    [House Hearing, 118 Congress]
    [From the U.S. Government Publishing Office]

                        WHY HEALTH CARE IS UNAFFORDABLE:
                     THE FALLOUT OF DEMOCRATS' INFLATION ON
                         PATIENTS AND SMALL BUSINESSES

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

                                    HEARING

                                   before the

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                          COMMITTEE ON WAYS AND MEANS
                            HOUSE OF REPRESENTATIVES

                        ONE HUNDRED EIGHTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 MARCH 23, 2023

                                   __________

                                Serial No. 118-5

                                   __________

             Printed for the use of the Committee on Ways and Means

                    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                                   ______

                     U.S. GOVERNMENT PUBLISHING OFFICE

    53-009                    WASHINGTON : 2024

                          COMMITTEE ON WAYS AND MEANS

                        JASON SMITH, Missouri, Chairman

    VERN BUCHANAN, Florida               RICHARD E. NEAL, Massachusetts
    ADRIAN SMITH, Nebraska               LLOYD DOGGETT, Texas
    MIKE KELLY, Pennsylvania             MIKE THOMPSON, California
    DAVID SCHWEIKERT, Arizona            JOHN B. LARSON, Connecticut
    DARIN LaHOOD, Illinois               EARL BLUMENAUER, Oregon
    BRAD WENSTRUP, Ohio                  BILL PASCRELL, Jr., New Jersey
    JODEY ARRINGTON, Texas               DANNY DAVIS, Illinois
    DREW FERGUSON, Georgia               LINDA SANCHEZ, California
    RON ESTES, Kansas                    BRIAN HIGGINS, New York
    LLOYD SMUCKER, Pennsylvania          TERRI SEWELL, Alabama
    KEVIN HERN, Oklahoma                 SUZAN DelBENE, Washington
    CAROL MILLER, West Virginia          JUDY CHU, California
    GREG MURPHY, North Carolina          GWEN MOORE, Wisconsin
    DAVID KUSTOFF, Tennessee             DAN KILDEE, Michigan
    BRIAN FITZPATRICK, Pennsylvania      DON BEYER, Virginia
    GREG STEUBE, Florida                 DWIGHT EVANS, Pennsylvania
    CLAUDIA TENNEY, New York             BRAD SCHNEIDER, Illinois
    MICHELLE FISCHBACH, Minnesota        JIMMY PANETTA, California
    BLAKE MOORE, Utah
    MICHELLE STEEL, California
    BETH VAN DUYNE, Texas
    RANDY FEENSTRA, Iowa
    NICOLE MALLIOTAKIS, New York
    MIKE CAREY, Ohio

                           Mark Roman, Staff Director
                     Brandon Casey, Minority Chief Counsel

                                     ------

                             SUBCOMMITTEE ON HEALTH

                        VERN BUCHANAN, Florida, Chairman

    ADRIAN SMITH, Nebraska               LLOYD DOGGETT, Texas
    MIKE KELLY, Pennsylvania             MIKE THOMPSON, California
    BRAD WENSTRUP, Ohio                  EARL BLUMENAUER, Oregon
    GREG MURPHY, North Carolina          BRIAN HIGGINS, New York
    KEVIN HERN, Oklahoma                 TERRI SEWELL, Alabama
    CAROL MILLER, West Virginia          JUDY CHU, California
    BRIAN FITZPATRICK, Pennsylvania      DWIGHT EVANS, Pennsylvania
    CLAUDIA TENNEY, New York             DANNY DAVIS, Illinois
    BLAKE MOORE, Utah
    MICHELLE STEEL, California

                             C  O  N  T  E  N  T  S

                                  ----------

                               OPENING STATEMENTS

                                                                       Page
    Hon. Vern Buchanan, a Representative from Florida, Chairman......     1
    Hon. Lloyd Doggett, a Representative from Texas, Ranking Member..     2
    Advisory of March 23, 2023 announcing the hearing................     V

                                   WITNESSES

    Kelly Moore, Owner, NAPA Auto Parts..............................     5
    Matt Niswander, NP, Owner and Nurse Practitioner, Niswander
      Family Medicine................................................    11
    Brian Blase, Ph.D, President, Paragon Health Institute...........    16
    Karen Kerrigan, President & CEO, Small Business &
      Entrepreneurship Council.......................................    33
    Patricia Kelmar, Senior Director of Health Care Campaigns, U.S.
      Public Interest Research Group.................................    39

                               PUBLIC SUBMISSIONS

    Public Submissions...............................................    93

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                        WHY HEALTH CARE IS UNAFFORDABLE:
                     THE FALLOUT OF DEMOCRATS' INFLATION ON
                         PATIENTS AND SMALL BUSINESSES

                                  ----------

                            THURSDAY, MARCH 23, 2023

                      House of Representatives,
                                Subcommittee on Health,
                                   Committee on Ways and Means,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 2:27 p.m., in
    Room 1100, Longworth House Office Building, Hon. Van Buchanan,
    [chairman of the subcommittee] presiding.
        Chairman BUCHANAN. The committee will come to order.
        Thank you all for being here today. I am excited to kick
    off the work of the Ways and Means Health Subcommittee for the
    118th Congress with today's hearing about unaffordability of
    health care in America.
        Thirteen years ago, former-President Obama signed the
    largest regulatory overhaul and expansion of federal health
    coverage since 1965.
        At the time, President Obama and the Congressional
    Democrats made a lot of promises in the lead up to the passage
    and signing of Obamacare.
        Then Vice President claimed that it was a ``big deal.''
    Unfortunately, he was right.
        It has accelerated health care costs faster than at any
    point in the last 50 years and created an unworkable Federal
    bureaucracy that took away control from patients and doctors.
        Luckily, since then, Congressional Republicans and
    President Trump worked to undo some of the damage that the bill
    created:
        Repealing the disastrous ``individual mandate'';
        Repealing the ``Cadillac Tax'';
        Repealing the Independent Payment Advisory Board, so our
    seniors can keep access to their care.
        Since 2010, however, the Congressional Democrats and now
    President Biden have done everything they can to artificially
    prop up the Obamacare exchanges. The Congressional Budget
    Office's initial estimate for enrollment was off by one-third.
    Yet Democrats continued down this road and called it a success.
        The only time enrollment has come close to the original
    projections was after Democrats spent billions of dollars to
    make coverage essentially free for anyone making up to $90,000
    a year.
        In the spring 2021, the American Rescue Plan included
    generous subsidies to convince people to sign up for Obamacare
    plans. While the number of enrollees increased, those subsidies
    caused health care spending and inflation to go further in
    terms of inflation.
        They doubled down last year with the Inflation Reduction
    Act which has instead continued fueling our current level of
    inflation by extending these federal subsidies through 2025.
        If Obamacare coverage is what people wanted, why do they
    feel they needed Biden to get them involved?
        Instead of just throwing more Federal dollars at the
    problem, we need to come up with real reforms to our national
    health care system, both delivery and coverage of care, and put
    patients and doctors back in charge of the decision-making, not
    the Federal bureaucrats.
        Rather than government telling patients what they need, we
    must continue our work to help constituents get the right
    coverage for their families.
        For example, Republicans have promoted the use of
    Association Health Plans for small businesses so they can buy
    at a better rate and provide coverage to their employees.
        We have also returned the definition of short-term limited-
    duration insurance plans to what it was before President Obama
    changed it at the end of his administration.
        While there is no simple answer to bringing down the
    ballooning cost of health care in America, increasing
    competition, reducing government meddling, and putting patients
    and doctors back in charge is a good place to start.
        I worked with my Republican colleagues on Speaker
    McCarthy's Healthy Task Force in terms of health care to come
    up with a patient-centered vision of how to reduce government
    involvement in medical decisions.
        The hearing is the first step to implementing many of those
    changes.
        The Task Force spent over 18 months meeting with numerous
    stakeholders, providers, patient groups and others in the
    health care sector to gather recommendations of how to address
    the high cost of health care.
        I know in my district, in the last eight years, it has gone
    up 75 percent in Florida.
        Congressional Democrats negotiated Obamacare behind closed
    doors, and I introduced a resolution to require those
    negotiations take place under the watchful eye of the American
    public, when then Nancy Pelosi pushed through the $1.2 trillion
    bill and cut along secret deals, so to speak.
        House Republicans, on the other hand, have worked to
    address the shortcomings of our Nation's health care system
    through open discussions with various people and economists so
    they can weigh in, as well as our constituents.
        We are on an unsustainable path of health care spending,
    with over $4.3 trillion spent in 2021, accounting for nearly 20
    percent of our GDP. It is at long last we need to work together
    and find a way to rein in the spending and make sure we deliver
    for our constituents.
        Chairman BUCHANAN. With that, I am pleased to recognize the
    gentleman from Texas, Mr. Doggett, for his opening statement.
        Mr. DOGGETT. Thank you, as always, Mr. Chair.
        Through health care crises like the COVID-19 pandemic right
    up to the economic challenges caused by Putin's brutal
    aggression and the war crimes in Ukraine, the Affordable Care
    Act has been the safety net that has kept so many Americans
    covered and healthy.
        Increased enrollment in both Medicaid and the marketplaces
    actually reduced uninsured rates modestly during the pandemic,
    despite the fact that many were losing coverage with initial
    job losses and economic turmoil, a situation that was, of
    course, made much worse by Trump's denial, delay, and dithering
    regarding the pandemic.
        Affordable Care Act coverage has also ensured providers
    receive stable payments. That has been essential for rural
    hospitals and other health care providers so that they can stay
    open and assure patient access.
        Whether it is an unexpected medical emergency or a
    diagnosis of some dreaded disease or just day-to-day wellness
    checks, the Affordable Care Act is there for patients and for
    providers.
        In my home State of Texas, a true mark of the success of
    the Affordable Care Act is the fact that last year we had a 42
    percent one year increase in the number of those who enrolled
    in the plan.
        Now, over 2.4 million Texans are insured through the
    marketplace. Their families do not just have insurance, they
    have quality health care protection that covers their essential
    needs and they do not have to worry about being disqualified
    because of a preexisting condition.
        Though the Affordable Care Act does not permit
    discrimination, too many, primarily from communities of color
    and low-income families, are still not receiving any benefit
    from it.
        I am pleased that today, North Carolina finally joined the
    majority of States doing right by expanding Medicaid coverage.
    Those who are denied the benefits of the Affordable Care Act
    result from the kind of obstruction that we have in Texas where
    Republicans continue to deny access to a family physician for
    almost as many Texans as the number who benefit from
    marketplace coverage.
        As if 50 or 60 previous votes in this committee and this
    Congress to repeal the Affordable Health Care Act and losing
    three lawsuits were not enough, today we have yet another
    hearing to complain about the Affordable Care Act.
        While there is health care inflation no doubt, it hardly
    began with the Affordable Care Act. Health care costs have long
    been soaring much more rapidly than the overall cost of living
    for decades.
        Returning to the days of fine print limitations, junk
    insurance, and exclusions and denials of coverage at the very
    time the coverage is needed the most will not lower anyone's
    health care costs. That will only deny health care coverage to
    Americans.
        Instead, we must work to tackle the longstanding
    distortions in our health care system.
        And, of course, the poster child to that is the
    pharmaceutical prices. Big Pharma continues to spike prices
    year after year. Most recent data show an average 31.6 percent
    drug price increase, almost four times the rate of inflation.
        Pharmaceutical companies use their government-approved
    monopolies to extract the highest prices in the world, despite
    American taxpayers financing and underwriting much of the
    research and development for new drugs.
        Instead of rewarding taxpayers for their investment in drug
    research, manufacturers price gouge and manipulate the patent
    system to wrongly extend their monopolies and fend off good old
    American competition.
        While innovators certainly deserve a profit and an
    incentive to innovate and reasonable patent protection,
    layering patents to extend monopoly power and monopoly prices
    for decades is an outrageous failing about which this Congress
    has done very little.
        Charging Americans up to six times as much as patients in
    other countries for a drug whose development relied upon
    taxpayer dollars is certainly not reasonable.
        Some of us have been working for years to repeal the ban on
    drug price negotiation and place some restraint on these
    aggressive monopolies. Yet it still remains illegal to
    negotiate on the vast majority of drugs, and for the handful
    that will be subject to negotiation, no price reduction will
    occur for more than two years, and then, unless you rely on
    Medicare, you get no benefit whatsoever.
        I hope that in coming months our committee can work on a
    bipartisan basis to seek ways to have a productive response to
    health care price inflation instead of just relitigating worn
    out and unsubstantiated accusations against the Affordable Care
    Act.
        And I yield back, Mr. Chairman.
        Chairman BUCHANAN. Thank you, Mr. Doggett.
        And I also look forward to working with you and see if we
    can come up--I knew we have got some challenges. Let's see what
    we can do about moving the country forward on health care, and
    I know you are committed to it, and so am I.
        I am pleased to recognize the Chairman of Ways and Means,
    Chairman Smith, for his opening statement.
        Chairman SMITH. Chairman Buchanan, Ranking Member Doggett,
    I am pleased to join you in convening this first hearing of the
    Health Subcommittee in the 118th Congress.
        It is also a first step in a renewed effort to address the
    high cost of health care in America.
        Thank you, Chairman Buchanan, for your leadership, your
    knowledge, and your expertise. Your background as a business
    owner will ensure the success of the subcommittee in advancing
    policies that can lower the cost of health care for more
    Americans, for small businesses, and their employees.
        The high cost of health care is a painful reality for many
    Americans. In field hearings, we have heard how small
    businesses, particularly those in rural communities, are
    struggling to attract and retain workers and the increasing
    cost of providing incentives to do so.
        Health insurance is one of those key benefits, but
    unfortunately costs have been steadily increasing. One survey
    showed 91 percent of small business owners rated addressing
    health care costs as a major priority.
        While the rising cost of health care has been a challenge
    for many years, we also know that higher inflation today has
    driven up cost. Today families are paying nearly $2,000 more
    out of pocket than they were two years ago.
        Medical supply costs have increased 15 percent, which makes
    it harder for independent medical providers to keep their doors
    open and treat patients. We need solutions that offer patients
    and small business owners greater choices and flexibility.
        In today's hearing and in future hearings, including field
    hearings, we will examine the many factors driving the
    unaffordability of health care and what can be done to expand
    care to communities who today see hospitals and clinics closing
    because they cannot afford to keep the lights on.
        But the cost of care is only so important as families
    actually having access to care. I look forward to this
    subcommittee and our full committee diving further into some of
    those issues.
        We will listen to the American people, including those
    workers, families, farmers, job creators and the job creators
    we are meeting in our field hearings across the country.
        Through that work, we will identify the problems and the
    solutions in which I hope will be a bipartisan effort to
    address rising health care cost and improve the access and
    quality of care available to all Americans.
        I yield back, Mr. Chairman.
        Chairman BUCHANAN. Thank you, Mr. Chairman.
        I now will introduce the witnesses. I am very excited. We
    have got three or four people that have been in business and
    some since 1970. I am too young for that, but I am just very
    excited about having people because you make up the real world.
    You are the job creators.
        And I have been in business like you in certain businesses
    back 40 years with a couple of employees and a couple of bucks
    and built something up, but all of us want to do what we can to
    help you, and one of the things is adjusting the cost of rising
    health care costs.
        So you are going to be able to deliver that reality to us
    hopefully today.
        So the witnesses, Kelly Moore is owner of NAPA Auto Parts.
        Matt Niswander is the owner of his family medicine
    business.
        Brian Blase is the President of Paragon Health Institute.
        Karen Kerrigan is President and CEO of Small Business and
    Entrepreneurialship Council.
        And Patricia Kelmar is the Senior Director of Health Care
    Campaigns at the U.S. Public Interest Research Group.
        Ms. Moore, I will start with you.

            STATEMENT OF KELLY MOORE, OWNER, NAPA AUTO PARTS

        Ms. MOORE. Chairman Buchanan, Ranking Member Doggett, and
    members of the House Ways and Mean Subcommittee on Health,
    thank you for inviting me to testify today on behalf of the
    small business community.
        As said, my name is Kelly Moore, and I am the owner of
    three NAPA Auto Parts stores in Eastern Ohio.
        In 2004, my husband Greg and I bet on the promise that
    through hard work we could achieve the American dream. We
    opened two stores, put everything on the line to do that. We
    had 20 team and family members employed.
        The hard work paid off and we opened two additional stores
    in 2006. In 2017, we combined two of our stores and closed one,
    so we have currently owned the same three stores.
        Our employees are the lifeblood of our company. Our
    employees are incredibly valuable, well trained, and we rely on
    their dedication, their resilience, and their passion for our
    business to help the business thrive.
        When our business thrives so we do, but so do our
    employees.
        Their wellbeing is a top priority for my family and me. One
    of the most significant challenges we face is the affordability
    of health insurance.
        Another challenge we face is maintaining our valued
    employees and filling the open positions with qualified
    candidates. We want to be sure we are offering a competitive
    local wage and a competitive benefits package.
        Making matters worse, small business owners do not have the
    scale or regulatory flexibility that large corporations enjoy,
    making it difficult for us to compete, especially when it comes
    to being able to offer health insurance.
        Before the Affordable Care Act mandates were imposed, we
    paid 80 percent of the premiums for our employees and their
    dependents. However, every year after the enactment of the ACA,
    my insurance premiums increased by double digits.
        In 2010 alone, the very first year, we experienced a 30
    percent increase in premiums. Not only did we as a business
    experience that. Our employees experienced it in their share of
    the premium.
        By 2015, the year-over-year increase was 21 percent. By
    2016, it was 18 percent. And in 2017, benefit year was
    scheduled to be an additional 24 percent year-over-year
    increase.
        During the six years following the ACA, we were forced to
    scale back our premium contribution in order to afford our
    insurance premium. We scaled it back to 70 percent and
    eventually to 60 percent. We made other changes, as well.
        Additionally, our employees could no longer afford the plan
    we could secure with the plan's exorbitant deductibles and out-
    of-pocket limits. We were forced to terminate health insurance
    in 2017.
        It was a gut-wrenching decision. I lost sleep. I spent a
    lot of hours making phone calls trying to crunch numbers,
    trying to find a way to insure those employees.
        But the search for individual plans by my employees was
    even more frustrating and confusing. The terminology of health
    insurance plans, the apples-to-oranges comparisons, the
    unfamiliarity with the limits associated with different plans,
    they left our employees both disgusted and disgruntled with the
    ACA.
        Currently our employees have coverage due to recent
    legislative and regulatory actions. We reinstituted coverage in
    2019 when the Tax Cuts and Jobs Act small business deduction
    allowed us to deduct 20 percent of our pass-through income.
        In 2020, a change in the regulations by the Trump
    Administration allowed NAPA Auto Parts to offer an Association
    Health Plan. If either of these valuable government policies
    were to expire, we would no longer be able to afford or offer
    health insurance as a benefit and an attraction to new
    employees.
        The status quo is unsustainable. We need cost containment,
    choices, flexibility when it comes to our health insurance so
    that we can provide the best possible coverage for our
    employees without breaking the bank.
        In closing, I would like to thank the committee for
    allowing me to testify, for listening to the small business
    community's concerns, and for your efforts to empower the small
    business owners, especially in the arena of health care.
        I will answer any questions.
        [The prepared statement of Ms. Moore follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman BUCHANAN. Thank you, Ms. Moore.
        Mr. Niswander, you are recognized.

    STATEMENT OF MATT NISWANDER, NP, OWNER AND NURSE PRACTITIONER,
                       NISWANDER FAMILY MEDICINE

        Mr. NISWANDER. Chairman Buchanan and Ranking Member
    Doggett, members of the subcommittee, my name is Matt
    Niswander. I am from Lawrenceburg, Tennessee. I am a first-
    generation cattleman, a family nurse practitioner, and the
    owner of Niswander Family Medicine.
        I am here to highlight the difficulties and struggles that
    owners and ranchers, small business owners, health care
    workers, and middle-class families like mine encounter every
    day pertaining to the cost of high-quality individual health
    insurance.
        Small businesses like mine are struggling with the cost of
    providing insurance to our employees. And also, I want to
    discuss how increasing operating costs are making it a struggle
    to continue to take care of our communities.
        I have the honor and responsibility of supporting nine
    families as employees in my medical practice. Last year we
    celebrated as one of my nurses found out she was expecting her
    third child. Her and her husband decided to check on insurance
    through the marketplace and found that they could get a bronze
    policy coverage plan for their family for $150 a month, but
    with a $14,000 deductible.
        Her husband owns a small dirt excavating business and has
    no option for coverage through an employer, and we did not
    offer employee coverage at the time.
        So we decided to check on the cost of providing that
    benefit to all of our employees. To cover just our employees
    and not their families, it was going to cost our office $34,000
    a year for a plan that our employees would pay around $350 a
    month for a deductible of $12,000.
        If we decided to cover our employees and their families, my
    business cost skyrocketed to $140,000 for the same plan
    coverage.
        Here I am running a medical practice, and I cannot even
    offer medical benefits to my employees because of the cost. How
    is a small business supposed to budget for these ridiculously
    high prices?
        And even if I could afford to offer my employees benefits,
    why would I want to pay for something that is going to cost
    them $350 a month and $12,000 annually before it even helps
    them out?
        At this point, my employee decided to sign up for the
    bronze high deductible plan. She then paid $250 at every OB
    appointment during her pregnancy and $1,800 immediately after
    delivery, for a total of over $4,000 and a $14,000 deductible
    that was never met.
        You will be happy to know that Mother and Baby are doing
    just fine, but their budget is not.
        The cost to operate small businesses like mine have
    increased substantially in the last few years. Not only have
    the costs of supplies increased threefold compared to pre-
    pandemic prices, but supplies have even been unavailable at
    times.
        Before 2019, we bought gloves for $10 a box. That same box
    of gloves is now $30. How can we continue to afford these price
    increases?
        We provide health care to almost all available insurance
    plans in our area. The problem is that we have no bargaining
    power concerning the payments for these insurance companies,
    and payments from these companies have remained the same even
    though our expenses have skyrocketed.
        We have seen many of our uninsured and Affordable Care Act
    covered families struggle with the decision of making a house
    payment and buying groceries versus taking care of the
    uncontrolled diabetes and high blood pressure that require an
    office visit and prescription medication.
        As the cost of living in stress, especially for health care
    workers, increased exponentially during the COVID-19 pandemic,
    my employees needed and deserved raises that we gave them
    during this time. But due to economic stresses, we had to
    carefully weigh the viability of our practice with increased
    expenses and the same amount of income.
        Instead of increasing our prices, we are getting creative
    and trying to rent out space in our office for other medical
    professionals to practice and offset our expenses slightly.
        But mostly we just take the loss ourselves to continue to
    support our employees and our community. I do not know how many
    medical offices have and continue to absorb this cost, but in
    towns all over rural America, medical practices like mine and
    hospitals are closing. There are no new providers coming in to
    fill those gaps in those communities.
        The ACA may have wanted to provide high quality, affordable
    insurance plans for Americans, but in rural America working
    class families are not seeing that.
        The families in rural towns are getting older and have
    lower incomes and budgets that cannot include health care and
    have less access to primary care providers and specialists than
    ever before.
        With less than ten percent of medical providers choosing to
    practice in rural areas due to more complicated aging patient
    populations covered by Medicare and Medicaid with lower
    reimbursement rates, access to those providers is only going to
    get worse.
        Maybe ACA has decreased the number of uninsured individuals
    in America, but how do you expect people to use insurance that
    is going to make them pay more than $14,000 annually before it
    ever helps them out?
        And if they decide to use that coverage, rural Americans
    are having to travel farther, wait longer, and require more
    extensive care than ever before, straining the health care
    system even more.
        Benefits attract the best talent, but how can businesses be
    expected to sign up for terrible insurance coverage that costs
    us as much as hiring an additional full-time employee?
        And as the expenses of operating business continue to
    increase, the options for redefining and pivoting become fewer
    and fewer.
        Rural America is increasingly becoming a desert for
    medicine and a graveyard for our friends and families because
    we lack the access to affordable, high-quality insurance as we
    are simultaneously running off the doctors and nurse
    practitioners and nurses, psychiatrists, and specialists to
    treat the unique needs of our rural towns.
        My wife and I are the sole owners of our medical practice.
    We decided medical care for the people is more important than a
    profit.
        But there is nothing affordable about the care that the
    Federal Government is acting like the rural Americans are
    getting.
        Thank you, and I look forward to your questions.
        [The prepared statement of Mr. Niswander follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman BUCHANAN. Thank you.
        Dr. Blase, you are recognized.

      STATEMENT OF BRIAN BLASE, Ph.D., PRESIDENT, PARAGON HEALTH
                               INSTITUTE

        Dr. BLASE. Thank you, Chairman Buchanan, Ranking Member
    Doggett, members of the committee.
        It is a privilege to testify before you today, particularly
    since I was once a House staffer.
        My name is Brian Blase. I am president of a new health
    policy think tank, Paragon Health Institute, and my testimony
    today represents my own views.
        I will focus on how well intended government policy aimed
    at making health coverage and care more affordable often does
    the opposite.
        For example, the Affordable Care Act causes premiums to
    soar. Individual market premiums more than doubled in the first
    four years after its implementation. Yet plans cover fewer
    doctors and hospitals.
        By 2021, the average ACA plan premium plus deductible for a
    family of four exceeded $25,000. Since coverage is cost
    prohibitive, most enrollees need extremely large subsidies to
    afford these plans.
        Taxpayers pay for more than 80 percent of the premium, on
    average, and pick almost all the cost of premium increases over
    time.
        This gives insurers significant pricing power and, in turn,
    leads to higher premiums, an inflationary spiral.
        At the outset it is important to acknowledge some basic
    truths. First, the U.S. does not have a free market for health
    care. Half of U.S. health care spending is by the government.
    Most of the rest is heavily impacted by government policy.
        As government's role in health care has expanded, prices
    have skyrocketed. Hospital prices have increased more than any
    other major economic sector, rising three times faster than
    inflation since 2000.
        By contrast, in sectors where government's role is minimal,
    inflation adjusted prices typically decline while quality
    improves. Too often high health care prices and spending do not
    correspond to high value and improved health.
        For example, the ACA expanded coverage and significantly
    increased spending primary through Medicaid, but American life
    expectancy declined for three straight years following the
    ACA's coverage provisions taking effect.
        In fact, American's life expectancy was lower in 2019,
    before the pandemic, than it was in 2013.
        There is too much government bureaucracy in health care.
    Government rules, despite good intentions, often restrict
    options for coverage and care, stymie innovation, and prevent
    providers from being able to best meet their patient needs.
        Government also mismanages programs to an epic degree.
    There is $100 billion in annual improper Medicaid payments, for
    example.
        There is too much insurance bureaucracy in health care.
    Insurance is important, but having insurance pay for routine
    and shoppable services leads to over-consumption and waste.
    People often secure better prices by not using insurance.
        One study estimated that cash prices are 40 percent cheaper
    than prices with insurance.
        For health care services where third party is limited, such
    as cosmetic surgery and Lasik, real prices have declined while
    quality has increased.
        Moving forward we should keep two principles in mind.
    First, policy changes always produce unintended consequences.
    We should evaluate the outcomes, not the intentions behind
    policies.
        For example, many ACA proponents thought it would reduce ER
    visits because people would get a usual source of care. The
    exact opposite happened. ER use surged with the ACA, often for
    non-emergent care.
        Second, when government subsidizes something, it becomes
    more expensive. Subsidies increase demand, raise prices, and
    increase total spending, and must be funded by taxpayers.
        Both the American Rescue Plan Act and the Inflation
    Reduction Act expanded the ACA's already substantial subsidies.
    Most of the benefit went to people who already had coverage.
    Families with incomes well above $250,000 now qualify for large
    subsidies.
        The expanded subsidies incentivize employers to drop or
    replace coverage, raising overall deficits, and all of the new
    spending on the expanded subsidies also increases inflation.
        Congress should consider building on existing policies that
    expand coverage options in improving status, including
    Association Health Plans, which allow employers to have
    economies of scale in obtaining health insurance for their
    employees, making coverage more affordable.
        Individual coverage health reimbursement arrangements
    enable employers to offer coverage by making tax preferred
    contributions if the workers can buy coverage that works best
    for them.
        Price transparency rules empower patients and employers to
    know prices before purchasing services, and health savings
    accounts give people incentives to ensure value from their
    health care expenditures.
        In conclusion, Congress should trust people and let
    Americans have the freedom to spend their own money on the
    health care and coverage that works best for them.
        Thank you, again, for the opportunity to testify today, and
    I look forward to any questions.
        [The prepared statement of Dr. Blase follows:]

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        Chairman BUCHANAN. Thank you.
        Ms. Kerrigan, you are now recognized.

    STATEMENT OF KAREN KERRIGAN, PRESIDENT AND CEO, SMALL BUSINESS
                      AND ENTREPRENEURSHIP COUNCIL

        Ms. KERRIGAN. Good afternoon, Chairman Buchanan and Ranking
    Member Doggett and members of the committee.
        Again, my name is Karen Kerrigan. I am the service
    president and CEO of the Small Business and Entrepreneurship
    Council, SBE Council.
        It is an honor to be with you this afternoon to explore how
    high costs are impacting small businesses and possible ways we
    can strengthen and improve affordable health coverage and
    increase flexible choices for entrepreneurs and their
    employees.
        Access to health care has remained a core issue for our
    network of small business owners since our founding nearly 29
    years ago. Both in good economic times and in bad, the cost of
    health care has remained one of their top issues of concern.
        Obviously, the sting of higher cost is felt more acutely
    during challenging periods or times of high inflation and
    economic uncertainty, as we are currently experiencing.
        And, indeed, inflation and higher costs are hitting small
    businesses hard. These increases stretch across inputs
    including health coverage cost.
        Inflationary pressures have been a painful drag over the
    past year or more, and recent surveys show that inflation
    continues to rank as the top concern. An Upswell Small Business
    Owners survey reports that 47 percent of respondents cite
    inflation as their top concern, 17 points higher than a year
    ago.
        A February 2023 Goldman Sachs 10,000 Small Businesses
    Survey reported that inflationary pressures worsened over the
    past three months for 72 percent of the business owners polled.
        Higher health coverage costs are adding to the pressure. An
    October 2022 survey by Small Businesses for America reported
    that 41 percent of small business owners said that the rising
    cost of health insurance caused them to increase prices of
    goods and services.
        These cost pressures come on top of the challenges small
    business owners are facing when it comes to finding and
    retaining workers and upward pressure on labor costs, in
    general.
        Indeed, next to inflation being ranked as a top challenge,
    filling job openings ranks as a close second or on par with
    inflation. That is why business owners view benefit offerings,
    such as health coverage, as a competitive necessity in their
    efforts to attract and retain employees.
        Health coverage costs have been increasing every year. 2023
    is no different. Many of our small business members have
    reported increases in their range of five percent to 20
    percent. This is unsustainable, especially in the current
    environment.
        As my written testimony points out, small business owners
    place high importance on access to health coverage. When asked
    to identify the biggest benefit of offering health coverage,
    business owners say it is to promote the health and wellbeing
    of their employees. That is, providing health coverage is the
    right thing to do.
        But only 17 percent of small business owners believe that
    the health care solutions available to them have kept up with
    changing times. They want policies that provide them with
    choices, relief, and incentives.
        In our survey, 72 percent believe that employers and
    employees, not the government, should decide which health plan
    to offer workers.
        Congress can support small businesses by reforming existing
    programs, options, and policies, and make targeted improvements
    that we need to increase small business coverage.
        In my written testimony, I note areas for possible reform,
    enhancing the small business health care tax credit, making
    targeted fixes to QSERHRAs, enhancing health savings accounts,
    and tax changes that would produce equity for the self-employed
    regarding their ability to exclude health insurance premiums
    from the self-employment tax.
        SBE Council looks forward to exploring these solutions and
    others, including how telehealth, emergent technologies, and
    Web3 can play a growing role in delivering quality care in cost
    effective and innovative ways.
        Obviously, the health and wellbeing of all of our citizens
    are critical to the competitiveness of our Nation. Certainly
    this is a vital issue that drives the liability of so many of
    our Main Street businesses and firms.
        I look forward to our discussion today and follow-up
    conversations in the future that will lead to meaningful
    reforms for small businesses and their employees.
        Thank you.
        [The prepared statement of Ms. Kerrigan follows:]

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        Chairman BUCHANAN. Thank you.
        Ms. Kelmar, you are recognized.

     STATEMENT OF PATRICIA KELMAR, SENIOR DIRECTOR OF HEALTH CARE
             CAMPAIGNS, U.S. PUBLIC INTEREST RESEARCH GROUP

        Ms. KELMAR. Thank you very much, Chairman Buchanan, Ranking
    Member Doggett, and members of the subcommittee.
        I am Patricia Kelmar, the Senior Director for Health Care
    Campaigns for U.S. PIRG, the Public Interest Research Group.
        We are nonprofit consumer advocates who have been working
    for 50 years to protect consumers.
        We are aligned this afternoon in a common mission to
    identify the best solutions to high prices that we pay so
    health care can be affordable for everyone.
        Every week I interact with patients who contact us for help
    in solving difficult medical problems. For example, David, an
    engineer, and Christy, an IT analyst who shared their
    experience with the birth of their first child last fall.
        Baby Theo arrived early and was having breathing
    difficulties. The doctors at their local hospital recommended
    specialist care at the nearby children's hospital.
        Theo was transferred by ambulance 16 miles to get to the
    children's hospital, and he was able to receive the care that
    allowed him to go home with his folks just two weeks later.
        The grateful parents had paid their deductible and their
    out-of-pocket maximum when the hard bill came in. What put them
    over was the $7,000 bill from the ambulance company. Insurance
    had paid $1,000, but the couple was shocked to learn that they
    had to pay the remaining $6,000 because that 16-mile ambulance
    ride was provided by an out-of-network provider.
        They tried negotiating with the health plan and the
    ambulance company, unsuccessfully. They had to set up a 30-
    month payment plan with the ambulance company, which means that
    Baby Theo will be almost three years old by the time they end
    up paying off that medical debt.
        Circumstances like this can set families back for years,
    struggling to pay for expensive medical bills that they cannot
    control or negotiate.
        In the U.S., we rely on several different types of
    insurance. It comes in public programs, like Medicare,
    Medicaid, and through private insurance, through our employers
    or unions or through the ACA marketplace.
        Insurance works when everyone has it because we spread the
    cost of all that care amongst a broader population, and the ACA
    has enabled us to get most people insured, filling in those
    gaps.
        But when the prices of care are so high, health insurance,
    no matter how we design it, will not change the amount that we
    have to spend. Three-quarters of the money that is spent in
    employer insurance goes to prescription drugs and the services
    provided at in and out of out-patient hospital facilities.
        Prescription drug prices have increased 60 percent in the
    last ten years. Even with insurance, one in four families find
    it difficult to fit prescription drugs and medications into
    their family budget. They either do not fill their scripts or
    they skip doses, all resulting in worsening health.
        And the high prices charged by hospital-owned facilities
    make up more than half of our insurance health care
    expenditures. Tremendous consolidation is driving up prices.
    With recent vertical integration, those high prices from
    hospitals are coming into our own family-owned and smaller
    health care physician practices that are being bought up by the
    larger conglomerates.
        And those prices are set by that larger health care system,
    not by our local providers.
        The patient is the last in that conversation. They are the
    ones who are paying the prices.
        Private equity investment is also growing in the health
    care sector, and of course, they have to maximize profits for
    their ROI.
        These higher prices have not improved the quality of care.
    So the most effective way to achieve affordability is to
    address high prices of prescription drugs, in particular, and
    hospital-based services. Those are the cost drivers.
        And the best way to do that is by improving competition and
    constraining overcharges in both of those sectors.
        You have already made very important headway with the
    important bipartisan law, the No Surprises Act, which prevents
    over a million surprise medical bills every month, and with the
    ability for Medicare to negotiate prescription drug prices in
    the coming years.
        But we can do better. When generic drugs come to market, we
    know that competition can drive prices down by as much as 80
    percent. We need to put an end to the tactics like patent
    thickets, product topping, and other mechanisms that keep
    generics and biosimilars from making it to our pharmacy
    shelves.
        We need a menu of tools to address the impact that
    consolidation has brought on prices and causing them to go up.
    We need greater enforcement against anticompetitive practices
    and ensuring that nonprofit hospitals promote and distribute
    their financial assistance money to people that need them.
        States are even experimenting with good ideas like cost
    containment boards, and California is, frankly, actually making
    its own medications to address high drug prices.
        It is time for bold, innovative price containment ideas to
    help the millions of insured Americans like Christy and David
    so they are not staying up at night wondering if that next
    cancer diagnosis or car accident will end up putting them into
    bankruptcy.
        So thank you very much. I look forward to taking your
    questions, and thank you for listening to perspective of the
    consumer today.
        [The prepared statement of Ms. Kelmar follows:]

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        Chairman BUCHANAN. Well, thank you.
        And I want to thank all of you for your testimonies. Now we
    will proceed to the question-and-answer part. I will go first.
        Ms. Moore, you know, it looked like you had started
    business back in the 1970s or so, and that is when we first
    started, but I know for 20 years that I was in business, the
    first 20, we only had five, ten, 15. We paid for everything,
    100 percent. There were no deductibles.
        And it seems like in the last ten, 15 years, it has gotten
    pushed and it is only impacting in a negative way small
    businesses like yourself, but it has gotten pushed to the
    families.
        Where we used to pay everything, now we pay half or we pay
    60 percent. They are picking up 40, and then you wonder why is
    it that so many people seem to be working paycheck to paycheck.
        One of the biggest reasons, in my opinion, is just because
    of the growth of the cost of health care and having to pick it
    up. It impacts small business, but that family of four is
    typically, and every area it is different, but let's say 1,600.
    But they are paying 700 a month out of pocket.
        So what is your experience with that as you look back? Is
    it the same thing where everything has been accelerated?
        I am not looking to place blame, but I am just looking at
    what the reality is for someone like yourself.
        Ms. MOORE. We inherited the health plan when we opened our
    first doors from the previous owner until that premium period
    ran out. Back then employees had a $500 deductible.
        Like I said, we not only covered employees and dependents.
    We offered spousal coverage at that time.
        With the ACA came the challenges of meeting payroll and
    also health insurance. Payroll, it was a time in business that,
    quite frankly, the 2008-2009 recovery time was not coming fast
    enough for businesses like mine.
        So what happened was we dropped that coverage for spouses;
    and then, we had to decrease the premium contribution, as I
    said, from 80 to 70, then 60. We ended vision, life, and dental
    insurance coverage for our employees.
        But I am glad to tell you that because of those changes
    made after 2019 or I guess they were enacted in 2017-2018, we
    were able to reinstitute not only health insurance but pay 100
    percent of a life insurance policy for our employees and all of
    their dental and vision.
        Chairman BUCHANAN. What is your cost for a family of four?
        Ms. MOORE. For health insurance?
        Chairman BUCHANAN. Yes. You have got an employee, married
    and two kids. What are you paying per month or per year?
        And I am saying not you. Just overall what is the bill? And
    how do you split it today?
        Ms. MOORE. Currently the bill for nine eligible employees
    who are taking advantage of ours is $7,800, and they are paying
    a portion of that.
        Chairman BUCHANAN. And do you mind me asking? What are they
    paying, their portion? Are they paying half?
        Ms. MOORE. Sixty percent of that. So you are looking at----
        Chairman BUCHANAN. Four or 5,000 a year then they are
    paying.
        Ms. MOORE. Yes.
        Chairman BUCHANAN. That is my point.
        Ms. MOORE. And the median income in our area is about
    $50,000 per household income, median income.
        Chairman BUCHANAN. So that is a lot of money, 4,000.
        Ms. MOORE. That is a whole lot of money.
        Chairman BUCHANAN. And I want to touch because it is not
    about tax, but you did say 199(a) because you are a pass-
    through entity, and you took advantage of that, that 20 percent
    reduction, because a lot of people do not understand it passes
    through you, yourself, and if you are married, your husband.
        But explain that a little bit more, how that made the
    difference for you, that 199(a). It is just obviously less
    taxes and you are able to cover more for the employees. Is that
    what happened?
        Ms. MOORE. That is exactly what happened.
        And in addition to that, we were able to take some of that
    income and boost our inventory. Our inventories had been
    dwindling because the cost of inventory was escalating. So that
    20 percent not only helped us cover health insurance. It helped
    us meet some other significant expenses for our business.
        Chairman BUCHANAN. Let me just switch gears here a little
    bit.
        Mr. Niswander, let me ask you. In your business you have
    what, nine employees did you say?
        Mr. NISWANDER. Yes, we have 11 including me and my wife.
        Chairman BUCHANAN. Okay. Let me ask you about your
    patients. You are in a rural community. What are they doing for
    insurance? Are most of them on Medicare or Medicaid?
        But what are the small business people or people who are
    trying to buy insurance that do not have that coverage? Someone
    mentioned that 50 percent of people have some insurance through
    the government or whatever, but there is another 50 percent or
    more, whatever that number is, that does.
        So you have got your experience, but what are you finding
    about just the rural community in general in terms of who pays
    what and how much?
        Mr. NISWANDER. In our practice, about 40 percent of our
    patient load is Medicare or Medicaid insured patients.
        Chairman BUCHANAN. Okay. And then in terms of the people
    that do not have the coverage, what are they doing for
    insurance?
        They come into your office. Do they have insurance, small
    business people like yourself?
        Mr. NISWANDER. The ones that we see in our community that
    are covered under Medicaid and ACA coverage, oftentimes do not
    come to our office because of the looming figure of that
    $14,000 deductible that blue collar working families like
    myself just do not have in the bank.
        Chairman BUCHANAN. Yes. I saw a poll today, and I am glad
    to get it out to everybody, but they were saying, which was
    shocking to me, 40 percent of people do not go to the doctor
    for something because they cannot afford to pay for it and 25
    percent of that or let's say 25 percent of the total basically
    have real issues and they are serious issues and they know they
    need a doctor, but they do not do it because they cannot afford
    to pay the bill.
        Thank you, and now I will recognize the gentleman from
    Texas for any questions he might have.
        Mr. DOGGETT. Thank you, Mr. Chairman.
        And to all of our witnesses, you know, it really is
    remarkable that today we are celebrating the 13th anniversary
    of the Affordable Care Act. It has been amazingly resilient. It
    survived literally dozens of attempts in this committee and
    other places within the Congress to substitute Nothing Care for
    Obamacare. It has been all the way to the Supreme Court three
    times with one lawsuit after another, and it has been upheld.
        And we have had four years of sabotage by President Trump.
    I think that against that background the fact that so many
    Texans decided last year to vote themselves by enrolling in the
    Affordable Care Act is an indication of the value that it
    offers.
        Let me ask you, Ms. Kelmar, before the Affordable Care Act,
    we are all concerned about rising prices today, but before we
    had an Affordable Care Act, were health care prices or goods
    and services soaring and high above the ordinary cost-of-living
    index?
        Ms. KELMAR. Health care prices have been rising for
    decades. It has been higher than inflation, and it has
    continued to rise. So yes.
        Mr. DOGGETT. What about those individuals who have no
    coverage at all. Providing people Nothing Care so that they are
    without insurance, what will that do in terms of decreasing
    health care costs?
        Ms. KELMAR. The average amount of money in a person's
    savings account in the U.S. is about $400, and when we can see
    just one simple ambulance bill being, you know, $6,000, we just
    know that folks do not have that kind of money to pay off a
    bill in an emergency situation, let alone be able to go to the
    doctor for their regular preventative checkups.
        That is why insurance is so important, because it allows us
    to spread the costs among wider populations, helping everyone
    to be able to access that care that they need, whether they are
    healthy or very sick.
        Mr. DOGGETT. How about these junk insurance policies that
    President Trump was so fond of that excluded essential
    services? Some of them had preexisting condition limitations.
        What do those do to reduce the cost of health care?
        Ms. KELMAR. So the best insurance is the one that is
    promoting the primary care and the preventive services and
    covers those kinds of treatments, and then makes sure that we
    are trying to look at the broader population health.
        So when we have gaps in coverage and the important
    treatments are not provided, then people ignore the care or
    cannot get the care and/or alternatively, they are going into
    debt to get the care, which makes them a less active member of
    society and the economy.
        So it is really important that our insurance programs are
    reliable, trustworthy, that we can depend on them to provide
    the care that we need, but that is the reason why we really
    need to get at the price issue, because prices of insurance are
    going up because of the payouts to the drug companies and to
    the hospitals for that care.
        So we need to get a handle on those prices, and we need to
    probably come up with a menu of solutions in order to address
    them.
        Mr. DOGGETT. And I believe you had a statistic about drug
    price inflation. Of all the forms of health care inflation, are
    not drug prices right at the top?
        Ms. KELMAR. Certainly, and a lot of that has to do with the
    fact that we have not been seeing the kind of generic
    competition that we need in the marketplace to make sure that
    we can bring down drug prices.
        With just the introduction of a couple of drugs into the
    market to compete, that enables people to shop around or the
    insurance companies in this case to shop around and get a
    better price and bring down the drug prices in the marketplace.
        So it is really important that we encourage great generic
    and biosimilar competition, and we break down those barriers
    that are keeping them off the shelves.
        Mr. DOGGETT. Well, I think every significant new drug
    approved in the last decade has had significant taxpayer
    funding in the research, and yet taxpayers do not get any
    break. They have to pay more than people in other countries,
    and we face continual resistance in this Congress to doing
    anything about that.
        Similarly, you reference other problems that could help
    bring down prices, such as dealing with the role of private
    equity, which has been involved in the consolidation and
    increase in prices in many parts of the health care industry.
        Similarly, the important work of the Biden Administration
    through the Federal Trade Commission is often overlooked, but
    when you have a monopoly, whether it is in prescription drugs
    or in some other health care sector, you get monopoly prices,
    and things are driven up.
        So there are many areas we need to work together on and
    overcome lobby resistance to try to bring health care cost
    down.
        Thanks to all of you.
        Ms. KELMAR. Thank you.
        Chairman BUCHANAN. I now recognize the gentleman from
    Nebraska, Mr. Smith.
        Mr. SMITH of Nebraska. Thank you, Mr. Chairman.
        Thank you to all of our witnesses for sharing your
    perspective and your insights.
        Where do I begin?
        The cost of health care pre-inflation that we have seen in
    the last couple of years was bad enough, and now it is even
    worse. I grow frustrated when there are comparisons made from
    the dais perhaps here that are not really reflecting reality.
        I am concerned that the overall cost of health care has
    driven up health insurance plans for workers, public sector,
    and private sector. I marvel at the fact that before
    Obamacare--I cannot quite call it the Affordable Care Act
    because I do not think that is accurate--but before there was
    this outsized intervention by the Federal Government, we had,
    you know, high risk pools that existed that, yes, those premium
    levels were offensive. They were painful.
        But now, it seems that everyone in the individual market,
    now that they pay a similar amount, it is not as offensive. I
    worry about things like that.
        And I worry about the fact that a recent Gallup poll found
    38 percent of Americans delay medical treatment in the last
    year because of cost concerns.
        I worry that the cost of medical equipment and supplies has
    increased 15 percent just since the beginning of the Biden
    Administration.
        Hospitals have seen nearly a 25 percent increase in labor
    cost per discharged patient since the beginning of the
    pandemic.
        I could go on here with further notes, but suffice it to
    say that we have got a worker shortage. We had a worker
    shortage even before the vaccine mandate. Found out perhaps the
    vaccine mandate was not as productive as some would have
    argued. We have finally gotten rid of that, but there has been
    a lot of pain along the way.
        So I hope that we as a combined body of policy makers and
    certainly experts with some great insight, that we can have the
    conversations that we need to have to deliver better results
    for the American people.
        I believe my colleagues who supported Obamacare meant well.
    The results, I think, have been disastrous. I think that my
    colleagues who supported the spending two years ago out into
    the economy against the warnings of economists, very reasonable
    economists, against their warnings that it would trigger
    inflation, I worry that those results have also been
    disastrous.
        So as we sort out all of this and hopefully get our country
    on a better path certainly as it relates to small businesses
    and actually workers in whatever size business, I hope, can
    experience better results moving forward.
        But, Mr. Niswander, I have to say I am impressed with your
    diverse professional background, and I am guessing that you
    provide some great services to your community and help feed the
    world. I appreciate that.
        Can you perhaps tell us how the rising labor cost has
    specifically impacted your business across the industries in
    which you work and what you would do if the cost of paying your
    employees increased by another 25 percent over the next three
    years that we are all fearful of?
        Mr. NISWANDER. So like I mentioned in my opening statement,
    prices have increased threefold, and we are talking about basic
    supplies to run a medical office, Band-Aids, syringes, needles,
    things that are fixed that I cannot pass on to the patient and
    that I cannot control there.
        We are talking about pennies sometimes, but the price of
    syringes, for instance, has increased by about 15 cents apiece,
    which does not sound like much, but when you use hundreds a
    week that adds up to your bottom dollar.
        That has impacted us that we cannot offer this cost that we
    would have maybe paid for health insurance. We cannot offer
    that to our employees. We cannot retain the talent that we
    need. We cannot invest in new and better technologies, better
    serve our rural communities that do not have access to those
    new and advancing technologies.
        But for me personally, it created a lot of sacrifice. I am
    a first-generation cattleman, and since I was 16 years old
    working on a dairy farm, I dreamed about having a farm. I
    bought that farm in 2014, and last year I had to sell it in
    order to keep our medical practice alive and our patients taken
    care of and my employees' families fed.
        I do not have another farm to sell.
        Mr. SMITH of Nebraska. Thank you.
        And do not have a lot of time left, but I hope that we can
    get to the point where we truly address cost rather than just
    shifting around who pays for what and saying everything is all
    better.
        Thank you. I yield back.
        Chairman BUCHANAN. I now recognize the gentleman from
    California, Mr. Thompson.
        Mr. THOMPSON. Thank you, Mr. Chairman.
        And thank you to all of the witnesses that are here today.
        I really truly appreciate my Republican colleagues giving
    us an opportunity to point out and talk about the health care
    cost issues that we face collectively. I believe strongly that
    every American should have access to quality, affordable health
    care and want to work to make sure that that becomes a reality.
        I do wish, however, that my friends on the other side would
    help us figure out how to address these issues rather than just
    spend all of their time criticizing why the many things that we
    have done to date have not completely solved this issue.
        The issue of access to quality, affordable health care has
    long been something that plagued us before the Affordable Care
    Act and after the Affordable Care Act. But I think it is
    important to point out that last year it was Democrats that
    passed legislation allowing Medicare to negotiate the price of
    prescription drugs. That provision alone is going to save
    Americans and the Medicare program billions of dollars on their
    prescriptions.
        We also passed legislation capping the price of insulin for
    Medicare beneficiaries at $35 a month, and now that is being
    followed by private sector providers as well.
        And of course, 13 years ago, as has been pointed out, we
    passed the Affordable Care Act, historic legislation on which
    tens of millions of Americans rely for health insurance and
    which for the first time required insurers to cover a range of
    mental health challenges that all Americans face.
        Unfortunately, my colleagues who are quick to criticize
    also voted against all of those provisions. So no to lower drug
    prices, no to affordable insulin, no to mental health coverage.
    Over 70 times they voted to do away with the Affordable Care
    Act.
        But all of their efforts failed because the law actually
    does work. I am willing to work with anyone to lower the cost
    of health care, but let's be honest. Virtually every step
    Congress has taken to lower health care cost has been opposed
    by my friends on the other side.
        I would like to enter into the record a statement from Keep
    Us Covered, which outlines why the Republican proposals, some
    of which are being discussed today like the individual coverage
    HRAs, will undercut the gains made in the ACA and allow for
    discrimination against workers.
        Mr. Chairman.
        Chairman BUCHANAN. Without objection.
        [The information follows:]

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        Mr. THOMPSON. Thank you.
        And I want to also point out that the average premium for
    ACA plans in my district was $697 without subsidies, but $241
    for those eligible for the ACA tax credit.
        And also, I want to point out that California's uninsured
    population dropped from 17 to seven percent after the ACA was
    put into place.
        And then as I mentioned before, the ACA provided mental
    health coverage to an estimated 48 million people who otherwise
    would have gone without that help.
        I have a couple of questions. Ms. Kerrigan, you talked
    about the importance of telemedicine. That is something that
    ironically has good bipartisan support. Legislation of mine was
    put into the COVID legislation that expanded telemedicine for
    Medicare folks. It has created a very safe environment for
    people to get health care.
        And we actually extended that. I believe that we should
    really expand telehealth and provide that access to folks who
    are in Medicare and others as well.
        Could you talk just briefly on how much that will help with
    access and how much it will help with affordability?
        Ms. KERRIGAN. Oh, I think it would be extraordinary and
    significant, and it was also great to see at the end of last
    year, you know, the CARES Act piece where employers could
    reduce covered telehealth services by allowing employers to
    provide pre-deductible coverage for such services. That has
    been expanded, and I think that needs to be made permanent.
        But absolutely, technology can play a big role in reducing
    health care and giving people more access to health care. I
    think particularly in rural areas, too, where you do have, you
    know, the challenges cited by the other witnesses in terms of,
    you know, hospitals being closed or are closing and not having
    access to providers.
        So people who lack mobility, I just think all in all it
    would do a lot to help drive down the cost of health coverage,
    give people more access, and just help the system be more
    productive and efficient.
        Mr. THOMPSON. Thank you very much.
        Mr. Chairman, Mr. Schweikert and I have telehealth in a
    bill and we would appreciate any help you could provide to get
    that marked up on the floor.
        Chairman BUCHANAN. I look forward to working with you.
        Mr. THOMPSON. Thank you.
        I would like to recognize the gentleman from Pennsylvania,
    Mr. Kelly, who is obviously like myself and some of us up here
    that have been in business a long time and dealt with this
    issue head on.
        Mr. Kelly.
        Mr. KELLY. Thank you, Chairman.
        And thank you all for taking a day out of your life to come
    down here.
        We have been attempting since this session started to go
    out into the country. So we were in Oklahoma one time, and we
    were in West Virginia another time in very small, small
    communities.
        And, Ms. Moore, I am also in the automobile business. So I
    am really interested. You know, when I looked at your input to
    this and I hear your testimony, I cannot help but be impressed
    by your story. What you and your husband have been able to
    accomplish is the American dream.
        I do not know that you had a lot of government help doing
    that. I think once you became profitable, the government came
    knocking, and we find many ways to shake pennies out of
    people's pockets because we are going to do it the right way.
        And we are only $33 trillion in debt. So I would challenge
    anybody. If you want to watch a model, please do not bring
    anybody here in to tell you how to run your business.
        So but looking at what you do, and I know this because I am
    the same way, the same as Mr. Niswander. Really, how many
    sleepless nights do you have trying to figure out how you are
    going to make payroll?
        And how many times do you have to pay everybody but
    yourselves in order to keep that out there?
        Now, you did talk a little bit about inflation because
    there are many times that we talk about things and it kind of
    takes your mind off of what is really happening in your store,
    in your neighborhood, in your county and your State and in your
    country.
        So can you talk a little bit on what inflation and supply
    chain disruptions have impacted, how it has impacted your
    business and how you have had to adjust to the benefits that
    you provide to your employees?
        Ms. MOORE. Well, with the supply shortages are critical. We
    have shared this with a number of people, but in Keith Lines,
    we are getting shipped 40 to 60 percent of what we order. Those
    orders come with a discount, which we then are able to pass on
    to our customer.
        When we cannot secure those with a discount, we are having
    to get rapid items much more expensively. So it is driving up
    not only our costs, but also the cost of our customers, putting
    a hurt on the small business customers we have.
        Not everyone is a giant corporation in our area. Most own a
    garage or diesel mechanic shop and help out with the stone
    haulers or the cement workers. The fleet garages are our big
    customer.
        So supply shortages continue to challenge us. We are
    thinking of creative ways. We are looking for outside
    suppliers, but then you have a product that you may not be
    familiar with, you may not have experience with. So warranty
    items become an issue.
        Mr. KELLY. Yes, and we are in the same position. I think
    any of us that are in businesses know how tough it has been to
    attract talent and give the benefits package to them that they
    need to have.
        Because you are in competition with everybody else that is
    looking for talent.
        Ms. MOORE. Yes.
        Mr. KELLY. So the benefits package is a big deal.
        Mr. Niswander, just between the two of you all, I said it
    and I am sure Vern has gone through the thing. There are many,
    many nights when I sleep. Mrs. Miller and I agree on everything
    because she is also an automobile dealer.
        But if you all can talk about it because it comes down to
    this. We are talking about health care and how it is soaring,
    the cost of keeping people healthy. What is it that we could
    do?
        And you want to keep these benefits there to attract the
    best people to address the people that you serve.
        So, Mr. Niswander, I do not know how you have done it, but
    having health care in a rural area, being able to take care of
    those folks and knowing that your model, your model for a
    profit is very small and leaves little room for any types of
    mistakes.
        And that is why I think we keep talking about we are going
    to get good health care for people. I really appreciate that. I
    cannot afford anything we are doing right now.
        You know we started off at 80-20. Then we went to 70-30.
    Then we went to 60-40, and right now we are contemplating going
    to 50-50 because we cannot afford to be in a competitive area
    with another person who has also the same products that we do,
    and it is all based on total cost of operation.
        So, Mr. Niswander, just share a little bit. I mean, for you
    to do what you had to do and keeping the medical part going on
    right now, the rural part, and calling on people and trying to
    keep them healthy.
        Mr. NISWANDER. There is a word that my colleagues here and
    some of you had mentioned, and it is the word ``affordable,''
    and you talked about out-of-network payments, right?
        You tell uninsured Americans what good is that insurance if
    they get the card with their name on it but they cannot use it?
        Access to health care is a problem. Mr. Doggett mentioned
    maintaining keeping rural hospitals open. Texas leads the
    Nation in closed hospitals in the last ten years. In my State
    in Tennessee, 16 hospitals have closed in the last ten years.
    Thirteen of those have been in rural areas.
        My hospital in my county is on the verge of closing. The
    county next to me just closed last year. Access to health care
    is a problem, people. It is not affordable.
        Families are having to drive from my practice over two
    hours to get to a specialist, as simple as an ear, nose and
    throat doctor. It is not that there is not one closer. Medicaid
    pays on average about 60 cents on the dollar compared to
    commercial payers. What physician office wants to accept that?
        They drive past ten, maybe 20 specialists to get to the one
    that will accept their insurance.
        People in my community do not make a lot of money. Thirty-
    six thousand dollars is the average income. They are asking
    them to pay a $14,000 deductible, drive two hours to get to a
    specialist, take a day off work that they cannot afford that is
    going to take food out of the kids' mouths?
        Affordable Care Act is anything but that.
        Mr. KELLY. Thank you.
        Chairman BUCHANAN. I now recognize the gentleman from New
    York, Mr. Higgins.
        Mr. HIGGINS. Thank you, Mr. Chairman.
        You know, it is obvious that we are still discussing health
    care. You know, there are still many challenges in front of us.
    I believe that health insurance companies jack up premiums, and
    then when you go to use the health care that you have already
    paid too much for, there is very little underlying insurance.
        And that was a problem before the Affordable Care Act
    because people convinced markets junk policies. It really did
    not mean anything to anybody other than the temporary
    satisfaction that you had health care.
        Since the Affordable Care Act, I voted for it, not perfect
    by any means, but 35 million more people have health insurance
    that is more affordable because of the Affordable Care Act.
        Prior to the Affordable Care Act, if you had a kid that was
    stuck with cancer, insurance companies could deny you coverage
    because of a preexisting condition. You cannot do that anymore.
    It is against the law.
        Policies have to cover preexisting conditions. What are
    they? Diabetes, cancer, epilepsy, lupus, asthma, pregnancy, and
    that is just part of the list.
        So the insurance company always had the upper hand. The
    idea here was to pool the American people so that there was
    leverage to negotiate a better deal for consumers that they did
    not have on their own.
        And if the Affordable Care Act is so bad, why did our
    colleagues' efforts 51 times to repeal it fail? Because maybe
    it is not perfect, maybe we can do better, but the Affordable
    Care Act is better than what we had. And the whole objective
    was to bend the cost curve and to increase the number of people
    who would have health insurance coverage. Both objectives have
    been met.
        You talk about the high cost of premiums. You are right.
    Before it was about 15 percent annually. Bending the cost curve
    is not taking away the annual growth in health care premiums.
    It is lowering them.
        Are they as low as we want them to be? Absolutely not. But
    if this Congress worked in a bipartisan way like we did with an
    infrastructure bill which was bipartisan, we could create a
    better program than the Affordable Care Act.
        Why are we not allowing people to buy into Medicare at 50
    years old? They would save 40 percent on their premiums. You
    would not have to create a new program. You just allow them to
    enroll in the program at their own cost.
        So I guess my point here is that, you know, we are not
    defending the perfect here. Everybody, even the most vociferous
    proponents of the Affordable Care Act will acknowledge that it
    is not perfect, and we still have a long way to go.
        But every story that you tell, the problem with rural
    areas, that we do not have doctors and nurses and health care
    providers, they do not want to go there. Why? Because that is
    not the population where they can make as much money as they
    would otherwise be able to do in a more densely urban or
    suburban area.
        So we all have an obligation on both sides of the aisle to
    do a lot better for you.
        The Inflation Reduction Act, again, was just a start. I
    have been here for a lot of years, and everybody has been
    talking about ``Why is Medicare not authorized to negotiate
    drug prices?'' The VA does it and they realize a significant
    reduction.
        Why? Because life and insurance are all about leverage. So
    why would we not use the leverage of Medicare beneficiaries to
    lower the cost and drive up the quality of health care on
    behalf of all of you who have a personal story that I believe,
    that I believe.
        So the Inflation Reduction Act begins to do that, but
    unfortunately, progress in Congress is typically very
    incremental. We should be making major progress to hold down
    the cost of insulin, which this bill does, to hold down the
    cost of individuals on a yearly basis to $2,000.
        But they are never a finish. They are a start, and all of
    us should demand much better from Congress, particularly
    hearing your stories and particularly when it comes to the high
    cost of health care.
        With that I yield back.
        Chairman BUCHANAN. Thank you.
        I now recognize the gentleman from Ohio, Dr. Wenstrup.
        Mr. WENSTRUP. Thank you, Mr. Chairman.
        Thank you all for being here today.
        Of course, we all know that the inflation that we are
    dealing with today is not helping the situation whatsoever, and
    you know, people talk about insurance as though that equals
    care, and I think most of you on the panel know that does not
    equal care just because you have a policy.
        And we talk about negotiating drug costs. There is a
    difference between the negotiation and a dictation, and if
    there is a dictation and it is ``take it or leave it,'' and
    then you are left out, then that drug is no longer available
    and it stymies the possibility for more research and
    development, and we have to be considerate of that.
        And I am bothered when I hear my colleagues say things like
    they want to accomplish something on this committee, but then
    they say Republicans are for Nothing Care.
        Well, I am sorry. That reminds me of a line from The
    Princess Bride. ``We are all men of action. Lies do not become
    us.''
        So let's have serious conversation. We are about a healthy
    America, is what Republicans are for. We are about prevention.
    We are about diagnosis and treatment and making America a
    healthier place.
        But what we do not want is the government in between the
    doctor and the patient, and I can tell you that first hand, and
    I know Dr. Murphy can as well, and I know Mr. Niswander can as
    well.
        That is part of the problem. So when you are trying to
    create savings, you have created the problem. It is interfering
    with the doctor and patient.
        Look. I love our safety nets. I am proud to live in a
    country that has programs like Medicaid and Medicare, and
    especially with Medicaid though. I want fewer people to need
    it, not more people on it.
        And that is a difference between Republicans and Democrats.
    Democrats call success putting more people on the government
    program when we say success is fewer people needing it.
        When I started in practice, I had two employees, and if
    someone was sick my mom came in. You can probably relate to
    that, right?
        And the patient came in. If it was just for an office
    visit, I gave them their bill. They paid it, and they submit it
    to insurance.
        Now we get the government involved, and now everything has
    got to change, and I have got to hire more employees, and I
    have got to, you know, file all of the claims, and I have got
    to have every word perfect in the chart.
        You know, there was one time I had a patient and he said,
    ``Doc, how much is this going to cost?''
        And I said, ``Well, I can numb you up here in the office
    and it's about $300.''
        And he said, ``Honestly, I don't have any money.'' And then
    he said, ``You know what? I raise chicken. Do you like
    chicken?''
        I said, ``You have got a deal.''
        You can probably relate to that, too.
        And I did not expect anything of him, but he delivered with
    that, by the way, and I took care of him. But now you cannot
    because now you are giving someone a special favor because of
    all the rules coming in from the government.
        Oh, no, you are giving favoritism to one person over
    another. How about you are helping somebody in need? And why
    can that not be okay?
        But that is where we are today. So I went from my practice
    and grew my own administration. Then I joined a large
    orthopedic group, and you know, recently because of things like
    decreased reimbursement to physicians, the change in the
    Surprises Act that HHS put in that we did not put in the law,
    the bipartisan bill that we passed, they changed the rules to
    favor the insurance companies and drive down what you pay
    doctors. That is when they quit. And that is when they quit
    taking calls.
        But that is what our government is doing.
        I do have a rural community in my area, and a lot of rural
    communities, and one of the doctors, he said, ``I just do not
    take insurance at all because mostly what I do are office
    visits, and if I have to refer to a specialist, that is when
    their insurance kicks in, but they just pay me a small amount,
    and it is half of what it would be if I was taking Medicare and
    everything else.''
        And it works. It works in that environment. So we have got
    to get the government out.
        And to the point, too, the other large orthopedic group in
    our town, they went private equity, and they quit taking
    Medicaid. When I first started, if I saw one or two Medicaid
    patients a month or something, I did not care. That was about
    all I saw.
        But as the numbers grow, you cannot keep your doors open.
    It is a business, right? And it is very hard.
        So my question for you, Mr. Niswander, and I think this can
    kind of hit home with everything because I talked about the
    need to practice with very little assistance in the office. You
    said you have 11 employees. How many of those actually touch
    patients and provide medical care?
        Mr. NISWANDER. Every one of them.
        Mr. WENSTRUP. So out of 11, you have them all. So there is
    no one who is just administrative. There is no one who is
    just--that is what I am trying to differentiate.
        Mr. NISWANDER. So we have a billing company and a company
    that processes our claims for us. That is two separate
    companies there. We pay them a percentage out of our income as
    well, every claim that is processed.
        Mr. WENSTRUP. For many people that is in their office and
    those are the employees.
        Mr. NISWANDER. That is correct.
        Mr. WENSTRUP. So you have people producing, but you do have
    to pay for all of the administrative burdens that have been put
    on us over the years.
        Well, I think this is what we have to focus on, and let's
    focus on the health of America and our patients and be sure
    that when we are doing something from the government level, we
    are actually helping, not hurting.
        And I yield back.
        Chairman BUCHANAN. Thank you.
        I now recognize the gentleman from Pennsylvania,
    Congressman Evans.
        Mr. EVANS. Mr. Chairman, I wanted to thank you for calling
    us together to mark the 13th years since President Obama signed
    the Affordable Care Act into law.
        First, Mr. Chairman, I would like to ask to submit the
    testimony of Walter Rowen, co-chair of the Small Business for
    America's Future and President of Susquehanna Glass in
    Columbia, Pennsylvania, for the record.

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        In his testimony, Mr. Rowen states, ``Before the
    implementation of the Affordable Care Act securing affordable
    health care for small businesses and their employees, there was
    a much more hostile battle. However, the Act has revolutionized
    the landscape for providing affordable options to small
    businesses through initiatives such as the small business tax
    credit, the Small Business Health Care Option Program
    Marketplace, and the Individual Health Insurance Marketplace.''
        He goes on to say, ``It also helps start a wave of new
    small businesses by incentivized people to take the leap into
    entrepreneurship.''
        And towards the end, he states, ``Repeatedly weakening
    health care will be a blow to the vital small economic
    contributions.'' This is important.
        Mr. Rowen makes clear, however, the Affordable Care Act has
    helped small businesses across America, and I thank him for
    sharing his testimony with us.
        The Affordable Care Act was a life changing model that
    improved countless lives. I will list just a few examples.
        The ACA provided coverage to millions of Americans and
    initiated over 21 million through Medicare expansion and over
    16 million were enrolled in marketplace plans.
        The ACA people were successful in preventing--and it is
    important, as he then said this. When it approached time, it
    gave people a sense of hope. No, it is not perfect, but it gave
    people a sense of hope.
        I want to take a moment to talk about the medical dent the
    Affordable Care Act made and what it has attempted to do. More
    than 100 million Americans are dealing with this issue of
    medical debt. Let me repeat that: over 100 million Americans.
        In the past five years more than half of U.S. adults fought
    against debt. I want to thank those not here and the members
    who took the lead on this issue. It was working together that
    made a difference.
        We cannot afford to go back. American families cannot
    afford having more costs thrown on their budgets, and it is
    important that it will only work when we work together.
        President Biden has moved in the right direction when he
    called the Affordable Care Act a big deal. I will say it is a
    little stronger than that.
        I look forward to working with my colleagues in trying to
    provide and make sure that health care is a reality. No, it is
    not a question that is perfection, but it is an issue that we
    all must work together.
        So I sit here today saying to my colleagues on both sides
    of the aisle that, yes, we can. We can help and be beneficial.
    We must keep that in mind in terms of who we are working for,
    and it is important to recognize that the people are really
    watching all of us in terms of our ability to make a
    difference.
        Not a question of repeal, but a question of how can we do
    better. I would say to you, Mr. Chairman, that this hearing is
    a beginning. We must keep working together.
        Thank you. I yield the time back, Mr. Chairman.
        Chairman BUCHANAN. I like that mindset. This is the
    beginning. So that is my goal.
        Pursuant to committee practice, we will now move two-to-one
    questioning order.
        I recognize the Congressman, Dr. Murphy from North
    Carolina.
        Mr. MURPHY. Thank you, Mr. Chairman.
        And I want to thank all of the witnesses for coming today.
        This is a difficult problem. It is a strangling problem.
    Medical debt is the number one cause of bankruptcy.
        But let's look at the facts. I love my Democratic
    colleagues, and we are throwing all of these platitudes forth,
    but you are guys that are in business and actually seeing real
    life things compared to [audio disruption].
        I think they are. Look. I am amphibious. I can move to a
    different one.
        So all right. It is back. Now I am in stereo.
        So I have lived in the real world. I have practiced for
    over 30 years. I have run a practice. I know where every
    paperclip was as far as our overhead, and then I worried,
    worried, worried. There were several quarters where I never got
    paid because we had to pay for our employees.
        And we debated because when I first started practicing, we
    paid for every penny of our employees, but let us look at what
    has happened with government health care. So let us look
    honestly, objectively at what has happened since Obamacare.
        I am going to give you a few parameters that show us what
    it has done. It has been abysmal to medicine.
        Since Obamacare, one-quarter of physicians more have had
    their practices fail in one way or another and then what
    happens? They do one of three things.
        They either quit because they cannot take it.
        Number two, they get assimilated by a hospital where the
    cost of care by employee physicians is close to twice what it
    is for a private physician.
        Or, three, they just take cash, and we are seeing more and
    more and more of this because if you look at what has happened
    to premiums, let us look at real cost of health care. It has
    skyrocketed since Obamacare. Why? Consolidation.
        That is the number one reason where you have monopolies not
    only with hospitals and large systems--and God has given me a
    voice now--not only with large systems, but look at insurance
    companies. Look at PBMs that have actually destroyed
    pharmaceutical medicine, the cost of pharmaceutical medicines.
        So let me ask you this, Mr. Niswander. If it continues on
    the present trajectory, given the cost of living, the equipment
    cost of inflation over the last two years, the fact that you
    cannot charge any more for Medicare patients because you can
    charge them--I love this--I can charge them a million dollars
    for a surgery, but I will still get a buck 50. It does not
    matter what I charge, but what Medicare pays, Medicare pays.
        Where do you see your practice in five years?
        Mr. NISWANDER. So currently we have been able to continue
    practicing medicine. Our nurse practitioners make less and get
    reimbursed less. My employees do not get their benefits that
    large systems do.
        We tried to rent out space to other medical professionals
    to practice to kind of offset our costs there.
        And as I mentioned, I sold my farm in order to keep our
    office going.
        And you are correct. Right now we have got a problem where
    rural hospitals are closing and they are the backbone for these
    rural communities for these families to get health care instead
    of having to drive several hours away to find that same
    hospital for emergency care.
        I do not have another farm to sell. I mean, you look at
    this happening again. What am I supposed to do?
        Practices like mine, I have had two close in the last year,
    primary care offices, and those offices are not being filled.
    They are for sale. Nobody wants to buy them.
        Mr. MURPHY. Rural areas--I do not want to interrupt just
    because we have a limited amount of time. But the way this
    trajectory hits and continues is the cost of care, cost of
    care, cost of care goes up until nobody can afford it anymore.
        We spend now, and everybody talks about Medicare for all.
    They have absolutely no understanding of what that means,
    absolutely none. It makes them feel good inside. It makes them
    feel great inside, but they have no clue as to what that means.
        The cost of care, we had to fight tooth and nail against
    the other side so that physicians and providers would only be
    cut two percent last year rather than eight percent.
        So you cut, you cut, you cut to feed an absolutely
    monstrous government bureaucracy which has grown and grown and
    grown in the last 13 years, until you cannot cut anymore and
    people say to hell with it. I am done.
        We are going to have a cataclysm occur in the next three to
    five years with surgeons in this country because nurse
    practitioners, PAs cannot do surgery. They can help with
    primary care. They cannot do surgery.
        So, no, there were some good things with the Affordable
    Care Act. There were. There were some good things, but what it
    has done to medicine as a whole has crippled this country.
        I thank you for what you do, but it is important that
    people who are in the field give testimony to what they are
    doing, not only people that own small businesses, but people
    who own practices because you are in double jeopardy there
    because you are getting your rates cut at the same time you
    cannot expense it more, at the time that inflation is killing
    you.
        Thank you, Mr. Chairman. I will yield back.
        Chairman BUCHANAN. Thank you.
        I am excited to always have two doctors on this committee
    because you have worked in the real world, not just in
    medicine, but running a practice, running your business. So we
    appreciate your knowledge and capability.
        I now want to recognize the Congressman from Oklahoma, Mr.
    Hern.
        Mr. HERN. Thank you, Mr. Chairman.
        You have five business people in a row here. I spent 35
    years in business running all kinds of businesses, owning,
    operating, you know, from aerospace to agriculture, to banking
    and 34 years of McDonald's franchises.
        You know, I have never seen something so convoluted as the
    health care industry in this country, and it has not gotten
    simpler. Having seen hundreds of thousands of dollars taken off
    the bottom line and wasted when you could supply health
    insurance to your employees, in any other industry you would
    know the cost of service of the product you are buying, and as
    a consumer you can shop for the best price, but in health care,
    people have no idea of the true cost of the health care service
    or the treatment.
        It is the only thing you buy if you think about it for a
    minute. It is the only thing you pay for that you do not know
    what the cost is before you get it.
        The exorbitant cost of the health care, a mass of
    subsidies, tax credits, employer and insurance contributions.
    Not a single person in this room can tell me the true cost of
    their last health care appointment, and that is a problem.
        Unfortunately, the hidden cost of health care is
    exacerbated by the Democrat policies. Just last year my
    colleagues on the other side of the aisle voted to completely
    hide the cost of health insurance under the disguise of free,
    zero premium health care for many Americans.
        The expansion of the Obamacare subsidies cost the American
    taxpayers $64 billion, but the greatest cost of all is to the
    society. We need a safety net for people that are falling on
    hard times, falling through the cracks, but not families that
    are making upwards of $600,000 as we are currently stating.
        Do we need a safety net that empowers people, high ended
    cost of health care through government subsidies? Why impose
    families that are already struggling to pay their bills under
    Biden inflation?
        We should not be surprised that Democrats keep pushing for
    these policies. My colleagues today were pointing to reports
    with increasing enrollment in the Obamacare markets and
    Medicare roles.
        It is not a victory to have a health insurance card in your
    pocket but no cash in your wallet. I think you said that
    earlier, especially if the services that come with the health
    insurance care are too expensive.
        Democrats are misleading Americans telling them that they
    have care when all they have is a plastic card. The actual care
    costs are even more.
        Coverage mandates began with the passage of Obamacare over
    a decade ago. Since then Democrats have continued to almost
    exclusively focus on those policies and the individual market,
    have done nothing to help the 48 percent of Americans who
    obtain their coverage from their employer.
        It should come as no surprise when there has been no work
    for Democrats to salvage their failed small business exchanges
    and small business health tax credits. I would encourage my
    colleagues to go to HealthCare.gov/smallbusiness, and see for
    yourself that small businesses have no options, no options for
    coverage in the shop exchange in many States, including my own
    home State of Oklahoma.
        No shop insurance means no access to the small business
    taxpayer, which explains why only 6,000 people used the small
    business tax credit in 2016. Let me say that again. There are
    33 million small businesses in America, and only 6,000 were
    using the tax credit.
        It is really sad that Democrats could expand Obamacare tax
    credits for a family making nearly $600,000, but do nothing to
    fix Obamacare's broken small business provisions.
        But this is a new day in the House of Representatives. The
    American workers spoke loud and clear last November. America's
    workers are tired of being left behind and punished for
    pursuing the American dream.
        I am proud for the health care policy platform we put
    together and the commitment to America with the Healthy Future
    Task Force over the last year, as chairman of the Task Force
    Affordability and Subcommittee Chairman.
        I want to quickly highlight some reforms from this list
    that our committee should consider.
        The first one is make health care coverage portable.
        Make health care savings accounts accessible to more
    people.
        Reduce the Obamacare paperwork burden on small businesses.
        And allow businesses to join together through association
    health plans.
        Mr. Blase, we have spoken many times. You did a lot of
    great work on that year of work. We have seen the highly mobile
    labor market, and now more than ever workers need health care
    that is portable.
        Can you speak to how health and reimbursement accounts
    provide American workers and employers more flexibility?
        Dr. BLASE. Yes. Thank you, Congressman.
        It is the new individual coverage health reimbursement
    arrangement. They took effect in 2020, and it allows employers
    to offer a contribution that workers take and then buy the
    individual plan that works best for them.
        So it is really the small business owners, they care about
    the workers. They want to offer them health coverage. It is
    about trusting people to make the best decisions for them and
    giving them as many options as possible for their coverage.
        Mr. HERN. What has been the effect of the expanded
    subsidies on the employer market?
        CBO and JCT estimated that 2.3 million employers would drop
    coverage, and do you agree with that estimate?
        Dr. BLASE. Yes. I actually think it could be more than that
    if the expanded subsidies are made permanent. The expanded
    subsidies are really large. So it provides employers with an
    incentive to drop coverage.
        They could increase wages when they drop coverage and have
    their workers qualify for expensive tax credits in the
    exchanges that just add to deficits and just worsen the overall
    inflation problem.
        Mr. HERN. Thank you, and I yield back.
        Chairman BUCHANAN. Thank you.
        I now recognize Congressman Davis, the gentleman from
    Illinois.
        Mr. DAVIS. Thank you, Mr. Chairman.
        And let me thank you for calling a very informative and
    important hearing.
        And I also want to thank all of our witnesses, and I
    appreciate greatly the voices that we are hearing today from
    small businesses.
        But I would also like to note that not all small businesses
    are expressing the same sentiments, and I ask unanimous consent
    to submit for the record a statement from Small Business
    Majority, whose opinions are quite different.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        As a matter of fact, their opinions suggest that efforts to
    chip away at the ACA will only serve to disrupt the marketplace
    and, in turn, harm small business owners, their employees, and
    self-employed individuals.
        If the Republicans are successful in repealing the
    Affordable Care Act and substantially reducing Medicaid,
    Illinois families will have higher health care costs. Without
    the ACA, 68,000 Illinoisans will have higher premiums, up to an
    average of at least $6,500.
        At least two million people in Illinois with preexisting
    conditions will be subject to the denial of health care
    insurance coverage and charged more by market health insurance
    enterprises.
        We would be looking at 4.5 million Illinoisans at risk of
    lifetime benefit caps.
        Ms. Kelmar, if I could ask you, if the ACA is repealed,
    what would be the impact on mental health?
        Ms. KELMAR. It is already very difficult for people to get
    mental health services and to pay for it out of pocket. So
    having a good insurance plan that covers that and offers that
    is a really great way to not only make sure that folks have the
    coverage for the kinds of care that they need, but we all know
    that good mental health plays into your physical health as
    well.
        Mr. DAVIS. And just thinking of average basic health care
    that several million people now have been able to acquire
    coverage who otherwise would not and did not have it prior to
    the ACA, what would be the impact on the economy and the
    economics of the environment where they are?
        Ms. KELMAR. Well, people need insurance because there is no
    way they can pay for all of their care out of their own pocket,
    and wages will never cover those kinds of costs, especially for
    the sickest.
        So the reason that the United States has moved towards an
    insurance system is because it spreads out the risk and it
    spreads out the cost of the sickest people onto everyone so
    everyone can have access to care.
        Having a good insurance policy also enables us to be able
    to get that preventative care that we need to make sure that we
    are not getting sicker, and we have to address that we have a
    very different health care system now than we have had in the
    past.
        With the consolidated health markets, we are seeing prices
    just skyrocket, and there is no ability for insurance plans to
    be able to shop around and find another alternative when that
    can mean it only has one consolidated health system demanding
    the same prices throughout.
        So we really have to get to the cost issue to make sure
    that the health insurance programs that we are running in the
    U.S. are paying reasonable prices and not inflated prices.
        Mr. DAVIS. Let me thank you very much.
        I come from a school of thought that says let the good
    outweigh the perfect, and I think this is one of those
    instances why that is the case.
        Thank you very much, and I yield back, Mr. Chairman.
        Ms. KELMAR. Thank you.
        Chairman BUCHANAN. Thank you.
        I now recognize the Congresswoman from West Virginia, Mrs.
    Miller.
        Mrs. MILLER. Thank you, Chairman, and thank you, Ranking
    Member.
        And thank you all for being here today because it helps to
    have people testify on the real impacts from the policies that
    come out of Washington, D.C.
        About a month ago, this committee met in my home State of
    West Virginia, and we heard about the tangible impacts of the
    failed Democrat policies, many of which have contributed to
    record high inflation and what effect it is having on folks
    outside of the Beltway.
        One of the most compelling testimonies that I heard was
    from a lady named Ashley Bachman who owns a restaurant in
    Petersburg, West Virginia. And she testified that she was
    unable to offer health care to her employees because of how
    expensive it was.
        As a matter of fact, her whole family is uninsured because
    she cannot afford the monthly health care bill on top of all
    the costs associated with her business.
        And I was really kind of sorry to hear that story.
        Ms. Moore, first of all, I want to thank you for showing
    the respect that you have for your employees and how important
    they are to your business. So many times people in this bubble
    seem to think employers are the bad guys.
        And you are not, and you do really appreciate your
    employees.
        You shared the difficulties of being a small business owner
    in the Appalachian region. Ohio is part of the Appalachian
    region. You talked about your experience having to cut health
    insurance benefits for your employees.
        Can you just talk a bit about making that decision and how
    hard it was as a business owner?
        Ms. MOORE. I will share and I will try not to tear up
    because these are individuals. We know their children. We know
    their extended families not because I grew up in those
    communities that I have business in; only because we have a
    relationship as an employer-employee relationship that extends
    far beyond a paycheck.
        When I had to look an adult man in the face and tell him,
    ``I cannot help you anymore. Find insurance for your family,
    for your two growing sons, and I know that your wife is not
    eligible at her employer for insurance. So I am going to leave
    the whole family of four out to defend for themselves. I cannot
    do a single thing for you.''
        I could not even because of the mandates supplement and
    give him extra money to help find. I mean my hands were totally
    tied.
        Mrs. MILLER. I hate to stop you because we only have so
    much time, and I am really happy that you are now able to
    reinstate their health coverage.
        You know, your employees thankfully have health coverage,
    but most people in rural America still do not, and I need to
    ask Mr. Niswander a couple questions.
        Your being a health care provider for such a rural
    community certainly gives you a unique insight into the
    struggles of rural America and what we face when trying to
    receive health care.
        Have you seen patients who are unwilling to get treatment
    for their medical services because they are worried about the
    high cost?
        Mr. NISWANDER. I have actually. Just last week I had a
    patient that came in that I have not seen for a long time who
    is a very brittle diabetic who needs several bottles of his $30
    insulin every month that she cannot afford, and she delayed
    care for many months, even from calling me, to a point that her
    foot developed a necrotic wound that put her in the hospital
    with a high deductible plan on the ACA coverage.
        She came to my office with a wound bag attached to her foot
    and talked of amputating that foot now. It was the fear of the
    high deductible plan that kept her from getting care.
        Mrs. MILLER. It is just so difficult for patients to
    physically travel where they need to, let alone receive the
    care, and it is a shame that the cost of care is just another
    barrier.
        It seems another issue I feel is an obstacle to quality
    health care in rural America is the difficulty retaining a
    robust rural health workforce, and I think you all agree to
    that.
        Can you talk just a bit about finding health care providers
    to come and join your practice?
        Mr. NISWANDER. It is difficult in rural America. The
    insurance reimbursement rates, like Dr. Wenstrup and Murphy are
    aware, are fixed. We have no bargaining power whatsoever.
    Expenses are going up.
        The pandemic is over but the price increases are not. That
    translates into many medical practices closing down because of
    the strain that puts on the ones that are left.
        We talked about mental health resources. Over 70 percent of
    psychiatrists do not accept insurance because the reimbursement
    rates are so terrible.
        Our patients are suffering because rural America's
    hospitals are shutting down left and right.
        Mrs. MILLER. You are exactly right.
        Mr. Chairman, I yield back my time.
        Chairman BUCHANAN. I now recognize the gentleman, the
    Congressman from Pennsylvania, Mr. Fitzpatrick.
        Mr. FITZPATRICK. Thank you, Mr. Chairman.
        Thank you to the panel for being here today.
        Many employees are seeing their insurance premiums rise. At
    the same time hospital finances are worse than they have been
    in recent memory.
        In my district in Bucks County, Pennsylvania, many
    hospitals that I hear from are experiencing what they refer to
    as unsustainable losses.
        Mr. Niswander, how have you dealt with facing narrow or
    even negative margins for the care that you provide in your
    institution?
        Mr. NISWANDER. We have fixed costs in medicine that we
    cannot pass along to the patients. They just are what they are,
    and we have to have those things to operate. We have nurse
    practitioners that earn less. My employees do not get the
    benefits that they deserve and need, and we and my wife often
    eat the cost.
        Patients come in with high deductibles, and we give our
    care away completely for free.
        I do not know how many hospitals or how many primary care
    physicians can do that or continue to do that, but I know that
    they are closing down left and right in rural America.
        Mr. FITZPATRICK. The reality is there are hospitals losing
    money. In Southeastern Pennsylvania, the region I represent,
    and also across the entire country, but at the same time costs
    of providing health insurance for employees have gone up
    significantly.
        If premium increases are not translating into greater
    financial stability for these struggling health care providers,
    my concern is those increased premium costs are being lost to
    inflation and other statutes in the health care market,
    threatening to leave hospitals and health care providers like
    Mr. Niswander with difficult choices that generally mean either
    reduced access to care or further increased prices for
    patients.
        Mr. Blase, what do you think has been the primary factor
    driving these insurance costs up?
        And do you think patients and small businesses can see even
    further price hikes in response to some health care providers
    continuing to struggle?
        Dr. BLASE. Yes, I think there are two reasons, Congressman.
    One the other witness talked about, the growing consolidation
    in the health care sector. That really accelerated with the ACA
    with hospitals merging and with hospitals acquiring physician
    practices.
        The ACA had one provision that reduces hospital
    competition. So they prevent Medicare payments from going to
    new physician-owned hospitals, which is anticompetitive. And,
    you know, whenever you have anticompetitive policies, that is
    going to increase overall costs.
        I do think, too, just the design of the health insurance,
    that we talk about health insurance as expensive because health
    care prices are high, and that is true. But you also have the
    issue that when government mandates the health insurance be
    very expansive and then heavily subsidizes the health
    insurance, those things increase health care prices as well.
        So the government regulation over what health insurance has
    to cover, the very expansive subsidies that have been added to
    in the Inflation Reduction Act also push up health care prices.
        Mr. FITZPATRICK. Ms. Kelmar, how do you think hospitals
    struggling with increasing cost is ultimately going to impact
    patients?
        Ms. KELMAR. The problem is that we cannot see a lot of the
    quality measures that we really need to see and that we are
    still paying very high prices for.
        So we are in a system that we spend most of our health care
    dollars, especially in the commercial market, as a fee-for-
    service payment system, and so that means the more things that
    you do to a patient, the more money you can make, and that
    drives up prices as well.
        So between the consolidation, which is pushing our prices
    up because there is less competition in those local markets,
    and the way that we pay on the fee-for-service system, those
    are the kinds of things that keep driving up those dollars that
    are coming out of our insurance, which is causing pressure on
    both the businesses and employers who are trying to offer us
    our health insurance, but then they are having to shift off
    that extra cost onto us in our out-of-pocket premiums.
        Mr. FITZPATRICK. Thank you.
        Mr. Chairman, I yield back.
        Chairman BUCHANAN. Thank you.
        I now recognize the gentleman, Congressman from Virginia,
    Mr. Beyer.
        Mr. BEYER. Mr. Chairman, thank you very much.
        And I thank all of you for this. It has been a very
    fascinating hearing, and I have really appreciated hearing from
    all of us, including Dr. Murphy and Dr. Wenstrup.
        I want to point out, Mr. Blase, that you pointed out the
    18.3 percent GDP last year. Well, it was 17 percent in 2010
    before the ACA kicked in.
        I have also been in business for years, and all the things
    we talked about narrowly and how much we can pay for our
    employees, we did all that through the 1990s and the 2000s, and
    by 2010, we could barely pay for any of it before ACA kicked
    in.
        So I am thrilled that we are here to think about the ideas
    dealing with consolidation, which we have seen again and again
    is a terrible thing. PBMs.
        I am thrilled that we are not turning away people now
    because of preexisting conditions, which I did more than once
    with my own employees very, very sadly.
        So let me just lay three ideas out there for you.
        Number one, claims data. Many of you already do this
    probably, but all payer claims' databases collect health care
    claims. They are personally I say great because Virginia has
    one, and it has State policy makers, private payers, and
    academics' critical data that inform decisions about health
    care costs and quality.
        And I strongly believe that increasing claims transparency
    has the potential to increase the quality and delivery of
    health care, in addition to making it more affordable.
        States are already leading the way in implementing this
    well-conceived innovation. Colorado uses APCD data to assess
    differences in pricing for common procedures and how the
    utilization of health care services changes over time.
        We have certainly seen the examples of some places where
    there are lots and lots of C sections and other places where
    there are personally none with the same population.
        Oregon uses the data to help guide its health system
    transformation, resulting in $139 million in savings from 2013
    to 2014. Minnesota uses it.
        Colorado and Utah took different approaches to Medicaid
    expansion, and they were able to evaluate expansion through a
    more rigorous approach by using neighboring control State data.
        These myriad differences in State administration create
    many opportunities to compare States and evaluate differences.
        The second thing I want to talk about is improving
    diagnosis in medicine. Everyone knows the story of someone that
    took six years to get a diagnosis when it could have taken two.
        According to the National Academy of Sciences, Engineering,
    and Medicine, diagnostic errors impact more than 12 million
    Americans every year.
        So we also found out that most people experienced at least
    one diagnostic error in their lifetime, and postmortem research
    has shown that diagnostic errors contribute to approximately
    ten percent of patient deaths.
        The estimates were that waste associated with diagnostic
    errors cost our health care system about $100 billion annually.
    Just imagine what those savings could do to the cost of health
    care.
        By the way, I forget what doctor it was who talked about
    the obnoxious part of government interfering in the
    relationship between the doctor and patient. Let me promise you
    way before there was ACA, you had insurance companies doing the
    exact same thing, to our great frustration.
        And lastly, I want to talk about ACA since it is, as my
    friend Dwight Evans said, the anniversary today. A key
    component has been many, many people have insurance they have
    not been able to get before. Our uninsured rate is at an all-
    time low. More than 133 million Americans with preexisting
    conditions protected after being denied coverage.
        This has been typical of many, many States. And one of the
    key things we can all agree on is the benefit to eliminating
    the lifetime caps and the creation of out-of-pocket cost caps.
        Before the ACA, insurance plans were not required to limit
    enrollees' total cost, and almost one in five people with
    employer coverage had no limit on out-of-pocket cost even when
    they were exposed to tens of thousands of dollars in medical
    bills before they became seriously ill.
        Let's not kid ourselves. Before the ACA, the number one
    reason for bankruptcy in America was health care cost, and it
    still is today. This is something we have to work on together.
        And one last thing for my anti-Choice Republican friends,
    whom I very much respect. ACA mandated birth control for all
    young women that wanted it, and we dropped abortions down to
    the lowest level since Roe v. Wade because of that.
        We also dropped the number of teen pregnancies in half.
    There were a lot of very good things that came out of it, and
    now we have to fix what did not work.
        With that I yield back.
        Chairman BUCHANAN. Thank you.
        I now recognize the Congresswoman from New York, Ms.
    Tenney.
        Ms. TENNEY. Thank you, Mr. Chairman and Ranking Member.
        Thank you so much for your testimony today. This is a
    really important hearing.
        I am a small business owner as well, and as I travel across
    New York's 24th District, which is up in the big, rural area,
    one of the largest agricultural districts in the Northeast, I
    hear the same thing from small businesses and employers who
    actually dominate our economy, that since Obamacare was
    enacted, the cost of their health insurance premiums has gone
    up in many cases 120 to 130 percent and deductibles have gone
    up similarly.
        So you may actually have an insurance card, but you cannot
    afford to go to the doctor, and that was the big fear that we
    all had.
        Now, I have a constituent who actually reached out to us, a
    guy named Ted Vermette. He is the owner of Design Concepts in
    Central Square, New York, and this epitomizes the effect this
    has had on small businesses, and I wanted to share this with
    some of you.
        Before Obamacare, this company provided health insurance to
    their 38 employees with a premium of $20 a week and a
    deductible of $20, very affordable.
        Now the premium is $120 per week for his workers, and the
    deductible is $2,600. This is unsustainable, and places
    enormous pressures on working class families and companies
    which could use some of this money to hire additional workers,
    as Ms. Murphy just talked about, or buying more inventory.
        And I am also a family business owner, and our business has
    been around since 1946, but we have seen a lot of our
    businesses in our community fold because of health care.
        So our family insurance plan and plan that we provided to
    our employees, we did that as a benefit. It was not a mandate,
    and we have over 50 employees, which means we fall within the
    mandated health care.
        So when some people say, ``Well, gee, you know, we had to
    give up our health care,'' we do not have that option. We must
    provide health care under the Obamacare legislation, and some
    of our increases for family plans are reaching $30,000 a year.
        I just got the latest numbers from my brother.
        So this is an enormous increase, and you know, it is really
    putting a burden on us getting quality care, and it also helps
    us attract great employees because so many of our employees
    work for government where they have government health care,
    whereas Dr. Murphy, Congressman, pointed out sometimes hides
    the actual cost of health care.
        One of the first, ask Mr. Blase, because New York was
    terrible before Obamacare. It is even worse now, and we are
    treading down a really bad path. In fact, our legislature is
    considering doing Medicare for All, which would really, really
    be a problem for New York State. We would probably have even
    more out-migration, the highest out-migration of people in the
    entire Nation, by the way, and jobs.
        But to Mr. Blase, I just want to ask you. As you know the
    cost for health care providers have been skyrocketing due to
    inflation, but these providers are often locked into multi-year
    contracts. They can only raise their reimbursement fees
    accordingly for renegotiation.
        With that in mind, how long do you think and to what extent
    will Americans feel the pinch of inflation on their medical
    bills?
        How is this going to change?
        Dr. BLASE. Yes. Actually New York should have, in the
    precursor that kept us from enacting ACA, was price
    restrictions because the New York's individual market was
    basically destroyed by a set of regulations which were then put
    into the ACA, and the reason that the ACA market continues to
    exist is because of the extraordinarily high level of
    subsidies.
        I think that, you know, health care inflation is likely to
    continue. I mean, I think if government policy continues to
    dramatically increase the subsidization, sort of these
    inefficient set of subsidies, without reforming those
    structures, without reforming the path that the Federal health
    programs are on, I mean, Medicaid and Medicare are both facing
    severe fiscal challenges.
        Medicare's unfunded liabilities exceed $50 trillion. I mean
    that is a ton of additional government spending that is going
    to need to be financed by debt, which will translate into
    higher interest rates and higher inflation.
        Ms. TENNEY. Right. And, of course, New York State, there is
    no incentive to lower our cost for Medicaid because they get
    the Federal reimbursement for the subsidy.
        I thank you for your comments. I appreciate it.
        Mr. Niswander, I just wanted to ask you if I could. In your
    testimony you highlighted the outrageous amount of cost of your
    practice to offer health insurance to your employees. If your
    practice was able to access one of these association health
    plans or another method to access more affordable care, do you
    think that would impact your employee practice?
        Would it help you if you had access to more?
        Mr. NISWANDER. Yes, rural America is struggling now to
    attract the best talent, and just numbers. We cannot get
    specialists. We cannot get surgeons. We cannot get
    psychiatrists, not just in my practice but in the hospitals in
    the counties surrounding me. All of the rural counties in
    Tennessee are struggling to maintain the labor workforce, which
    between the expenses of operating a small business or a
    hospital to hospital and not being a mutual labor workforce,
    which is forcing so many practices to close, that would
    definitely help us to retain the best and the greatest surgeons
    and physicians and nurse practitioners that we can find.
        Ms. TENNEY. Thank you so much. My time has expired. I would
    love to continue this conversation.
        Thank you.
        Chairman BUCHANAN. I now recognize the Congressman from
    Utah, Mr. Moore.
        Mr. MOORE of Utah. Thank you, Chairman, Ranking Member.
        Our witnesses, thank you for being here today, for sticking
    it out with us even with the bit of an overactive heater as
    well. You have endured quite a bit today.
        When I talk to my constituents from Utah, in particular
    some of my rural areas, you know, the things that have come
    back to me, from Cache County, to stagger the cost of his
    monthly insurance premiums and out-of-pocket costs, a
    constituent from Brigham City put it simply, ``We are just
    paying more and getting less.''
        Right? That has just been a consistent theme that we have
    seen.
        This is a really unique opportunity to be on the Health
    Subcommittee in this really important Committee, Ways and
    Means.
        Health care, any expenditures related to health are our
    Nation's number one expense, when you put it all together, and
    the topics that we talked about today and Dr. Murphy's
    testimony, it is not going to get played on the loop today on
    cable news. It is not what people are interested in. It is not
    the most vibrant topic to put out there in the world. It is the
    most important thing. And every single business owner and
    family recognizes that.
        So we have a real opportunity to do something here and
    avoid the platitudes that we oftentimes hear, and there are
    going to be a couple of platitudes that I am going to mention,
    and Mr. Blase, I am going to ask you to address it.
        Sometimes you hear that some of these overarching issues
    get mentioned without a lot of context. I am going to ask you
    to put a little bit of meat on the bones to the concept of
    price transparency and improved quality transparency.
        What would you add to that, what that can do to lower
    health care cost?
        You mentioned that Congress should trust people to make
    health decisions for themselves and that price transparency
    will encourage more consumers to shop and obtain lower prices.
        Patients do not always shop for their health care. This is
    a complex system.
        So put some context to those two overarching concepts, the
    price transparency and quality transparency.
        Dr. BLASE. Yes. So thank you, Congressman. That is a great
    question.
        You know, people know prices when they shop for everything
    else, and they are able to figure things out. So I think they
    can figure things out in health care as well, but they need to
    know what the prices are.
        So the Trump Administration finalized two rules, one that
    requires hospitals to provide price information, another rule
    that requires insurers to provide price information.
        The hospital insurers are beginning to comply with those
    provisions, and I think we can see when consumers have price
    information, when they have incentives to act on the price
    information, such as they have a health savings account, they
    shop and they make wise decisions. They save money. They do not
    skimp on anything that would reduce their health care.
        I think for employers, employers need price information as
    well. Like they are contracting with insurers to manage their
    benefits, and a lot of insurers have not negotiated great rates
    for those employers.
        I think the price information is going to help employers
    better monitor how the insurers are functioning.
        And on quality information, I think one of the things that
    is very clear is that there is a wide variety of outcomes that
    come from health care providers, and patients should know the
    quality of the providers that they are seeing.
        So, you know, if they are going in for cardiac care, they
    are going to providers that have low competition rates.
        Mr. MOORE of Utah. We used to take a job in this country
    with allowing or industries and consumers to dictate where
    things go with our typical economic principles of supply and
    demand.
        We have over-complicated this system to the extent that we
    are not giving the power back to the consumers, and so I
    appreciate that context.
        One of the last topics, you know, just to have you touch on
    is overcompensation, overconsumption. The overconsumption, you
    talked about turning the tide on red ink in your report and
    described how insurance can be designed to protect consumers
    from this catastrophic harm while not facilitating over-
    consumption.
        That drives up cost. Share just a little bit more just on
    specific, plain terms on what this means.
        Dr. BLASE. Yes, the analogy is if your auto insurance pays
    for your oil change, you are not going to be sensitive to the
    cost of that oil change.
        There are many things in health care. Health insurance is
    great. It provides financial protection for low probability,
    high expense events, but insurance is not the most appropriate
    way to pay for every health care expenditure. It discourages
    individuals to care about what the cost of those expenditures
    are, which again increases prices , which increases what we all
    are paying because of how heavily the government is subsidizing
    health care and health insurance.
        Mr. MOORE of Utah. Thank you, Dr. Blase.
        And I yield back.
        Chairman BUCHANAN. I now recognize the Congresswoman from
    California, Mrs. Steel.
        Mrs. STEEL. Thank you, Mr. Chairman.
        And thank you for all being here today.
        My constituents are anxious about the economy and for a
    good reason, for the Biden's inflation, prices have impacted
    everything, the cost of groceries to the price at the pump and
    even health care spending.
        Medical inflation has led to 43 percent of our dollars or
    their family members to put off or postpone needed health care
    due to increased medical cost, severely impacting Hispanic and
    AAPI communities, the most according to recent data from the
    Kaiser Family Foundation.
        So we have been hearing from the other side of the aisle
    about how important this permanent telehealth bill is. I
    introduced while I was not even a member of Ways and Means
    Committee at the time; I introduced the permanent telehealth
    bill in 2021. The other side of aisle only extended one year
    and failed to extend the first dollar coverage of high
    deductible health savings plan for the first three months in
    2022.
        I introduced again last year that another permanent
    telehealth bill in 2022. The other side of the aisle extended
    only two years last year.
        Now I hear from Congressman Thompson on the other side of
    the aisle that he agrees this telehealth bill is very important
    and to make it permanent.
        So I will introduce this telehealth bill again for the
    American people. So I do that and hopefully it is going to be
    agreed by the other side of the aisle.
        So I am asking Ms. Kerrigan if this were to expire again,
    how would this impact your members.
        Ms. KERRIGAN. I think it can expire. You are talking about
    the telehealth, correct?
        Mrs. STEEL. Right.
        Ms. KERRIGAN. I mean, one of the silver linings of the
    pandemic was, you know, sort of again that everyone to
    technology, and we saw 35 million Americans using telehealth,
    you know, to get their health care, whether families,
    individuals, senior Americans.
        And it is a very, very important piece, I think, to
    maintain as part of the health care system. I think
    particularly, again, for those people who cannot travel to the
    doctors, for rural America, once we get them broadband, all
    areas of the country broadband.
        So it would negatively impact a lot of lives, individuals
    and businesses. It saves times. It saves money, and it would be
    a backwards step if we did not move forward with permanency.
        Mrs. STEEL. Thank you so much.
        In California, we shut down all the businesses and all the
    schools actually in Los Angeles County. Today is the third day
    that kids cannot go back to school. So this is what is going on
    in California.
        We really needed this telehealth bill to permanently pass
    and that, you know, we can work on it.
        So CalCAN, Dr. Niswander, CalCAN recently witnessed Madera
    Community Hospital's closure, impacting hardworking taxpayers
    the most with very limited options nearby that you talked about
    a little bit about the hospitals.
        With medical inflation, supply chain issues, and major
    expenses, what are the consequences of major practice closures?
        And with your experience, how do closures combined with
    rising medical cost impact?
        You have been talking about your businesses. How about the
    patients?
        Mr. NISWANDER. Yes. I appreciate the promotion calling me
    doctor, but I am a family nurse practitioner. Thank you.
        So talking a lot about quality measures and lots of studies
    have actually looked at that and they have shown that as
    Medicaid enrollment increased, quality of care did not equal or
    increased Medicaid enrollment did not equal more utilization or
    higher quality of care.
        The Bureau of Labor Statistics have many studies showing if
    somebody spends more than five percent of their out-of-pocket
    expenses on health care costs, they are considered uninsured.
        We are talking about the $5,000 premium per year, a $14,000
    deductible for somebody who makes $36,000 a year. That is
    uninsured even though they have got a card with their name on
    it.
        This is like setting up a hamburger stand in a town full of
    vegans. They are just not going to use it.
        The access to care is definitely a problem, and we need to
    find a way to change that. The access is the issue.
        In Tennessee, rural hospitals and physicians' offices are
    closing left and right. The patients are the ones suffering
    from these increased premiums, the increasing deductibles that
    they cannot afford to pay, working families like me, but they
    cannot find a provider that even takes that insurance in our
    area.
        Mrs. STEEL. Thank you so much.
        Mr. Chairman, I yield back.
        Chairman BUCHANAN. Thank you.
        I now recognize the Congresswoman from Alabama, Ms. Sewell.
        Ms. SEWELL. Thank you, Chairman Buchanan and Ranking Member
    Doggett.
        I want to thank all of our witnesses today.
        Today is the 13th anniversary of the Affordable Care Act,
    and thanks to the Affordable Care Act, millions of Americans
    are able to afford health coverage that was completely out of
    reach before its passage 13 years ago.
        I have testimony for the record from over 30 patient
    groups, including ARS Association, the American Cancer Society,
    and the American Diabetes Association, to name a few, stating
    the importance of the expanded health care coverage that the
    ACA provided to more than 120 million people with preexisting
    conditions.
        And I would like Mr. Chairman, to include it in the record.
        My constituents in Alabama are disproportionately impacted
    by chronic health conditions, including diabetes, heart
    disease, and cancer.
        Sonya, a constituent of mine from Montgomery, Alabama,
    wrote to me about her father who had been denied coverage prior
    to the enactment of the Affordable Care Act's preexisting
    condition protection due to his cancer diagnosis.
        Sonya wrote that her family prayed that it would stay in
    place because of the security this protection offered her and
    her family.
        For millions of low-wage workers the ACA expanded access
    and affordability through Medicaid expansion, making this one
    of the most transformational policies of our time.
        Uninsured rates in expansion States plummeted in the years
    following the ACA's implementation. Medicaid expansion has
    helped patients access preventive care like cancer screenings,
    increased access to transplants, and made diabetes medication
    more affordable.
        Unfortunately, millions of Americans have experienced none
    of these gains simply because of where they live.
        You see, my State, the State of Alabama, has not expanded
    Medicaid, and I think about the many hospitals that have closed
    in the rural parts of my district.
        I was not surprised, although I was shocked that 85 percent
    in the last ten years of rural hospitals that have been closed
    have been closed in States that did not expand Medicaid.
        The Affordable Care Act is the law of the land. I believe
    in this great country, that no person, no person should not be
    able to have access to affordable and quality health care. I
    believe it should be a right.
        The fact that we are the last of the industrialized
    countries in the world to not have, you know, universal health
    care as a part of our DNA, it really does sadden me. And it
    saddens me because we get caught up in names and titles.
        I think about my constituent Hank, and Hank is a farmer, a
    fifth-generation farmer, and had farmed all his life, and his
    dad farmed. His grandfather farmed. He was a third-generation
    farmer who never was able to afford health care.
        In 2014, a navigator named Doug visited Hank on his farm to
    get him and his family enrolled in the Affordable Care Act, and
    even though Hank was not a supporter of President Obama, he
    signed up for a Blue Cross plan that cost him only $100 a
    month, thanks to the premium tax credits and cost sharing
    reductions.
        The following summer, Hank was working on his farm when his
    hand got caught in his hay baler. When he tried to pull his
    right hand out, his left hand got stuck as well.
        The family's plan, which they had had for less than a year,
    covered the emergency air flight and his hospital bill. Hank
    was able to avoid a financial catastrophe like so many
    Americans experience who are uninsured.
        Clearly, Hank's story serves as an example of how the
    Affordable Care Act does protect millions of Americans from
    devastating medical debt.
        The sad part about it, and Hank has admitted to me, when
    the navigator knocked on his door, he said, ``Do you want to
    have health care insurance, affordable health care insurance?''
        He did not say, ``Do you want to be enrolled in
    Obamacare,'' and Hank admitted to me had he said, ``Do you want
    to be enrolled in Obamacare?'' he probably would not have had
    this lifesaving insurance that literally saved his family from
    catastrophe.
        Mr. Chairman, I hope that we can put politics aside and
    really think about what is in the best interest of all the
    people. I am talking specifically to my State. I really hope
    that they will take an opportunity to expand Medicaid so that
    more and more people can get insured.
        In fact, for the 2022 coverage, over 200,000 Alabamians
    enrolled in the exchange. Guess how many would have also
    enrolled had we expanded Medicaid.
        Thanks.
        Chairman BUCHANAN. Thank you.
        I want to thank all of our witnesses. You do not realize
    how big of a positive impact you have on the panel like this
    because a lot of people do not understand sometimes the real
    world.
        And I can tell you I chaired our local Chamber in Sarasota.
    We had about 2,600 businesses at the time, and they told me--I
    was kind of shocked--90 percent were 20 employees or less.
        That is America, and we have got to do more to help you not
    just in the health care space, regulation, and other things, to
    make it simpler for you and keep your taxes low.
        Because people say, ``Why do you always talk about the
    small business or medium business?''
        I said, ``Because they are the job creators. The better you
    do, the better America does.''
        That is the mindset some of us have. I know my good friend
    Mike and others and Carol have the same mindset, that if you
    are in business, but again, the better you do the better the
    country does.
        So I really appreciate you being here. It has made a big
    difference. You guys were all very impactful.
        Please be advised that members have two weeks to submit
    written questions to answer later in writing. Those questions
    and your answers will be made part of the formal hearing
    record.
        With that, the committee stands adjourned.
        [Whereupon, at 4:44 p.m., the subcommittee was adjourned.]

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