That is with Utah, Oregon, Washington, Nevada, 
Wyoming, et cetera. And so we have been able to address that.
    We have been working also with association health plans. 
The biggest dilemma there is in many cases some of the 
associations want to just carve out special niches and insure 
those. And we pushed back on that and said, look, you have got 
to take everybody who is a member of that association.
    Mr. Curtis. Yes.
    Mr. Cameron. If you are a Chamber, you have got to pick 
everybody who is a Chamber.
    Mr. Curtis. And you will excuse me for jumping in, but we 
have got such limited time.
    I would like to just reiterate something that you just said 
in your opening remarks about the States being laboratories. 
And I think you have brought many good examples today. I wish 
we could bring all 50 State commissioners to the hearing to 
learn individually what they have learned about all of their 
different ways to approach things.
    Quickly, Ms. Mann, we have heard a lot of emphasis today on 
why not all of the States are jumping into Medicaid expansion, 
and I have a theory on that, and that is that we want this one-
size-fits-all from Washington, DC, without letting them have 
any flexibility.
    Bipartisan healthcare solutions and the Medicaid program 
include 12-month continuous coverage in addition to promoting 
greater fiscal responsibility with the waiver program.
    Utah was previously approved for waiver that included work 
requirements. That is important in our State, but the Biden 
administration recently notified the State that its waiver did 
not promote the objectives of the Medicaid program.
    Do you believe we could get more participation from States 
and have better policy if we did not have this one-size-fits-
all Medicaid approach?
    Ms. Mann. Congressman, that is a really important question.
    And I would say that, first--I will get to the work 
requirements issue in a second--but first, there is an enormous 
amount of flexibility in the Medicaid program, and you know, 
there is the common phrase which I think is accurate, which is 
if you have seen one State's Medicaid program, you have seen 
one State's Medicaid program.
    States decide on their delivery systems and their payment 
rates.
    Mr. Curtis. Ms. Mann, we are going to run out of time. I 
would love to let you go because you have so many important 
things to say.
    Let me say in the last few seconds I have got, just a real 
plea for the individual needs of States, realizing that we do 
not have all of the answers at the Federal level.
    I wish we had more time. I am sorry. I am out of time.
    Ms. Mann. I could not agree more.
    Mr. Curtis. Thank you.
    Ms. Eshoo. The gentleman yields back. Thank you, Mr. 
Curtis.
    A good exchange. We learn so much in hearings. I love 
hearings. They are long, but they are highly instructive.
    It is a pleasure to recognize the gentleman from Maryland, 
Mr. Sarbanes, for his 5 minutes of questions.
    Mr. Sarbanes. Thanks very much, Madam Chair.
    I am very honored to have Ms. Hatcher on this panel as one 
of my constituents today, and I want to thank her for her very 
important perspective.
    Ms. Hatcher, thank you for sharing your family's story. I 
wondered if you could describe a little bit more the challenges 
caused by the COVID-19 pandemic in terms of the impact on your 
family and how you were able to access the ACA marketplaces for 
coverage, in view of that, and just generally share your 
perspective on why that kind of coverage opportunity is so 
critical.
    Ms. Hatcher. Thank you so much for your question. It is a 
pleasure to be here as well.
    First, I just want to recognize that so many people, 
particularly communities of color who we know have been very 
hard hit by this pandemic, have had it more difficult than I 
have. I am grateful for my ability to work from home, and I am 
grateful for my resources like computers that I have been able 
to take advantage of.
    But having said that, the COVID pandemic has been very hard 
on my family, as it has been for many others. My daughter, who 
is a senior in high school, she has missed pretty much every 
milestone.
    For my son, online learning has been really hard. He has 
got cognitive disabilities, and remote therapy and remote 
classes, you know, I am very worried about the regression that 
this may have caused him.
    It has also been really hard to juggle supporting Simon in 
those ways and, you know, try to work full time in this current 
economic environment.
    Losing Simon's DSP, losing those kinds of supports, that 
has been a real blow. We were really focused on working towards 
his independence, and not being able to have those resources 
has made it even more challenging in an already challenging 
time.
    Being able to access the ACA has been one of the bright 
spots. It has allowed us to have the security of knowing that 
we have health coverage, especially when, you know, we are in a 
global pandemic, and it is pretty scary out there when it comes 
to one's ability to maintain one's health.
    Having the ability to choose what program we went with, 
having the ability to have the Medicaid support for Simon has 
been enormously beneficial.
    Mr. Sarbanes. Thank you very much. I appreciate that.
    You know, one of the things that the American Rescue Plan 
did was it built, as we know, on the Affordable Care Act in 
significant ways, potentially transformative ways on making it 
possible for more Americans to access in an affordable way 
healthcare coverage at a time when they were struggling 
financially.
    It expands the ACA's tax subsidies, including for the first 
time for Americans above 400 percent of the Federal poverty 
line. And we know that this has been a real issue for families 
across the country. So the ARP was a meaningful response to 
that challenge.
    Ms. Keith, can you talk briefly about how many individuals 
are expected to see their monthly premiums decrease as a result 
of the American Rescue Plan, sort of what we built onto the 
ACA, improved it, and how many uninsured individuals will 
qualify for these expanded subsidies?
    Ms. Keith. Thank you for that question.
    So the current 9 million subsidized enrollees are going to 
see their premiums go down. They can return to Healthcare.gov 
or their State-based marketplaces in most States beginning on 
April 1 and start to see savings on average of about $50 per 
month per person. So big savings, money back in people's 
pockets.
    That is in addition to the 14.9 million uninsured people 
who will be eligible for these subsidies, including the 3.6 
million uninsured families who are above that 400 percent 
poverty line threshold that you mentioned who have never been 
eligible before.
    And I think this is really going to close the gap for some 
of the people that have enrolled in the short-term plans and 
the Healthcare Sharing Ministries and have really been cut off 
from access. I think it is going to be transformative for these 
families.
    Mr. Sarbanes. I appreciate that very much.
    You know, for a long time we talked about how we could 
build on the foundation of the ACA, strengthen it, expand it 
with, lift it higher.
    For years we had to be in a kind of defensive posture 
against the repeal efforts, and that made it hard for us to do 
that. The American Rescue Plan has shown that there really is a 
path forward to expand coverage and to view the ACA as that 
bedrock.
    And I think we can learn from that, Madam Chair, and 
continue to offer great ideas to strengthen and improve 
coverage for all Americans.
    And I yield back.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize our colleague from Georgia, 
the ever moving around in his car every time we have a hearing, 
Mr. Carter.
    How are you?
    Mr. Carter. I am good, and thank you, Madam Chair. I 
appreciate it. I am trying to figure out how to do the 
background so you will not know I am in a car, but 
nevertheless, I want to truly thank you for this hearing and 
thank the panelists.
    This is a great hearing, a much-needed hearing, certainly 
something that we in the State of Georgia--this is important 
because I will tell you that we have been working for the last 
2 years to try to figure out why almost a million Georgians 
that are uninsured and are eligible for subsidies under 
Obamacare have not enrolled in the exchange.
    And about a little bit over 150,000 of these that are 
eligible for the Bronze Plans would have zero- or single-digit 
premiums per month, and we found that there are really two 
issues.
    First of all, we need to get to the people where they buy 
their insurance. And, secondly, the insurance is still far too 
costly.
    On the first issue, and that is about getting the people to 
the insurance, Georgia has proposed not using Healthcare.gov 
and instead using a network of private web browsers, such as--
or web brokers, I should say--such as HealthSherpa or 
GetInsured and other health insurance carriers to find people 
where they are.
    And what I wanted to ask you, Mr. Cameron, is have you 
found that brokers in your experience are more successful 
enrolling people than Federal trained navigators?
    Mr. Cameron. Absolutely, Congressman. I will tell you that 
Idaho has its own State-based exchange, and we did it for some 
of the same reasons you have talked about. We are the only 
Republican State that has a State-based exchange. We would 
welcome others to join us because we think it can be less 
expensive and be able to reach more people.
    Mr. Carter. So not using Healthcare.gov has not hindered 
enrollment in Idaho?
    Mr. Cameron. Not at all. That is not our issues. Our issues 
are affordability and those folks who do not believe they need 
the coverage.
    Mr. Carter. OK. So that is the first problem that we had. 
The second problem that we have had, or the second issue: 
Georgia's 1332 waiver is also planning a reinsurance model so 
that we can lower premiums up to 25 percent in some rural areas 
where there is less competition.
    And listen. There are two Georgias. There is Atlanta, and 
there is everywhere else. And in South Georgia, it is a 
problem, a big problem. We do not have as much competition as 
we should.
    But if we were to do this, Mr. Cameron, can you talk about 
how reinsurance in Idaho and how it has helped to lower 
premiums?
    Mr. Cameron. You bet. First of all, we did not use the 1332 
waiver. We attempted to, frankly, found that the 1332 waiver 
process was too cumbersome and too difficult for what we were 
going to gain from it.
    So we just adopted our own program, and we looked 
prospectively. We have one-quarter of our premium tax looking 
prospectively. It is deposited into our account. We set up the 
reinsurance process with a board that I appoint that is made up 
of both consumer advocates as well as insurance carriers.
    And the insurance carriers have to pay a premium in order 
to buy the reinsurance. Plus they can be assessed if we ever 
get upside down.
    But we are not. We are operating in the black with several 
million dollars carrying over from year to year, and it does 
help reduce rates, and we hope it would reduce rates more 
significantly down the road as our pot continues to grow.
    Mr. Carter. Well, you know, we may reach out to you to find 
out exactly how you were able to do it.
    We are trying to do the 1332 waiver in the State of 
Georgia, and I hope that this administration does not think it 
knows better than what we know in Georgia what we need, and I 
hope that the flexibility that the 1332 waiver offers is 
absolutely crucial to getting more Georgians access to quality, 
affordable health insurance.
    So we will be monitoring this, and Mr. Cameron, we may be 
in touch with you to find out how you could help.
    But my message is simple, and that is we do not need to be 
relitigating this 1332 waiver. This is something that is 
extremely important to the State of Georgia, and I hope that we 
will be successful in this.
    And with that, Madam Chair, I will yield you back 30 more 
seconds.
    Ms. Eshoo. Well, we thank the gentleman who yields back, 
and drive safely. I think someone else is driving, right?
    Mr. Carter. Oh, yes.
    Ms. Eshoo. It is a pleasure to recognize the gentleman from 
California, Mr. Cardenas, for your 5 minutes of questions.
    Great to see you.
    Mr. Cardenas. Great to see you, Madam Chairwoman, and all 
of my colleagues, and thank you so much to all of the witnesses 
who are giving us some insight and expertise about what's going 
on out there in America when it comes to healthcare.
    And also, I would like to thank the Ranking Member Guthrie 
as well for having this hearing.
    The Affordable Care Act, the ACA, significantly reduced 
racial and ethnic disparities in health coverage for children, 
including by reducing the coverage gap between Latino children 
in all up to three points in 2016.
    Nevertheless, according to recent research, the Georgetown 
Center for Children and Families, the gap between coverage 
rates for Latino children and all children widened in 2018 for 
the first time in a decade, threatening to undo the progress of 
the ACA and placing Latino children in a more vulnerable 
situation in the years prior to the pandemic.
    Ms. Keith, what can Congress do not only to reverse the 
trend and restore the gains of the ACA for Latino children, but 
fully close racial and ethnic coverage gaps for all children?
    Ms. Keith. Thank you for that question, and I would also 
welcome Ms. Mann's comments on this as well, since she focuses 
on this issue.
    I think there are many things that can be done, including 
extending coverage as you all just did under the American 
Rescue Plan to parents and making sure that parents have access 
to affordable coverage, because that translates to children's 
coverage gains.
    There have already been steps to roll back the public 
charge rule, which was disincentivizing enrollment, and again, 
I think having navigators' outreach in a moment making folks 
aware that these options are available is going to be 
critically important, including in Spanish language and with 
trusted partners out in the community doing this very important 
work.
    Much to be done. Many gains that could be made.
    Mr. Cardenas. Thank you.
    And, Ms. Mann, if you can answer that with an additional 
question that I have for you.
    Thank you so much, Katie.
    The ACA helped provide coverage to at least 4 million 
Latino adults and 600,000 Latino children once the ACA became 
law, but many of the law's benefits remain inaccessible to 
millions due to their immigration status, including those with 
Deferred Action for Childhood Arrivals, otherwise known as 
DACA.
    Latinos continue to have one of the highest uninsured rates 
in the country, at nearly 19 percent when last checked in 2019, 
and noncitizen Latinos have higher uninsured rates than all 
other noncitizen groups, regardless of income or work status.
    Ms. Mann, as Congress considers how to build upon the ACA 
and expand coverage, what can it do to better integrate 
individuals otherwise left out due to their immigration status?
    Ms. Mann. Thank you, and it is a really important question.
    So, as Katie had noted, the public charge rule certainly 
chilled people's ability to get care and to sign up for 
coverage even when they were eligible.
    So that rule has now been repealed, rescinded, but it will 
take a lot more than rescission to be able to really restore 
trust among families that they can go and apply for the kind of 
coverage that they are, in fact, eligible for. Many mixed 
households, immigration households of citizens' children were 
refraining from looking for coverage and seeking care, and that 
is very unfortunate on all levels.
    So we need to really be aggressive now about getting the 
word out and making sure people do feel comfortable when they 
are eligible.
    Then there are some people that simply are not eligible. 
There is still a 5-year bar from any lawfully present 
individuals to be able to access Medicaid coverage and CHIP 
coverage, and that can be addressed.
    And there are several groups of people who are lawfully in 
the United States, including the DACA people, who do not 
qualify and could be brought into a coverage program through 
Federal action.
    Mr. Cardenas. Thank you, Ms. Mann.
    I have a question for you, Laura, Ms. Hatcher. Are you 
aware, Ms. Hatcher, that Congress tried to end the ACA more 
than once?
    Ms. Hatcher. Thank you for your question.
    Yes, I am aware of that.
    Mr. Cardenas. How did you and your family feel when you 
witnessed that over and over and over?
    Did it seem like no big deal, or was it something that 
actually you felt afraid if the ACA were to end?
    Ms. Hatcher. When Congress initially began the attempt to 
repeal the ACA, I felt frightened and powerless, and then when 
I watched adults with disabilities lining----
    Mr. Cardenas. We have 10 seconds, Laura. Let me ask this 
one question.
    Did it feel like life and death for your family, perhaps, 
if the ACA were repealed?
    Ms. Hatcher. It is life and death for my family.
    Mr. Cardenas. It is life and death.
    Ladies and gentlemen, millions of families are in the same 
situation. Let's make the ACA better and stronger for every 
family in America.
    I yield back.
    Ms. Eshoo. The gentleman yields back.
    A pleasure to recognize Dr. Joyce of Pennsylvania for your 
5 minutes of questions.
    Mr. Joyce. Thank you for yielding, and thank you, Madam 
Chair Eshoo and Ranking Member Guthrie for holding this 
hearing. And thanks to all of the panel for appearing with us 
here today.
    Mr. Cameron, you mentioned in your testimony that the 1332 
waiver process was too burdensome and difficult, and you were 
able to implement a reinsurance program without it.
    Congress had debated increasing flexibility in 1332, and 
the Trump administration's guidance provided as much 
flexibility as it could within the law.
    Do you think, Mr. Cameron, that Congress should look to 
build on the Trump guidance and increase the aforementioned 
flexibility?
    Mr. Cameron. Well, thank you for that question, 
Congressman, and that is a tough one.
    I think that Congress should look even further, and I am 
not going to suggest we build on anybody's foundation. I think 
you should look further to allow States to be the laboratories 
of innovation, laboratories of creativity.
    Some of the provisions in law did not even allow--we were 
trying to get the 1332 under the Trump administration and, 
frankly, could not, and you would have thought we would have 
been able to but could not because of some of the barriers and 
strict interpretation of the law.
    Things like the demand that it be cost neutral, and yet 
they would define what we could measure in order to make it 
cost neutral. We could show where we were reducing costs for 
the ACA members as well as others, but it still was not 
allowed.
    So it is sort of a sore spot in our journey.
    Mr. Joyce. Mr. Cameron, let's continue along the line on 
State innovation. H.R. 1796 before us today provides grants for 
State innovation. Yet the Biden administration has suggested it 
may repeal the Trump 1332 guidance.
    Do you recommend that Congress increase the 1332 
flexibility to get the best use of the proposed State 
innovation dollars should this proposal move through committee?
    Mr. Cameron. Absolutely. To throw additional grant money at 
it does not help unless you are going to expand that ability 
for States to do things.
    I would strongly encourage to allow that. Every State is 
different. Although we have commonalities, every State has 
their unique challenges, and we should allow States to innovate 
and hopefully find solutions to lowering cost.
    Mr. Joyce. You suggest in your testimony going from a 3:1 
age ratio to 5:1. Is this something currently permitted under 
1332 today, or is that a flexibility that we should be 
exploring and providing to States?
    Mr. Cameron. Absolutely, it is a flexibility that you 
should be employing. You should at least have the GAO or some 
private enterprise study it, but we think that flexibility 
should be there to States.
    We did our own actuarial analysis using a private firm, and 
by expanding from 1 to 5, it would lower cost for everyone, not 
just the young, but for everyone. So even the seniors would be 
able to take advantage if you went to a 1:5 instead of a 1:3. 
But it is not permitted under the current statute, at least 
according to CMS.
    Mr. Joyce. I am certainly encouraged by lowering the cost, 
lowering the cost to seniors, to individuals all ages, and to 
State innovation, the point that you have made repeatedly and 
that is so important for us to understand that each State is 
individual.
    So if this committee chooses to move forward with H.R. 
1796, what are your specific recommendations in terms of how 
those funds should be structured and how those funds should be 
used?
    Mr. Cameron. Well, thank you, and I do not know that I will 
give you as specific of an answer as I would like to.
    First, I would use those funds to allow for that 
innovation, that creativity, to allow for systems like what 
Idaho has done where we are trying to attract the young and the 
healthy.
    If you do not figure out how to attract the young and the 
healthy back into the ACA, the ACA will continue to spiral out 
of control, and even families like Ms. Hatcher will be 
eventually forced out of coverage unless they are on Medicaid.
    And to me, I think we have got to figure out ways to 
attract the healthy of all ages and the young back into the 
marketplace.
    The Congress in the American Rescue Plan addressed those 
above 400 percent of poverty. As we look at it, you could go 
forward with addressing those in the family glitch.
    Mr. Joyce. I thank you for your comments.
    I see my time has expired, and thank you, Madam Chair 
Eshoo, and I yield.
    Ms. Eshoo. Good questions, Mr. Joyce.
    I am going to have to step out for a short period of time, 
and our colleague Mr. Sarbanes is going to step into the chair.
    First of all, thank you, and I believe the next Member for 
you to recognize is the gentlewoman from Michigan, Mrs. 
Dingell.
    So thank you. I shall return.
    Mrs. Dingell. Thank you, Chairman Eshoo and Ranking Member 
Guthrie, for convening today's hearing discussing a number of 
reforms and doing it to strengthen Medicaid and the Affordable 
Care Act on the 11th anniversary.
    I cannot help but think of John today and all that he did 
for healthcare for many years, and he would say to Republicans 
and Democrats gathered, ``You need to work together.''
    But I am also reminded of his father, who was one of the 
authors of Social Security, and some of the things I hear today 
were said 80 years ago, and it is such a part of our fabric now 
that I hope we can all work together so that every American 
gets access to healthcare.
    I appreciate the inclusion of my legislation to make 
permanent the Money Follows the Person Rebalancing 
Demonstration Act. Since it was authorized, the Money Follows 
the Person Rebalancing Demonstration has helped many Americans 
transition from institutional care to their homes and the 
community.
    Money Follows the Person has led to positive health 
outcomes for the beneficiaries. It has improved quality of 
life, and it has generated savings for Medicaid and Medicare.
    Despite these benefits, someone not being 
institutionalized, being in a home-care setting and not costing 
as much money because they are at home and not in an 
institutional setting--it does not have permanent authorization 
or funding.
    Instead Congress has passed five short-term extensions to 
ensure program continuity. This uncertainty in funding as well 
as lapses in funding has caused some States to walk away from 
the program and has led to declines in efforts to transition 
individuals from the institutional setting to the community 
over the years.
    Ms. Mann, evidence has clearly demonstrated that funding 
uncertainty has had a damaging effect on Money Follows the 
Person programs. Can you specifically describe the short- and 
long-term impacts this has had on beneficiaries?
    Ms. Mann. Absolutely. And I applaud the introduction of 
that legislation, Congresswoman. As you say, it is a strongly 
supported, bipartisan-supported program both in Congress and in 
States across the country.
    I was at CMS at one point when Money Follows the Person was 
expiring, and it really caused a great deal of havoc and 
concern among both the individuals who were getting assistance 
from that among the States that had been funding programs to 
do, as you described, to help people transition from nursing 
homes into the community, to help people stay in the community 
and avoid institutional care when they needed long-term 
services and supports.
    It is just an incredibly important bridge that provides a 
lot of flexibility in the way that people have been talking 
about, and when there is not certainty about the long-term 
funding for a program like that, then there is a lot of worry 
in the community.
    And also it impairs States' abilities and communities' 
abilities to plan programs and really try and invest and make 
sure that the program is as effective as possible.
    So having that stability after how long it has been in 
place will be really a value added for everybody.
    Mrs. Dingell. So let me ask you another question that I 
think is really important. When MFP participants transition 
from receiving care in nursing homes to community-based 
settings, do Medicaid programs experience cost savings as a 
result?
    Ms. Mann. On a per-person basis it is overall much less 
expensive to care for people in the home. It is not cheap, but 
it is far less expensive than in the nursing home. And it is 
people's choice as well to stay in their homes or back in their 
homes in their communities.
    Mrs. Dingell. One last one. I have got 1 minute left.
    Do you think that a consistent, reliable funding stream for 
Money Follows the Person would help to revitalize programs that 
have struggled over this past year and encourage States that 
wound down their programs to reinstate them?
    Ms. Mann. Absolutely, absolutely. States are loath to jump 
in and set up new structures and fund services through it if 
they are not certain that the money will continue to be 
available.
    Mrs. Dingell. And in 30 seconds, how would making this a 
permanent part of the Medicaid program benefit 
institutionalized beneficiaries seeking transition to the 
community?
    Ms. Mann. Well, often the idea of you are in a nursing home 
and the idea of leaving that institution to go into the 
community is just very difficult for people to think about how 
to do that.
    So help finding affordable housing, help paying for that 
transition, providing ramps and retrofitting apartments or 
housing to be able to make it doable for people to be able to 
then also arrange for the care that they might need at home.
    It is all those components that can be very scary steps for 
a lot of people, but one that they are eager to do if they have 
the support.
    Mrs. Dingell. Thank you.
    Thank you, Mr. Chairman. I yield back.
    Mr. Sarbanes [presiding]. Thank you, Congresswoman.
    I believe now, Congressman Crenshaw, you are recognized for 
5 minutes.
    Mr. Crenshaw. Thank you, Mr. Chairman.
    Thank you, everybody, for being here on such an important 
topic.
    Look, I will start philosophical and then get into my 
passion on direct primary care, which I am new to this 
committee, but you will hear a lot out of me on direct primary 
care over this session.
    But starting at the 30,000-foot level, I do not want to 
keep funding things that are not proven to work well. We should 
be creative and flexible about how we deliver care.
    If we agree on that fact--and I think we actually do, that 
Americans need access to good healthcare--the question is how 
we do it.
    And when we are looking at a program like Medicaid that we 
continue to fund endlessly and unsustainably, and yet it does 
not have a corelation with improved outcomes. Study after study 
shows this.
    Nobody is saying that Medicaid causes bad outcomes, but if 
there is no correlation between Medicaid and good outcomes, we 
should at least have some questions in mind and be looking for 
more innovative solutions besides just increasing it endlessly.
    Yesterday we heard about how important primary care is. It 
is the gateway to healthcare. This is why direct primary care 
is such an important focus of mine, and I think that we can 
have some bipartisan agreement on it.
    I have heard in this committee hearing that there is 
already bipartisan agreement on the success of reinsurance 
program as a way to solve the tail end of the problem, where 
cost gets so overwhelming that insurance companies cannot cover 
them without raising premiums to extraordinary levels, and so 
an invisible reinsurance program works well for that.
    But we have to focus on the beginning of this too. In 
Texas, we have had really interesting success with self-funded 
programs where a company will contract with a direct primary 
care physician.
    This does a few things. It immediately has an outcome of a 
direct relationship between the doctor and the patient, now 
with no extra costs or copays. It also reduces their premiums 
on the back end as they renegotiate with their insurance 
companies. It benefits all around.
    So how do we expand this model is going to be a question of 
mine. I have a bill that does that.
    My first question to Ms. Carey: You lead an association of 
doctors who want to remain independent, and are the doctors you 
work with participating in the direct primary care model?
    Ms. Carey. Yes. Thank you for the question. It is such an 
important topic.
    In fact, last year we surveyed our members, and I asked 
them how many of them had a direct primary care practice--or I 
like to call it direct care because I do think there are 
specialists, pediatricians and obstetricians and 
gastroenterologists even that would like to practice direct 
care--and I asked how many were already doing this. It turned 
out 30 percent of my members already were in a direct care 
model or had a hybrid, and 30 percent wanted to move in that 
direction.
    Another 30 percent felt that they just could not. They are 
radiation oncologists and feel very wedded to the insurance 
plans.
    But for those who can move in that direction, they are 
experiencing far more freedom, far less regulations, and their 
patients and employment populations are enjoying greatly 
reduced prices. It is an excellent way to go.
    Mr. Crenshaw. It is, and correct me if I am wrong. On 
average I am told it is about $75 a month. So we are talking a 
gym membership basically.
    Now, I realize that it is not insurance, but this is a long 
list of services that you get a quarterback. You get a 
quarterback for your healthcare, and nobody has that in America 
right now. Well, not nobody, but a lot of people do not, and 
that is really frustrating, I think.
    Ms. Carey. I think that if employers could put that money--
that $85, $75 per employee or $125 for a family--and allow for 
those employees to get primary care, their labs, their well 
care, their radiology, all of that included, the rest of it can 
start to take care of itself with the self-insured employers 
that cover some of those costs, and it would save.
    The studies I have seen, the employees are extremely happy 
with the quality of care, the access, and the employers are 
saving 60 to 70 percent.
    Mr. Crenshaw. And the next question people have, of course, 
is, well, not everybody can even afford $75 a month. So my bill 
would allow for 1115 waivers to provide direct primary care to 
low-income patients and more flexibility through Medicaid.
    So, Mr. Cameron, do you think--that is something we are 
looking at in Texas. It obviously takes a waiver at the Federal 
level and then cooperation at the State level. Would something 
like that work in Idaho as well for increased flexibility?
    Mr. Cameron. Absolutely. We have attempted to promote 
direct primary care as well. One of the problems is that the 
ACA has primary care loaded into the price, and so you really 
in some ways ended up paying twice for that service.
    So we would welcome 1115 waivers or whatever waiver is 
necessary to allow that experimentation at any State.
    Mr. Crenshaw. Thank you, and I yield back.
    Mr. Sarbanes. Thank you very much.
    I believe Congresswoman Kuster is next. You are recognized 
for 5 minutes.
    Ms. Kuster. Thank you very much, Mr. Chairman, and thank 
you, again, to the Chair for having this important hearing.
    We need to repeat the fact the ACA has resulted in more 
than 20 million Americans gaining health coverage, and its 
consumer protections have ensured that millions will no longer 
face discrimination for preexisting conditions.
    There are over 52 million Americans and over 200,000 right 
here in the Granite State who live with preexisting conditions 
every single day and could have been denied access to 
healthcare prior to the ACA.
    The ACA required insurance companies to comply with 
comprehensive consumer protections, but we all know that junk 
plans are exempt from them. A committee investigation found 
that these short-term, limited-duration plans offer bare-bones 
coverage and subject consumers to an invasive review process on 
the back end in order to avoid paying for medical plans.
    These junk plans require consumers to provide up to 5 years 
of medical and prescription drug history.
    Ms. Keith, I will start with you. I understand that it is 
common for junk plans to refuse to pay for medical claims if 
they determine that it was due to a preexisting condition or 
resulted from a preexisting condition; is that correct?
    Ms. Keith. That is, yes.
    Ms. Kuster. And can you describe why Americans with these 
junk plans are left with thousands of dollars in unpaid medical 
bills despite having insurance and paying premiums?
    Ms. Keith. Yes. Thank you for that question.
    So the reason that patients get left with bills is because 
the coverage that they are in simply does not cover much. There 
are huge benefit gaps, as we have heard--not covering 
prescription drugs, not covering mental healthcare, not 
covering substance use disorder service, services that we have 
heard many members talk about being very important, very high 
out-of-pocket costs--and then the practice of rescission which 
we have discussed.
    Ms. Kuster. And another policy that surprised me, I 
understand that junk plans rescind the underlying policy, a 
practice that is banned by the ACA. Is that also correct?
    Ms. Keith. It is correct that the ACA banned rescissions 
except in the most narrow of circumstances, like fraud.
    Ms. Kuster. Thank you.
    And, yes, these junk plans rescind the coverage from 
patients if they decide that the consumer should have disclosed 
certain risk factors on their application. The committee 
investigation found that a patient was billed $190,000 for a 
treatment related to a heart condition, and the company 
rescinded the coverage because the patient failed to disclose 
he was previously diagnosed with diabetes.
    Junk plans also rescind coverage of cancer patients and 
deny claims related to cancer treatment.
    Simply put, these plans are a back-door way to deny 
coverage for Americans with preexisting conditions and bog them 
down with red tape paper trail requirements. They put 
vulnerable Americans at risk and leave families with massive 
supply bills.
    Ms. Castor's bill to subject these junk plans to the ACA's 
comprehensive consumer protections is important, and I am very 
pleased today to be reintroducing my legislation entitled 
Protecting Americans with Preexisting Conditions to ensure the 
consumer protections from the ACA cannot be undermined.
    And with that, Mr. Chairman, I will yield back, or I could 
yield my time to anyone else that needs it.
    [No response.]
    Mr. Sarbanes. Seeing none, we will take your time back, and 
I believe now, Congresswoman Kelly, you are recognized for 5 
minutes.
    Ms. Kelly. Thank you, Mr. Chair.
    Professor Keith, in your testimony you mentioned that Black 
and Hispanic individuals have seen the highest gains under the 
ACA, which has afforded them less cost related to prohibitions 
to care and greater access to primary care.
    Can you tell us a bit about how the American Rescue Plan 
will help address inequities not only in the Medicaid 
population but as well as the population who do not qualify for 
Medicaid but are still low-income and subject to inequities in 
healthcare coverage?
    Ms. Keith. Yes, thank you for that very important question.
    So Black and Latino communities, in particular, have seen 
the largest coverage gains under the Affordable Care Act, and 
the American Rescue Plan is going to even further those 
coverage gains and the progress that needs to be made. So 
hundreds of thousands of people of color will be newly eligible 
for subsidies because their income was too high and will be 
able to enroll in finding an affordable coverage option now.
    You mentioned this, but the data does show that, when folks 
have access to high-quality coverage, it helps get them access 
to care.
    There is more work to be done and certainly around 
disparities, but I think this is a very strong start and 
continues to build on the progress that has already been made.
    Ms. Kelly. Thank you.
    Ms. Mann, in your testimony you discuss how Medicaid 
expansion was significantly associated with the reduction in 
maternal deaths, with positive effects concentrated among non-
Hispanic Black women.
    As you may know, I am an ardent advocate for maternal 
health. In fact, part of my legislation, the Helping MOMS Act, 
was included in the American Rescue Plan, which expanded 
Medicaid coverage to post partum mothers from 60 days to 1 year 
after birth.
    Can you possibly talk about how the expansion of Medicaid 
and making CHIP permanent in conjunction with the extended 
coverage of post partum mothers work together to not only 
reduce maternal mortality in the U.S. but also have a positive 
impact on Black mothers, who die at a higher rate than their 
peers?
    Ms. Mann. It would be a pleasure to respond to that and 
thank you, and thank you for your advocacy on this incredibly 
important issue.
    As I am sure you know, the 60-day post partum coverage 
period that has been part of the Medicaid program was not based 
on clients. It was a number that was picked and it provided 
some post partum coverage for people, but increasingly, as we 
have seen the mortality rates and the morbidity rates increase, 
particularly among women of color and Black women in 
particular, more work has been done and investigation has gone 
on and more consideration about how those problems arise.
    And many arise in the post partum period. So we have seen 
just strong agreement across health professionals, around 
women's organizations and others that the extension to 12 
months post partum is consistent with the science, and it will 
be incredibly important as a way to reduce those disparities.
    The permanent authorization of CHIP will also contribute to 
reducing those disparities and help around prenatal care and 
post partum coverage as well. As you know, CHIP has an option 
to cover pregnant women. It is mostly for children, but it also 
has a pregnant women option, and so expanding that option for 
CHIP and then making CHIP a permanent program will ensure that 
the benefits of those policies will reach a lot more women.
    Ms. Kelly. If I can just go back again to maternal 
mortality, there is concern that making optional the provision 
in the American Rescue Plan that extends the post partum 
coverage means a number of States that have not chosen to 
expand Medicaid will also choose not to extend Medicaid 
coverage to post partum moms, such as Texas, Alabama, 
Mississippi.
    Do you think any of the bills discussed here today, 
especially the increased FMAP under H.R. 340, the Incentivizing 
Medicaid Expansion Act, would entice States that we suspect 
would not extend the coverage to post partum moms to extend it? 
I am very, very concerned about that.
    Ms. Mann. Absolutely. There is discussion in some 
nonexpansion States on the post partum coverage. There was some 
proposal to do that in South Carolina, but by and large it is a 
proposal that is considered in the context of a broader 
Medicaid program.
    I do not know if you were here when we talked earlier in 
the hearing about just last night Wyoming passed a bill in the 
House to expand Medicaid thanks to the incentives in the 
American Rescue Plan.
    Alabama is considering is, a State obviously with very 
significant disparities in health driven by race and ethnicity.
    So I think what you have done in combination has really 
opened eyes and provided some really very significant 
investments for States to reconsider whether they do the 
expansion and incorporate also to extend the post partum 
coverage period.
    Ms. Kelly. Thank you.
    And I yield back time I do not have. Thank you.
    Mr. Sarbanes. Thank you, Congresswoman.
    Congresswoman Barragan, you are now recognized for 5 
minutes.
    Ms. Barragan. Thank you, Mr. Chairman.
    Today is a great day to celebrate the ACA and what the 
Affordable Care Act has been able to do for expanding access to 
healthcare to many underserved, to many low-income families and 
communities, and the impact that it has had has been enormous.
    Today we also discussed bills that build on the Affordable 
Care Act to sort coverage gains, and I want to start with the 
CHIP program, and, Ms. Mann, this is going to be for you.
    The Children's Health Insurance Program is one of our 
Nation's most important healthcare programs by providing health 
coverage to 9.6 million low-income children, including nearly 
1.3 million children in California.
    Despite being so vital, CHIP is currently the only Federal 
health insurance program that requires its funding to be 
reauthorized periodically. This dangerous precedent leads to 
programs vulnerable to potential lapses in funding.
    This occurred in 2017, when CHIP temporarily expired for 
over 4 months, putting States at risk of running out of money 
for the program and threatening the coverage of children who 
rely on CHIP to get the care they require.
    This should never happen again. My bill, the Children's 
Health Insurance Program Permanency Act, will ensure that 
funding for this program will no longer be held hostage during 
partisan budget battles. Our goal should be to make sure every 
child in this country has access to the medical care she or he 
needs when they need it.
    I want to thank my committee colleagues Congressman 
Cardenas, Congressman Rush, and Congresswoman Schrier for 
cosponsoring this important legislation.
    Ms. Mann, can you please discuss CHIP's importance for 
children and how periodic reauthorization battles threaten the 
program?
    Ms. Mann. Absolutely. Thank you for the question, 
Congresswomen.
    CHIP has been a really valuable impetus for reform for 
coverage for children. I was around and working on children's 
coverage issues in 1997 when the Congress passed CHIP, and no 
one knew exactly how many children would be covered and how 
many States would pick it up.
    Every State picked it up by 2000, so just in the 3 short 
years, and it has been such a popular program, helping to allow 
States to expand their Medicaid programs to cover more children 
in Medicaid, as well as to set up separate children's insurance 
programs. It has really been a lifeline.
    I have also been around long enough to see what happens 
when the reauthorization did not occur. We saw the first time 
that that happened. We saw some States stop taking new 
applications. They did not know if the money was going to be 
there. It was not reauthorized. They had to stop taking 
applications. They put children on waiting lists to get the 
care that they need.
    We have seen that reoccur in different times when 
reauthorization has arisen. It is an enormously popular program 
going almost to its 25th year, and it is time to make it a 
permanent authorization in terms of the funding.
    Ms. Barragan. Well, thank you, Ms. Mann. It is a shame that 
our children would be used as pawns in a political battle and 
they would not have coverage for any period of time.
    Ms. Mann, can you talk about actions that States had to 
take after CHIP expired in 2017, including having to send 
letters to parents warning that their children may lose 
coverage?
    Ms. Mann. Absolutely. And this happened also earlier in 
2015, and I was at CMS at the time, and on one hand States 
juggle with not wanting to give people those notices because 
they hoped that reauthorization would happen, and they knew how 
much those notices would cause alarm in those families.
    And yet at some point when that reauthorization did not 
come through, they had an obligation. They had a legal 
obligation, they had a moral obligation to let families know 
what was happening.
    And then, of course, that caused great consternation in 
families wondering how their child would get the care that they 
need the next week and the next month. So it caused great 
hardships all around the country, and unnecessarily so.
    Because of the popularity of the program in a bipartisan 
way, we need to set it on a path where that never happens 
again.
    Ms. Barragan. Well, thank you.
    I just want to close by mentioning another program that I 
think is really great, the home- and community-based services 
that allow people to receive care in their own homes rather 
than having to go into an institution, to a nursing home.
    We have seen because of COVID how that has been even more 
important, and so we just want to continue to work on efforts 
to expand that and to make sure we provide protections.
    And with that, Mr. Chairman, I yield back.
    Mr. Sarbanes. Thanks very much.
    Congresswoman Rochester, you are recognized for 5 minutes.
    Ms. Blunt Rochester. Thank you, Mr. Chairman.
    And I would also like to thank the witnesses for joining 
us, and especially Ms. Hatcher. To have you represent the 
Little Lobbyists on the 11th anniversary of the Affordable Care 
Act is just an incredible moment.
    Access to affordable, comprehensive coverage has never been 
more critical. However, the Trump administration slashed 
funding by 90 percent for advertising and outreach for the 
Affordable Care Act's marketplace options and refused to 
establish a broad open enrollment during the COVID-19 pandemic. 
As a result, enrollment of new consumers in the ACA marketplace 
dropped 50 percent in 2021 compared to 2016.
    According to a survey by the Commonwealth Fund, over 40 
percent of uninsured Americans are unaware of the ACA 
marketplaces or available subsidies to help pay for coverage. 
Another survey by the Kaiser Family Foundation found that over 
half of uninsured consumers were not aware that the ACA 
marketplace has an actual annual open enrollment.
    Ms. Keith, can you discuss in more detail how gutting the 
ACA's advertising budget under the previous administration has 
impacted enrollment and how investing in outreach efforts and 
setting enrollment targets impacts new enrollment?
    Ms. Keith. Thank you so much, Congresswoman, for that 
question.
    So enrollment through Healthcare.gov has been stagnant 
until this year, when there was a huge increase in demand 
because of the pandemic. So enrollment actually declined year 
over year.
    You know, it works well for the folks who are already in 
it, but as you mentioned, the number of new consumers coming in 
every year and getting the coverage that they need declined 
significantly.
    And that is really where your outreach and marketing and 
the investments in those funds make a difference. Many studies 
have shown that bringing in new people, which often tend to be 
younger and healthier, helps keep a stable marketplace.
    And I think we lost a lot of opportunities to bring those 
people in in the past few years.
    Ms. Blunt Rochester. Thank you.
    It is almost like you anticipated my next question, which 
was to help us to understand how advertising and enrollment 
efforts that help younger and healthier individuals enroll 
really does have an impact on the cost of care for all 
Americans and access to affordable coverage.
    Could you talk a little bit about that?
    Ms. Keith. Yes, absolutely. I think that is a core part of 
doing the outreach in enrollment, is to make sure that, you 
know, especially younger and healthier consumers know that 
these coverage options are available and that it is affordable.
    I do not think it is hard to understand that older people 
or maybe people with health conditions, you know, know that 
they need to go and get health insurance. It is where folks are 
younger or healthier maybe think they do not need coverage or 
assume that it is too expensive. They are the ones who need the 
extra push, and that is who marketing and outreach really 
helps.
    Once folks learn the prices, once they learn that they can 
get good, quality coverage, they want that health insurance. It 
is just a matter of reaching them.
    Ms. Blunt Rochester. And the American Rescue Plan extended 
the ACA subsidies to more Americans, including for the first 
time to individuals with incomes above 400 percent of the 
Federal poverty line. Millions of families will experience 
lower premiums and out-of-pocket costs.
    Ms. Keith, how many uninsured individuals are likely to be 
eligible for the subsidies under the American Rescue Plan?
    Ms. Keith. The estimates I have seen are that 14.9 million 
uninsured people qualify, and that includes 3.6 million 
uninsured people who were above that 400 percent poverty line, 
so 3.6 million more middle-income families.
    Ms. Blunt Rochester. Great. And I understand that uninsured 
Americans are less likely to be aware of the deadlines and the 
availability of the coverage, and that this assistance is 
available. Is that correct?
    Ms. Keith. That is correct.
    Ms. Blunt Rochester. Thank you, Ms. Keith.
    And the American Rescue Plan expanded coverage to millions 
of Americans. However, many consumers still lack basic 
information about their coverage options.
    I am proud to have introduced H.R. 1872, the More Health 
Education Act, to invest $100 million annually for outreach and 
enrollment efforts. My bill will help lower healthcare costs 
and expand coverage to more Americans, and I urge my colleagues 
to support it as well as we move forward through this process.
    Thank you, and I yield back, Mr. Chairman.
    Mr. Sarbanes. Thank you very much.
    I believe the next Member to be recognized for 5 minutes is 
Congresswoman Schrier.
    Ms. Schrier. Thank you, Mr. Chairman. And thank you to all 
of our witnesses today.
    On this 11th anniversary of the ACA, I speak as both a 
pediatrician and a lawmaker when I say follow the data. 
Affordable coverage leads to better access to care, which leads 
to better health outcomes and lower costs, by the way.
    So I am thrilled to have my bill, Kids' Access to Primary 
Care, included in this hearing. In my State of Washington, more 
than 800,000 children access care through Apple Health, our 
State Medicaid program.
    And across the country, we know that the provider network 
for Medicaid patients is really strained. These patients have 
trouble finding providers who will see them. Physicians cite 
low reimbursement as the primary reason they are unable to 
accept additional Medicaid patients.
    So shoring up this absence to care by raising Medicaid 
reimbursement to match Medicare reimbursement rates will help 
kids grow up healthier and should play a vital role in reducing 
the health disparities by reaching underserved populations.
    So I want to turn to Ms. Mann. In your testimony you noted 
that Medicaid access translates into addressing needed care. 
Can you briefly talk about the importance of access to care and 
what this means for kids and their future health outcomes? And 
to address some of my colleagues' concerns about cost of care, 
what early care for children means for long-term costs to our 
healthcare system.
    Ms. Mann. I would be glad to. Thank you for the question, 
Congresswoman.
    So access to care in Medicaid is generally very strong in 
some areas of the country and for some services. There can be 
access issues, and in many instances that can be traced back to 
the payment rates, and particularly for primary care and for 
primary pediatric care. Unfortunately, the rates can be far too 
low to be able to sustain on the services that children need.
    Just as important to bring in more physicians, I would say 
also the adequacy of that payment level can help provide that 
platform for a nonperforming pediatric primary care system, one 
that does not take 15 minutes to check out a child but that 
really explores the developmental development for the child, 
works with the parent and the child to understand what is going 
on at home, whether there are hunger issues and other problems 
that might impair the individual's health.
    So in many different ways primarily care is a strong 
platform for being able to care for kids, and as I'm sure you 
know, it is so important particularly for young children. Those 
investments in care for young children, there is really lots of 
evidence showing that it will support that child throughout her 
childhood as well as when she becomes an adult.
    And that will, in fact, save dollars, and there is 
certainly lots of evidence about that. It saves healthcare 
dollars, education dollars, juvenile justice dollars, lots of 
different parts of the system.
    Ms. Schrier. Thank you.
    Ms. Mann. It is strengthening our systems of care.
    Ms. Schrier. Thank you.
    I want to quickly turn my attention to something my 
colleague just asked about, which is that access is not really 
access if you cannot afford premiums or deductibles. And the 
middle class has really been left out of so many of the 
subsidies that expanded care to others, many priced out of the 
marketplace, and that is why the American Rescue Plan offered 
tax credits and subsidies to cut premiums for nearly all 
Americans.
    In fact, 75 percent of people on the exchange in Washington 
State will be helped by this, and an additional 25,000 will 
gain coverage now because they can afford it.
    And, in fact, an average family of four in my district will 
see their premiums drop from about $14,000 a year to $8,500 a 
year, which is a significant 40 percent drop.
    In fact, one of my own patients' families looked at their 
$17,000 premiums compared to the $1,400 they would have spent 
just paying cash, and they just went without coverage.
    And so, Dr. Keith, could you talk about how the provisions 
for middle-class families will make healthcare more affordable 
and how that might also translate to lower costs overall for 
young families?
    Ms. Keith. Yes, thank you. And it is exciting to hear that 
data out of Washington State.
    So the way that the subsidies will extend for middle-income 
families is no one who is purchasing their own private health 
insurance will have to spend more than 8\1/2\ percent of their 
income towards premiums. It is going to really reduce those 
costs, as you just suggested, and make coverage much more 
affordable for people.
    Ms. Schrier. Thank you very much.
    I yield back.
    Mr. Sarbanes. Thank you.
    Congresswoman Trahan, you are now recognized for 5 minutes.
    Mrs. Trahan. Well, thank you, Mr. Chairman. And my thanks 
to each of the witnesses.
    So many of the questions have, you know, been answered, but 
I just wanted to sort of say, you know, 4 years before the 
Affordable Care Act became the law of the land, it was the 
Commonwealth of Massachusetts that blazed the trail of nearly 
universal coverage. Our healthcare coverage expansion served as 
a model for the ACA.
    Today the uninsured rate in Massachusetts is about 3 
percent, one of the lowest rates in the country. But not only 
is its healthcare accessible and affordable, in Massachusetts 
we also consistently rank among the best in the Nation for the 
quality of care that is delivered.
    And I think it is also worth noting that the expansion of 
coverage in my State occurred in a bipartisan basis, with a 
Republican Governor and State legislature controlled by 
Democrats. In other words, Democrats and Republicans can, in 
fact, work together to enact healthcare programs that maintain 
quality while expanding coverage.
    Ms. Keith, like so many Members on this committee, I am 
deeply concerned about the inequities in healthcare 
accessibility and affordability. Fortunately, the American 
Rescue Plan enhanced the ACA subsidies and significantly 
lowered premiums for Americans.
    And the American Rescue Plan also significantly reduces 
premiums for individuals already eligible for coverage and 
extends the ACA subsidies to Americans who are currently 
uninsured.
    Can you briefly discuss how these enhanced subsidies help 
make coverage even more affordable and accessible?
    Ms. Keith. Thank you for that terrific question.
    So the enhanced subsidies are going to not only save people 
monthly premiums in what they would otherwise be paying. I do 
want to emphasize that many folks will have the opportunity to 
buy an even more comprehensive plan with a lower deductible and 
lower out-of-pocket cost. So the subsidies are focused on the 
premiums, but it is actually going to give people even more 
buying power to go and get the even more significant financial 
protection that they need.
    And you are exactly right. That extends up and down the 
entire income scale. I really cannot emphasize enough how 
transformative this is going to be for millions of people.
    Mrs. Trahan. Terrific, and we are excited about expanding 
upon that as well.
    You know, Dr. Schrier, she touched upon the Medicaid 
expansion and how that is going to benefit our children.
    So with the remaining time that I have, I would like to 
turn to another important issue, which is the expansion of 
coverage to treat substance and opioid use disorder. And many 
of the States that have been hardest hit by the opioid epidemic 
have not expanded Medicaid.
    So, Ms. Mann, you briefly touched on this earlier in this 
hearing. Could you explain how the expansion of Medicaid 
increases access to treatment and care for those suffering from 
opioid use disorder?
    Ms. Mann. If you think about a State that has not covered 
any of their childless adults, right, not done the expansion, 
and for whom even parents are at very, very low income levels, 
the medium stage of nonexpansion States is at 40 percent of the 
poverty line, and when you earn anything above that amount you 
become ineligible for coverage.
    So with that extent of a coverage gap, what it means is 
that the only way people can get services and care if they have 
a substance abuse disorder is through charity care, through 
uncompensated care, or maybe if the State has some community 
treatments that it is paying for with its own dollars, which 
will generally mean it is quite limited.
    As States have expanded Medicaid coverage, they have 
brought in millions of people into coverage, and that allows 
them access to all the care they need, whether it is primary 
care, whether it is cancer screenings or whether it is 
substance use disorder treatments.
    And we have seen the States that have expanded coverage 
really do the most in terms of providing those services.
    Mrs. Trahan. Great. Well, I want to thank you for your 
thoughtful answers to these questions. I think it is clear from 
the testimony that Medicaid expansion offers tremendous 
benefits, and it is cost effective and provides quality, 
affordable care to those in most need.
    I am proud that my State made this decision early on to 
expand Medicaid coverage, and I hope the remaining States will 
make that same decision.
    Thank you, Mr. Chairman. I yield back.
    Mr. Sarbanes. Thank you.
    Madam Chair, I am going to yield the virtual gavel back to 
you. I believe Congressman Burgess is next in line, but I will 
leave it to you.
    Thank you.
    Ms. Eshoo [presiding]. Thank you. Thank you very much, 
John. I appreciate it.
    I was gone a little longer than I anticipated, but that is 
what happens when there are many Members of Congress that are 
part of a meeting. It gets stretched out.
    It is a pleasure to recognize Dr. Burgess of Texas for your 
5 minutes of questions.
    Mr. Burgess. Thank you for the recognition, and I also 
apologize to our panel. There are three different hearings that 
I am part of this morning. So it has been a little difficult to 
balance between Health, Budget, and the Rules Committee, but 
this is important.
    And I would like to ask Dean Cameron. You noted in your 
written testimony, while it is not necessarily right for 
everyone, short-term plans can be a helpful alternative for 
individuals in certain situations.
    You know, I am reminded there is a Fox News Bureau down in 
Dallas that I will sometimes be tasked with going down and 
giving an interview with a fellow there that controls the 
microphones and gets you seated and makes sure the shot is 
right.
    He asked me after one of my interviews that was about 
healthcare, he said, ``I hope you are going to do something 
about this.'' This was before the individual mandate was zeroed 
out. He said, ``I have got to pay a fine, and then I go and I 
am able to buy a noncompliant insurance policy that actually 
covers what I need.''
    And I could not help but think, you know, we have not 
really done this individual any great favor by fining him and 
then turning him loose to buy the actual coverage that he 
needs.
    So, Mr. Cameron, I wonder if you could expand upon and kind 
of walk us through what additional benefit we might see from 
keeping the short-term, limited-duration plans.
    Mr. Cameron. Well, thank you for the question.
    First and foremost I think you give choice, choices to 
consumers who cannot afford the ACA plans, and in spite of the 
adjustments that have been made in APTC here recently, there is 
still a large segment of the population in Idaho who will not 
qualify, particularly those who are younger.
    I looked the other day. We run studies of those that would 
get the enhanced APTC, and they are 50-year-olds and families 
of four, whereas if you are 25, married to a 25-year-old, you 
do not get anything.
    And so those individuals, those healthy individuals, really 
need someplace to go. And so from our approach, I think it is a 
legitimate question as to what benefit short-term plans should 
have and what are the requirements. That is a legitimate debate 
and question and one that I think many State insurance 
commissioners are addressing and working with their legislators 
on, and I commend them for their efforts.
    I think individuals who do not have choice end up going 
without coverage. There are conditions that come up, end up 
going undiagnosed and untreated, and so then they wait and come 
onto the ACA plan when they have got a condition. They wait 
until that case, and then that makes it more expensive.
    If you think about it--and I know it is an overused axiom--
but if everybody waited to buy homeowner's insurance to when 
their house was on fire, it would be tremendously expensive.
    So we have got to figure out ways to get everybody 
involved, the young and the healthy in the same risk pool. That 
is what we have done here in Idaho, is trying to get even those 
that are on those enhanced short-term plans that are in the 
same risk pool with the ACA, which it will help us hold costs 
down to those that are purchasing on the exchange.
    Mr. Burgess. That is a terribly intriguing concept and one 
that I hope this committee will spend some time studying.
    Let me just ask you, Mr. Cameron. Section 1332 waivers, 
they are actually part of the Affordable Care Act. The Trump 
administration was criticized for using 1332 waivers, but 1332 
waivers were actually written into law. As the labor law was 
written, they were delayed so that they would not go into 
effect until January of 2017, for reasons that I do not 
completely understand.
    But have you had any thoughts about the 1332 waivers?
    Mr. Cameron. Yes, thank you, Congressman.
    We do have very strong opinions about the 1332 waivers. We 
think they ought to be there, but we think they ought to be 
allowed to use States to become sort of the laboratories of 
innovation and creativity.
    In our experience, even under both administrations, the 
provisions of the 1332 made it very difficult, particularly for 
rural, small States, to participate and to utilize.
    Larger States could get the 1332 waivers. We actually even 
applied for 1115 and a 1332 combined. We called them the dual 
waiver approach, which was going to help reduce cost both to 
the Federal Government and to the State, reduce premiums by 25 
percent, and yet we could not quite get that across the finish 
line because of the strict interpretation.
    So we encourage additional flexibility and 1332 waivers.
    Mr. Burgess. I think that is an excellent point and one 
that we should look to.
    So you only pay for what you need. What an interesting 
concept.
    I thank the Chair. I will yield back.
    Ms. Eshoo. The gentleman yields back.
    I now will recognize the gentlewoman from Minnesota, Angie 
Craig.
    [No response.]
    Ms. Eshoo. Are you there?
    Oh, I am sorry. All right. The gentlewoman from Texas, Mrs. 
Fletcher. Lovely to see you. Thank you for your patience.
    Mrs. Fletcher. Lovely to see you. Thank you so much, 
Chairwoman Eshoo. Thank you for recognizing me now and for 
holding this hearing. It has been incredibly helpful to me 
listening.
    And of course, we focus on so many important provisions and 
achievements that we have been able to make because of the 
important provisions of the ACA on this anniversary and also 
identified some of the areas of improvement certainly that are 
needed. And so it has been an incredibly helpful hearing.
    I am also glad that we focused on the American Rescue Plan 
and a provision, a really important provision, that was 
actually from my bill, H.R. 871, the Expand Medicaid Now Act, 
to provide generous new financial incentives to States to 
expand Medicaid, and I am so glad to see that States are 
seriously looking at expansion, as Ms. Mann noted in her 
opening statement and again with questions.
    In my home State of Texas, this provision would result in 
billions of Federal dollars going to our State, and it is the 
State with the highest uninsured rate in the country. And we 
know that so many Texans are living in this coverage gap, that 
there is real and meaningful coverage expansion that we 
desperately need here in Texas.
    So, while I hope that the bill that is included in the 
Rescue Plan will provide the incentive to the remaining States, 
the nonextension States, I am somewhat worried other States 
will continue--and my own State, hopefully not--but will 
continue to refuse to expand.
    And so for that reason I wonder about the other options 
that exist to expand access, and I wanted to focus my questions 
on those.
    I understand that from 2007 to 2010 for select counties and 
then further expanded in 2010 to all counties, California 
allowed counties to expand Medicaid coverage through a Section 
1115 demonstration project. These individuals were later 
transitioned into the statewide expansion established under the 
ACA.
    Similarly, from 2012 to 2014, a county in Illinois also had 
an 1115 demonstration project creating Medicaid expansion for 
county residents who were then moved into the statewide 
program.
    My county that I live in, Harris County, is the third 
largest county in the United States, after Los Angeles County 
and Cook County, and so, you know, a similar extension project 
is, of course, of interest.
    To me conceptually as we are thinking about this, there was 
a similar demonstration project, I understand, in Cuyahoga 
County, Ohio, and so those kinds of projects could provide a 
model for new county demonstration projects in States like 
Florida and Texas and elsewhere.
    So I want to direct my questions on this topic to Ms. Mann. 
First of all, can you talk a little bit about how county 
extension projects might complement the additional expansion 
incidents we included in the American Rescue Plan?
    And then just because I talked for a while, I just want you 
in your comments to also talk a little bit about the expansion 
in the American Rescue Plan.
    I think some people may think that the 5-percentage-point 
increase is not a large number. So in the context of your 
discussion can you also explain why that is a good deal for 
States as you share your thoughts with us on expansion and 
these potential other avenues for expansion?
    Ms. Mann. Absolutely, and I am glad to be back on this one, 
and thank you for your question.
    The American Rescue Plan has provided a really strong 
incentive for States to reconsider that have not yet expanded 
coverage to say now may be the time. Now may be the time 
because so many people are uninsured and so many people are 
having health issues because of the pandemic.
    But now is the time in Texas because there are so many 
individuals who just do not have insurance, but percentagewise 
and numberwise, it is the largest in the country.
    And because of that, you know, because the Family 
Foundation has estimated that the 12 States together will get 
about $9.6 billion should they all go forward and expand 
coverage, and Texas will get the lion's share of those dollars 
because of the size of the uninsured population and the extent 
and their program.
    The 5 percent is a large amount of money because it is not 
for the expansion group. The 5 percent is for all expenditures 
in your Medicaid program, and so the base upon which it applies 
is a much larger base. For Texas it includes the coverage they 
are providing for people with disabilities and elderly. So it 
is a very large amount of money.
    In terms of thinking about counties moving forward, you are 
absolutely right. There have been instances in the past. They 
were all pre-ACA, or at least the effective date of the ACA, 
but they really did provide coverage and they really did help 
get States and communities ready for full statewide Medicaid 
expansion.
    I am, you know, heartened that everybody in Texas is 
continuing or many people in Texas are continuing to think 
about the ways in which coverage expansion in Medicaid can come 
to the Lone Star State. Hopefully, the American Rescue Plan 
incentive will do the job.
    But it is really good to hear that people are thinking 
about lots of different options.
    Mrs. Fletcher. Well, thank you so much for that. I 
appreciate your testimony and the testimony of all of our 
witnesses today.
    I have exceeded my time. Chairwoman Eshoo, thank you so 
much, and I will yield back.
    Ms. Eshoo. Thank you for your patience.
    I do not see any Republicans to call on. So I will go next 
and recognize the gentlewoman from Minnesota, Angie Craig. Is 
Angie there?
    [No response.]
    Ms. Eshoo. No. Not seeing Ms. Craig, we will now go to 
Members that are members of the full committee, not members of 
the subcommittee, but we welcome them and they are waiving on.
    And I will recognize the gentleman from Illinois, Mr. Rush, 
for 5 minutes of questions.
    Mr. Rush. I want to thank you, Madam Chair. Thank you for 
allowing me to participate in today's hearing on the ACA.
    Ms. Eshoo. You are always welcome. You are always welcome.
    Mr. Rush. Thank you so much, especially on this occasion of 
the 11th anniversary.
    I was proud, as you were, to vote for the ACA in 2010, 
which has since become a lifeline for millions of Americans.
    I also was pleased last month to vote for the American 
Rescue Plan, which delivered on Democrats' promise extending 
the ACA and making healthcare more affordable for all 
Americans.
    The improvements included in the American Rescue Plan and 
in the legislation that we are considering today are long 
overdue and cannot come soon enough.
    In 2020, it was estimated that 846,000 Illinoisans lost 
employer-sponsored insurance. During a global pandemic, it is 
critical that we ensure everyone has access to high-quality, 
affordable healthcare.
    COVID-19 has revealed a bright light on healthcare 
disparities, which are too common for Black and Brown Americans 
in my district and around this Nation. It is our duty to ensure 
that we conduct outreach to African Americans, to Latinos, to 
Asians, those who are more likely to have negative health 
outcomes from COVID-19.
    A Gallup survey conducted last year found that non-White 
adults were more than two times as likely to defer seeking 
treatment for COVID-19-like symptoms known to them than known 
to White Americans. Access to affordable healthcare insurance 
would reduce this disparity. Fortunately, the American Rescue 
Plan temporarily extends the marketplace premium tax credit to 
more individuals for 2021 and 2022.
    That said, Ms. Keith, are these increased subsidies 
available now for 2021? Of those already enrolled in the plan 
for 2021 through Healthcare.gov, what action, if any, is needed 
for these consumers to receive the subsidy for which they now 
qualify for?
    Ms. Keith. Thank you so much, Congressman, and thank you 
for your leadership on all of these issues.
    So the subsidies that you are talking about will be 
available through Healthcare.gov beginning on April 1st, and 
Federal officials are encouraging everyone who already has 
coverage or needs coverage to go back into the system and make 
sure that you say, ``Yes, I want to take advantage of these 
credits.''
    It is also the moment, though, to see if you want to change 
plans and maybe lower your deductible or lower your out-of-
pocket cost. It is really a moment to shop around and get the 
best deal for you and take care of your healthcare.
    And I have not said this yet, so I will emphasize: Anyone 
who is uninsured or needs healthcare or health coverage can 
enroll through Healthcare.gov through May 15th. It is really, 
really important to get the word out.
    Thank you.
    Mr. Rush. All right. Ensuring affordability of high-quality 
healthcare, as I said before, is a top priority, and I have 
been [inaudible] afforded short-term, limited-duration 
insurance. These junk plans often are sold to patients by 
insurance sales representatives who do not disclose the gap in 
coverage which will leave patients on the hook for literally 
thousands of dollars.
    Ms. Keith, are there any demographic breakdowns based on 
race for short-term, limited-duration plan enrollment?
    Ms. Keith. None that I am aware of, no, sir. The best data 
that we have really comes from the committee's yearlong 
investigation of these practices for these products.
    Mr. Rush. [Inaudible.] My time is running out, and I yield 
back the balance of my time.
    And thank you again for your consideration and for your 
grace and mercy.
    Ms. Eshoo. You are wonderful. You are always welcome. I 
think it is an eloquent statement about our subcommittee, that 
we always have Members that want to waive on. So each one of 
you is always welcome.
    It is a pleasure to recognize Ms. Schakowsky of Illinois, 
waiving on for 5 minutes of questions. And your patience as 
well because you have been onboard since before we began this 
morning. So you have had the benefit of hearing all of the 
questions and all of the answers. Welcome.
    Ms. Schakowsky. Well, thank you, Madam Chair, and I also am 
just grateful for the opportunity to waive on, and happy 11th 
anniversary to the Affordable Care Act.
    I was so proud to help craft it as a member of this 
subcommittee, the Health Subcommittee, and to be a member of 
the Energy and Commerce Committee, to actually get this done.
    And I have heard many wonderful, life-changing stories that 
people have experienced because of the ACA, and I want to just 
acknowledge the words of Laura Hatcher and thank you so much 
for your words and sharing your experience, but also for the 
Little Lobbyists we have seen at the Capitol for a long time, 
and it has just been priceless, the influence that they have.
    But still, we can definitely make improvements. In 
Illinois, we had a problem with network adequacy actually for a 
while. It is better now, but for a while many Affordable Care 
Act plans did not include any of the major hospital or 
affiliated doctors in the Chicago area, while the law 
absolutely says that they must have inclusive adequacy networks 
and access to specialists. It did not happen.
    And so, Professor Keith, I wanted to ask you: Can you speak 
to the importance of network standards to ensure that patients 
are able to have a good number of choices and have the doctors 
and the providers that are really needed for them particularly?
    Ms. Keith. Thank you for that very important question.
    So you are right. The Affordable Care Act included network 
adequacy standards. I think many people have started 
encouraging what we call quantitative network adequacy 
standards, which really say that a patient should be able to 
find a primary care physician or a specialist or a hospital 
within a certain distance from their home or where they work.
    And this is the idea that folks should have good access to 
actual providers in their neighborhood or close to them. An 
example would be being able to find a primary care physician 
within 10 miles or 15 minutes, and those standards would change 
based on rural or suburban areas, things like that. So really a 
way to include access to actual healthcare providers.
    Ms. Schakowsky. So the key word is ``quantitative,'' and 
let's hope that we can get there.
    I want to also mention to you that some States actually 
have the authority to lower premiums if they are felt to be 
exorbitant. Illinois is not one of those States. We can 
oversee, but we cannot do anything actually to change that. We 
can review these numbers.
    And so I wanted to ask you: Can we require, when we improve 
this Act, to make sure that all States are able to look at and 
review these rates and make adjustments to the rates?
    Ms. Keith. Certainly. So the Affordable Care Act included 
what we call rate review standards, but you are exactly right. 
Not every State has what we call prior approval authority, 
meaning they can actually deny the rate that an insurance 
company wants to use before it goes forward.
    I think there has been a lot of focus today on healthcare 
costs. I think rate review is one way that State regulators and 
Federal regulators could really leverage and put pressure on 
insurance companies to help bring down healthcare costs.
    The whole goal here is to make sure that costs are fully 
justified and that consumers are not paying more than they 
should be paying. I think it is a huge consumer protection.
    Ms. Schakowsky. Absolutely. So I just wanted to say that my 
bill that is in this packet, H.R. 1890, the Health Care 
Consumer Protection Act, has two things that I was just really 
talking about: to set network adequacy in the way that you 
describe--to make sure that everyone has access, and to make it 
standard, to set network adequacy standards--and I guess that 
my bill says that CMS would do that.
    And, secondly, to permit all States to be able to address 
the excessive rates by actually requiring a reduction in those 
rates. I know that there are many times that it would have been 
very helpful to us in Illinois not to just comment on it, not 
just to be reviewing it, but to have some actual power.
    So I am almost out of time, and I want to thank all of the 
wonderful panelists for being here, and it has been an honor to 
be able to waive onto your committee, Madam Chair.
    And I yield back.
    Ms. Eshoo. Well, we thank you.
    I see that the gentlewoman from Minnesota is back on the 
screen and with us. So I recognize the gentlewoman from 
Minnesota, Ms. Craig, for your 5 minutes, and thanks for your 
patience.
    And I also note that Mr. Veasey has joined us and will 
waive on. So I just want you to know that I see you there, and 
you will be coming up after Ms. Craig.
    So away we go with Minnesota.
    Ms. Craig. Thank you so much, Chairwoman Eshoo, for 
yielding, and thank you to the witnesses for your resilience 
here during this testimony today.
    The ACA in my mind led to historic coverage gains and put 
in place important and meaningful consumer protections. Over 
100,000 Minnesotans enrolled in health coverage through the ACA 
marketplaces in 2020, and 59,000 Minnesotans received tax 
subsidies to make their healthcare more affordable.
    Those Minnesotans include hard-working small business 
owners like Ali Hatoum, owner of Morning Glory Bakery in 
Rosemount. The ACA enabled Ali to secure affordable coverage 
for himself and his family and to put the resulting savings 
back into his business.
    Today we are building on that work to further lower 
healthcare costs and expand coverage for my constituents and 
all Americans.
    So I want to start with Ms. Keith here this afternoon. The 
ACA, as you mentioned in your testimony, established a 
temporary reinsurance program. Can you talk a little bit more 
about how that program helps to reduce premiums and the 
benefits of such a program in our State?
    Ms. Keith. Thank you for that question.
    So the temporary reinsurance program for the ACA was in 
place from 2014 to 2016, and while it varied year by year, that 
program was responsible for reducing premiums anywhere from 4 
to 14 percent.
    I would also add that we have seen 15 States use Section 
1332 waivers that have been discussed today to do their own 
State-based reinsurance programs, and as of 2020, the 12 States 
that had those programs in place have reduced premiums by about 
18 percent.
    So these programs do allow for significant premium savings.
    Ms. Craig. Thank you so much.
    I know that reinsurance helps to pay for the cost of those 
most high-risk patients in the pool, those with serious medical 
conditions, thereby reducing the premiums for all individuals.
    But can you talk just a little bit more about how 
reinsurance works? This is something that I want to make sure 
that my colleagues on the committee understand, as well as my 
constituents.
    And then maybe just more broadly, what other measures would 
be effective in lowering premiums and out-of-pocket costs?
    Ms. Keith. Certainly. So reinsurance can be designed in a 
number of ways, but at its core, it is about providing funding 
to help offset high claims, as you have mentioned. This is 
really a way of giving insurance companies stability so that 
they are not all raising premiums and pricing, expecting to get 
the people with the highest, most costly preexisting 
conditions.
    Once insurance companies know that they will have some of 
those claims offset, they can drop premiums for everyone so 
that they are not all pricing like they are going to get 
someone who is really, really sick.
    It just provides that market stability that insurance 
companies are looking for.
    And I will say it is--reinsurance programs and other 
programs as well, Medicare Part D, for instance--it is a 
noncontroversial program in our other Federal coverage 
programs.
    Ms. Craig. Yes, thank you for adding that. I often say that 
flood insurance, crop insurance, other types of insurance also 
have reinsurance as part of those policies and often cannot 
understand how they get involved in sort of political debate 
since that is just a normal, noncontroversial part of an 
insurance plan.
    Can you also just talk a little bit more perhaps about some 
of the other measures that you think would lower premiums for 
folks in the individual marketplace, in particular, and what 
else we could be doing to lower out-of-pocket costs for our 
constituents.
    Ms. Keith. Certainly. So this is an area where I am very 
excited about State experimentation. We have heard a lot about 
State labs as innovation, and I think providing States with 
additional Federal funding to lower healthcare costs, to lower 
patient out-of-pocket costs, to experiment in ways in advanced 
health equity, I think is the direction we should be going in.
    We have seen a number of States, California, Massachusetts, 
Vermont, New Jersey--I am probably missing some--who have 
actually decided to sort of directly help subsidize patient 
costs and building upon those programs.
    I think there is a whole range of options, and it would be 
great to really unleash States and see what they could do 
building off of the Affordable Care Act as a framework.
    Ms. Craig. Thank you so much, Ms. Keith.
    It will not surprise you to learn that the reinsurance 
proposal is my bill that I am carrying here in the U.S. House 
of Representatives, and again, I see this as super commonsense, 
straightforward policy that will help us bring down cost and 
reduce risk.
    So I encourage my colleagues on both sides of the aisle to 
cosponsor the bill and to support reinsurance.
    Thank you so much. And, Madam Chair, I yield back.
    Ms. Eshoo. Thank you, Congresswoman Craig.
    And I think that all of the members of our subcommittee 
have a special appreciation for the new Members that have come 
to our subcommittee--great, crisp, new ideas, all the energy in 
the world. So they are on display. You have heard them, and we 
are all really collectively proud, and you have got an 
important bill there.
    Now, let's see. Who is next? We will go to the gentleman 
from Texas, Mr. Veasey, who is also waiving on.
    And you are always welcome at our subcommittee, and you are 
recognized for 5 minutes of questions.
    Mr. Veasey. Madam Chair, thank you very much. I appreciate 
you letting me waive on.
    Ms. Eshoo. Sure.
    Mr. Veasey. I wanted to talk about this because this is 
hugely important.
    You know, Medicaid has done a lot, particularly after the 
ACA was passed, for so many different States, but there are 
still 12 States in the Union that have not expanded Medicaid.
    And my State of Texas, the Lone Star State, we are one of 
those 12, and it is really sad because, even though over the 
last 10 years we have had a tremendous amount of economic 
growth all around the State, including here in the Dallas-Fort 
Worth metroplex, we still have over a million uninsured just 
here in the DFW area.
    The district I represent, about a third or more of the 
constituents I represent do not have healthcare insurance. It 
is really that bad.
    And so that is one of the reasons why I am proud of the 
legislation incentivizing the Medicaid Expansion Act that I 
introduced as part of today's discussion, because the bill 
would establish incentives to expand Medicaid by providing the 
States with 100 percent matching fund rate for expansion during 
the first 3 years and gradually decline the rates to 93 percent 
by year 6 of expansion.
    And I think that this bill is really important now because 
of what we have seen as it relates to COVID-19 and how it has 
really hurt our State because of so much mismanagement.
    I wanted to ask specifically Cindy Mann. Cindy, you know, 
we have 7 years of data, and we have been able to look at 
Medicaid expansion and the impact that has had on the country. 
Have researchers found any positive health effects of Medicaid 
expansion?
    Because I know that there has been a lot of talk about, you 
know, people being able to finally see physicians on a regular 
basis, and I was wondering if you all could tackle that.
    Ms. Mann. Absolutely, and what an important question.
    And I am hopeful, Congressman, that Texas policymakers will 
see the new incentive as an opportunity to rethink their 
decisions about Medicaid expansion.
    So we have, with the anniversary of 11 years and coverage 
being in effect since 2014, there is lots of evidence and 
research, and it continues to mount showing the health impacts 
and value of coverage generally and of the Medicaid expansion 
in particular.
    We have seen cancer screening rates and cancer treatment 
rates increase among the expansion population. We certainly see 
people being able to access behavioral health services and 
services for substance use disorders that otherwise were not 
available to them.
    We have seen the ability for people with chronic illnesses 
to be able to get those illnesses managed, and we have seen 
reductions in low-birth-weight babies. We have seen reductions 
in maternal morbidity.
    There has really been a gamut of kinds of changes that you 
might expect when suddenly a population that historically has 
been marginalized and underserved begins to be able to access 
the care that they need.
    Mr. Veasey. At this point when you take that data that you 
just spoke about and you look at all of the other benefits, is 
there any legitimate reason--if you were a Greg Abbott and you 
were sitting in Austin, Texas, right now--is there any 
legitimate reason to continue to deny people the right to be 
able to access Medicaid expansion?
    Ms. Mann. Well, I am sure Governor Abbott has reasons, and 
it is far from me to say that his reasons are not legitimate, 
but as I see the evidence and the evidence, again, that is very 
strong and very mounting, it has been an undeniable success and 
the evidence all points to the value of going forward.
    And we have seen 36 States go forward. Two additional ones 
are coming forward in July. It is a very popular change in the 
States, and not one of those States--no matter what the 
political makeup is of the State policymakers, not one of those 
States has decided ``not really a good deal, not really helpful 
for my residents or my providers or for my State budget.'' They 
have all retained Medicaid expansion and continue.
    So that is voting with their feet.
    Mr. Veasey. Yes, and thank you very much.
    And, Madam Chair, let me say this in closing, that 
oftentimes during this argument about Medicaid expansion and 
other services that are similar to that, the constituents like 
the ones that I represent--I represent a district that is 
heavily Hispanic and Black--and oftentimes their story is told 
of people who are working hard to support people like the ones 
who live in my district at their expense, and become the foil 
for this narrative that you hear over and over again.
    But this Medicaid expansion would not only help 
constituents like I represent, but many of the ones that 
consider themselves Republicans that live in their districts 
too.
    And I want to be clear about that, 100 percent clear about 
that. This is something that has helped a lot of Americans, and 
we need to try and expand it, especially in States like mine 
that are growing so rapidly.
    Thank you.
    Ms. Eshoo. Thank you, Mr. Veasey.
    Each Member that waived on is value added to today's 
hearing.
    I do not see any other virtual hands raised. So to each one 
of our witnesses, thank you. We are very, very grateful to you.
    To Katie Keith, Dean Cameron, you are always welcome at our 
committee. You have testified before. We always welcome you.
    To Cindy Mann, we have called on you. I knew Chuck Manatt 
many, many years ago. So you know, his leadership is still 
around. He would be really proud of you, as we all are.
    To Marni Jameson Carey, thank you for your excellent 
testimony.
    To Laura LeBrun Hatcher, thank you. And give our best to 
Simon. Tell Simon that we are with him. We stand with him, and 
we thank him for everything he has done for telling his story. 
The Little Lobbyists are giants, really.
    You know, I started out this morning in my opening 
statement talking about the letter that Senator Kennedy wrote 
before he died. The letter was to President Obama and that it 
was not to be opened until he went to heaven.
    And that letter I have read and reread many times. I think 
that the cause that Senator Kennedy spoke of in that letter of 
ensuring that ``the state of a family's health will never again 
depend on the amount of the family's wealth was the great 
unfinished business of our society.''
    I think that together this morning, even though we have 
differences of opinion on various parts of this, but we have 
really moved the needle. We are in the process of moving the 
needle again to make good on that cause of ensuring.
    So I want to thank all of the Members of the time 
investment they made today, the excellent questions, both sides 
of the aisle, our witnesses, and that together that we will 
reach that North Star of every American, every American having 
good health insurance, not only access to it, but that they can 
afford it.
    That certainly has been the North Star of my public 
service, and I think it is for others as well.
    So from a very deep place in my congressional heart, I 
thank each one of you.
    Now, to my pal, the ranking member of the subcommittee, we 
have 21 documents that need to be entered into the record. So I 
would like to ask you for unanimous consent, unless you want--
--
    Mr. Guthrie. My choice is to have you read all 21, right?
    Ms. Eshoo [continuing]. To read all 21 documents.
    Mr. Guthrie. Yes, as much as I have enjoyed our time 
together and great testimony and questions, I will give 
unanimous consent so that we dispense of reading them all.
    Ms. Eshoo. And I thank the gentleman.
    We will submit these for the record.
    [The information appears at the conclusion of the 
hearing.\1\]
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    \1\ The proposed legislation and the Covered California, committee 
Democratic staff, and Galen Institute reports have been retained in 
committee files and are available at https://docs.house.gov/Committee/
Calendar/ByEvent.aspx?EventID=111378.
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    Ms. Eshoo. And pursuant to committee rules, Members do have 
10 business days to submit additional questions for the record, 
and I know that the witnesses welcome those questions, and we 
ask that you respond as promptly as you can to the questions 
that any of the Members submit to you.
    And, with all of my thanks to everyone, at this time the 
subcommittee is adjourned. So I think I will use my coffee cup 
as the mug.
    Our meeting is adjourned. Thank you, everyone. And happy 
anniversary, ACA. Thank you.
    [Whereupon, at 2:48 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
    
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