[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:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    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.]
      

                           PUBLIC SUBMISSIONS

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

      
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


                              [all]