    [House Hearing, 119 Congress]
    [From the U.S. Government Publishing Office]

                     A HEALTHY WORKFORCE: EXPANDING ACCESS
                    AND AFFORDABILITY IN EMPLOYER-SPONSORED
                                   HEALTH CARE

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

                                    HEARING

                                   Before The

                               SUBCOMMITTEE ON HEALTH,
                            EMPLOYMENT, LABOR, AND PENSIONS

                                     OF THE

                      COMMITTEE ON EDUCATION AND WORKFORCE
                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED NINETEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                 HEARING HELD IN WASHINGTON, DC, APRIL 2, 2025

                                   __________

                                Serial No. 119-7

                                   __________

        Printed for the use of the Committee on Education and Workforce

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

            Available via: edworkforce.house.gov or www.govinfo.gov

                                   __________

                       U.S. GOVERNMENT PUBLISHING OFFICE
    61-401 PDF                  WASHINGTON : 2025

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

                      COMMITTEE ON EDUCATION AND WORKFORCE

                        TIM WALBERG, Michigan, Chairman

    JOE WILSON, South Carolina           ROBERT C. ``BOBBY'' SCOTT,
    VIRGINIA FOXX, North Carolina            Virginia,
    GLENN THOMPSON, Pennsylvania           Ranking Member
    GLENN GROTHMAN, Wisconsin            JOE COURTNEY, Connecticut
    ELISE M. STEFANIK, New York          FREDERICA S. WILSON, Florida
    RICK W. ALLEN, Georgia               SUZANNE BONAMICI, Oregon
    JAMES COMER, Kentucky                MARK TAKANO, California
    BURGESS OWENS, Utah                  ALMA S. ADAMS, North Carolina
    LISA C. McCLAIN, Michigan            MARK DeSAULNIER, California
    MARY E. MILLER, Illinois             DONALD NORCROSS, New Jersey
    JULIA LETLOW, Louisiana              LUCY McBATH, Georgia
    KEVIN KILEY, California              JAHANA HAYES, Connecticut
    MICHAEL A. RULLI, Ohio               ILHAN OMAR, Minnesota
    JAMES C. MOYLAN, Guam                HALEY M. STEVENS, Michigan
    ROBERT F. ONDER, Jr., Missouri       GREG CASAR, Texas
    RYAN MACKENZIE, Pennsylvania         SUMMER L. LEE, Pennsylvania
    MICHAEL BAUMGARTNER, Washington      JOHN W. MANNION, New York
    MARK HARRIS, North Carolina          VACANCY
    MARK B. MESSMER, Indiana
    VACANCY

                         R.J. Laukitis, Staff Director
                  Veronique Pluviose, Minority Staff Director
                                     ------

            SUBCOMMITTEE ON HEALTH, EMPLOYMENT, LABOR, AND PENSIONS

                         RICK ALLEN, Georgia, Chairman

    ROBERT F. ONDER, Jr., Missouri       Mark DeSaulnier, California,
    JOE WILSON, South Carolina             Ranking Member
    VIRGINIA FOXX, North Carolina        JOE COURTNEY, Connecticut
    JAMES COMER, Kentucky                DONALD NORCROSS, New Jersey
    BURGESS OWENS, Utah                  LUCY McBATH, Georgia
    LISA C. McCLAIN, Michigan            JAHANA HAYES, Connecticut
    MICHAEL A. RULLI, Ohio               GREG CASAR, Texas
    RYAN MACKENZIE, Pennsylvania         SUMMER L. LEE, Pennsylvania
    MICHAEL BAUMGARTNER, Washington      JOHN W. MANNION, New York
                                         MARK TAKANO, California

                             C  O  N  T  E  N  T  S

                                  ----------
                                                                       Page

    Hearing held on April 2, 2025....................................     1

                               OPENING STATEMENTS

        Allen, Hon. Rick, Chairman, Subcommittee on Health,
          Employment, Labor, and Pensions............................     1
            Prepared statement of....................................     4
        DeSaulnier, Hon. Mark, Ranking Member, Subcommittee Health,
          Employment, Labor, and Pensions............................     7
            Prepared statement of....................................    25

                                   WITNESSES

        Shields, Angela, Chief Executive Officer, Tennessee REALTORS,
          testifying on behalf of the National Association of
          REALTORS...................................................    28
            Prepared statement of....................................    30
        Lilly, Bethany, Executive Director of Public Policy, The
          Leukemia and Lymphoma Society..............................    38
            Prepared statement of....................................    40
        Strouse, Marcie, Partner, Capitol Benefits Group, testifying
          on behalf of the National Federation of Independent
          Business...................................................    48
            Prepared statement of....................................    50

                             ADDITIONAL SUBMISSIONS

        Chairman Allen:
            Statement for the record dated April 2, 2025, from the
              Business Group on Health...............................    89
            Statement for the record dated April 2, 2025, from The
              ERISA Industry Committee (ERIC)........................    95
            Letter dated April 2, 2025, from the National Association
              of Manufacturers.......................................    98
            HR Policy Association document titled ``Advancing the
              American Workforce''...................................   100
            Letter dated April 1, 2025, from ATA Action..............   112
            Letter dated April 2, 2025, from the Partnership for
              Employer-Sponsored Coverage............................   114
            Statement for the record dated April 2, 2025, from The
              Coalition to Protect and Promote Association Health
              Plans..................................................   118
        Ranking Member DeSaulnier:
            Letter dated March 28, 2025, from the American
              Association of People with Disabilities (AAPD).........     9
            Letter dated March 5, 2025, from the Congressional Budget
              Office.................................................    21
            A Kaiser Family Foundation analysis titled ``The Math is
              Conclusive: Major Medicaid Cuts Are the Only Way to
              Meet House Budget Resolution Requirements''............    84
        Foxx, Hon. Virginia, a Representative in Congress from the
          State of North Carolina:
            Response to questions dated April 22, 2025, from the
              Paragon Health Institute...............................   135
        Courtney, Hon. Joe, a Representative in Congress from the
          State of Connecticut:
            List of health care provider groups opposed to medicaid
              cuts...................................................    58
        Scott, Hon. Robert C. ``Bobby'', a Representative in Congress
          from the State of Virginia:
            Article dated March 28, 2025, titled ``He had short-term
              health insurance. His colonoscopy bill: $7,000''.......    68
            Statement dated April 2, 2025, from 27 organizations.....    72
            Letter dated April 1, 2025, from the American Federation
              of State, County, and Municipal Employees (AFSCME).....   137
            Letter dated February 8, 2024, from the American Academy
              of Family Physicians (AAFP)............................   139
            Letter dated February 26, 2025, from the Governor Joe
              Lombardo...............................................   142
            Article dated February 24, 2025, titled ``$40,000 out of
              pocket: Retired Phoenix first responders want insurance
              to pay outstanding bills''.............................   145
        Walberg, Hon. Tim, a Representative in Congress from the
          State of Michigan:
            Testimony dated April 2, 2025, from Kev Coleman..........   151

                            QUESTIONS FOR THE RECORD

        Responses to questions submitted for the record by:
            Ms. Bethany Lilly........................................   157

                         A HEALTHY WORKFORCE: EXPANDING
                          ACCESS AND AFFORDABILITY IN
                         EMPLOYER-SPONSORED HEALTH CARE

                                  ----------

                            Wednesday, April 2, 2025

                      House of Representatives,
        Subcommittee on Health, Employment, Labor, and
                                              Pensions,
                          Committee on Education and Workforce,
                                                        Washington, DC.
        The Subcommittee met, pursuant to notice, at 10:15 a.m., in
    Room 2175 Rayburn House Office Building, Hon. Rick Allen
    (Chairman of the Subcommittee) presiding.
        Present: Representatives Allen, Onder, Foxx, Mackenzie,
    Walberg, DeSaulnier, Courtney, Casar, Lee, and Scott.
        Staff present: Vlad Cerga, Director of Information
    Technology; Libby Kearns, Press Assistant; Katerina Kerska,
    Legislative Assistant; Trey Kovacs, Director of Workforce
    Policy; Campbell Ladd, Clerk; R.J. Laukitis, Staff Director;
    Georgie Littlefair, Investigator; C.J. Mahler, Professional
    Staff Member; Danny Marca, Director of Information Technology;
    John Martin, Deputy Director of Workforce Policy/Counsel; Audra
    McGeorge, Communications Director; Daniel Nadel, Legislative
    Assistant; Ethan Penn, Deputy Press Secretary and Digital
    Director; Kane Riddell, Staff Assistant; Sara Robertson, Press
    Secretary; Ann Vogel, Director of Operations; Ali Watson,
    Director of Member Services; James Whittaker, General Counsel;
    Jeanne Wilson, Retirement Counsel; Ariel Box, Minority Intern;
    Ilana Brunner, Minority General Counsel; Daniel Foster,
    Minority Senior Health and Labor Counsel; Jo Howard, Minority
    Grad Intern; Carrie Hughes, Minority Director of Health & Human
    Services Policy; Amanda Lee, Minority Grad Intern; Jessica
    Schieder, Minority Economic Policy Advisor; Dhrtvan Sherman,
    Minority Research Assistant; Raiyana Malone, Minority Press
    Secretary; Marie McGrew, Minority Press Assistant; Ben
    Noenickx, Minority Intern; Eleazar Padilla, Minority Staff
    Assistant; Veronique Pluviose, Minority Staff Director; Banyon
    Vassar, Minority Director of IT.
        Chairman Allen. The Subcommittee on Health, Employment,
    Labor and Pensions will come to order. I note that a quorum is
    present. Without objection, the Chair is authorized to call a
    recess at any time. Thank you to our witnesses for joining the
    Subcommittee to discuss today's topic, A Healthy Workforce,
    Expanding Access and Affordability in Employer-Sponsored Health
    Care.
        As the Committee of jurisdiction over employer-sponsored
    health care, Educational Workforce Committee members understand
    that employers want what is best for their employees. Despite
    not being required to offer health coverage, small businesses
    often choose to do so in order to attract and retain top
    talent.
        According to NFIB, 56 percent of small employers offer
    health insurance, and 89 percent of small businesses with more
    than 30 employees offer health benefits. As a small business
    owner myself, I learned that investing in the health of my
    employees paid long-term dividends, both in productivity and
    the morale of the company.
        Unfortunately, it is getting more challenging for
    businesses of all sizes to offer competitive healthcare
    benefits to their employees. I have often said that competition
    is the only way to bring down cost. According to the Kaiser
    Family Foundation, premiums for family coverage for employees
    have increased 7 percent in each of the last 2 years.
        Rising costs have a disproportionate impact on small
    businesses as they are less able to absorb the impact of rising
    healthcare costs. 94 percent of small employers find it
    challenging to manage the costs of their health plans, and 98
    percent believe that the cost of their health plans will become
    unsustainable within this decade.
        The Biden-Harris administration's inflationary agenda,
    intent on tying the hands of employers with costly and
    burdensome regulations contributed to the healthcare cost
    challenges that small businesses face today. Fortunately,
    President Trump and House Republicans have common sense
    solutions that give small businesses flexibility to expand
    access and affordability to their healthcare offerings.
        The first solution is expanding access to associated health
    plans or AHPs. An AHP allows employers to band together to
    purchase health coverage. By combining purchasing power, small
    employers can negotiate more favorable rates the same way that
    larger employers do.
        In 2018, the Trump administration finalized a rule that
    expanded AHP availability to more businesses and to self-
    employed individuals. However, this rule was regrettably tied
    up in the courts and ultimately reversed by the Biden
    administration. The results speak for themselves. While the
    Trump Rule was in effect, new AHPs produced savings of up to 29
    percent on average, while realtor AHPs, like the one Ms.
    Shields will speak about today saw an average savings of up to
    50 percent.
        Congress should ensure that AHPs are a viable option for
    small businesses and self-employed individuals for years to
    come, which is why it is important for Congress to pass
    Chairman Walberg's Association Health Care Plans Act.
    Businesses of all sizes can use stop loss or reinsurance to
    insulate themselves from unexpected high medical claims.
        However, Democratic led states have sought to overregulate
    self-insured health plans using reinsurance by artificially
    classifying these plans as fully insured with the intended
    result to removing small businesses' ability to innovate and
    contain cost. Under Self-Insurance Protection Act would clarify
    that self-insured plans with reinsurance are still self-insured
    health plans.
        As we will hear in testimony today, the COVID-19 pandemic
    created an opportunity for small businesses to innovate by
    expanding telehealth coverage options. Chairman Walberg's
    Telehealth Benefit Expansion for Workers Act would return to
    employers this important tool used to expand coverage options
    and lower cost.
        Employers have also innovated by participating in direct
    contracts with providers, removing middlemen, and bureaucracy,
    and allowing employers to customize their coverage options to
    meet their employees' healthcare needs.
        This hearing will examine expanding businesses' ability to
    use innovative coverage models like direct contracts. Last,
    this Committee on a bipartisan basis has historically held
    ERISA preemption of State insurance law to be fundamentally
    important. ERISA preemption has allowed self-insured health
    plans the flexibility to design their plans in a way that works
    best for over 50 years.
        We look forward to closely working with the Department of
    Labor to defend ERISA preemption. I am hopeful that our
    Democratic colleagues will work with us to get businesses more
    options, more flexibility and more opportunities to offer high-
    quality, affordable coverage to their employees.
        I thank the Subcommittee members for joining this important
    discussion, and I look forward to our witnesses' expert
    testimony. Now, I yield to the Ranking Member for an opening
    statement.
        [The statement of Chairman Allen follows:]
        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. DeSaulnier. Thank you, Mr. Chairman. I want to thank
    you for having this hearing. As you know, as soon as we both
    knew we were going to have these assignments again, I reached
    out and we had a wonderful conversation. As two former small
    business owners--or, I am a former, the gray hair and the white
    hair came from politics mostly.
        Well, no, owning restaurants probably was worse. We have--
    we both met payrolls. We have paid for insurance. I want to
    really, and my hope is that while we go into our ideological
    approaches to this, there is an old saying, if you do what you
    have always done, you get what you have always got.
        That we do it through this, we could work in a way that
    seems to me to be completely bipartisan. How do we improve
    efficiently with performance standards, the delivery of care,
    and the cost to these--this marketplace? For you and I, as you
    have stated, and for large employers, clearly if you are a
    business owner, you want to get value out of your insurance,
    and you do not want to have high denials.
        You do not want to have, as you said, your employees not
    being as effective because they are not getting the support
    that they paid for. My concern is what is happening in the
    marketplace in this field. The previous session, the previous
    Chair and I, we had hearings on PBMs. What an inefficient part
    of the health care delivery system.
        We have stories now about private equity companies going in
    and buying out rural hospitals, taking out all the assets and
    leaving, and having emergency response people have to take
    people an hour and 15 minutes to the next nearest hospital, as
    opposed to 15 minutes.
        All of that is a structure that I do not know what the
    solution is. I have my own ideas, as you do, but it clearly for
    me is a level of urgency that this committee should really dive
    into. My respect for you, Mr. Chairman, and our collegiality
    over the years having been in the same class and our
    backgrounds, I think gives me hope that we can approach this in
    a way that we get good value for the employers, the employees,
    and the value includes the cost, but also the quality of care.
        I do not think we are talking enough in this hearing, but
    hopefully in future ones, about the quality of care. Then,
    secondarily, you know my passion about behavioral health,
    making sure people have that access, but we have also had
    hearings in the previous session, bipartisan hearings about
    denials.
        The facts about denials are just outrageous. I have had
    doctors tell me all over the country that claims they put in
    routinely for decades, they are now being denied. I have one
    example in my comments. Thank you for this. However, I have got
    to start out with the reality that the last 3 months with the
    current administration and DOGE and Mr. Musk, they have done
    irreparable harm without analysis to the health and safety of
    American workers.
        This is the next part. The reckless closure of key offices
    within the Department of Health and Human Services, and firing
    of tens of thousands of essential workers is contrary to the
    administration's supposed enthusiasm for efficiency. You do not
    take years of experience in any operation, private or public,
    and just indiscriminately get rid of them.
        There is value that taxpayers lost by doing this. I am fine
    with greater efficiency. We can always look at that, but
    efficiency also requires us to look at the current positive
    sides of the delivery of services. To me that is the essence of
    owning a business, is problem solving without already--already
    assuming what the solutions are and being open-minded to how we
    achieve those solutions.
        The Administration of Community Living or ACL, which is
    slated for closure, was formed specifically to streamline and
    bring under one umbrella, the various programs in the Health
    and Human Services Department.
        I would like to submit for the record a letter signed by
    more than 450 organizations expressing their dismay over the
    plan to eliminate the ACL and split its functions across three
    other agencies. I would like to submit this. I would like
    unanimous consent at this time to submit it for the record.
        Chairman Allen. Without objection.
        [The information of Mr. DeSaulnier follows:]
       [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. DeSaulnier. Thank you. Today we could discuss ways to
    improve access to care through employer-sponsored insurance by
    addressing exorbitant prescription drugs costs, or unjustified
    claims denials by large insurance companies. These are
    challenges we should tackle in light of the fact that last year
    alone 31 million Americans had to borrow an estimated 74
    billion dollars to pay for health care for themselves or a
    family member.
        Health care costs are the No. 1 reason for personal
    bankruptcy in the United States of America. That is completely
    unacceptable. Instead, against this backdrop, my congressional
    Republican colleagues are working to cut Medicaid based on
    their budget decisions, to pay for tax cuts for billionaires
    and corporations.
        While we could partner on efforts to expand coverage for
    all Americans, including through employer-sponsored insurance,
    my colleagues unfortunately are, press--in my opinion, are
    pressing forward on efforts to eliminate health coverage, and
    make health care costs skyrocket for many people, without an
    analysis of the quality of care.
        In February, House--the House majority approved a budget
    resolution that would give tax cuts to the richest 1 percent,
    with a price tag of over 1.1 trillion dollars. To help pay for
    this, Republicans directed the House and Energy and Commerce
    Committee to cut 880 billion dollars.
        The non-partisan Congressional Budget Office, CBO, reported
    last month that there is no way for the majority party to meet
    their targeted cuts without forcing the most significant cuts
    to Medicaid in American history. I would--I would like to enter
    this report into the record, and I ask unanimous consent to do
    so.
        Chairman Allen. Without objection.
        [The information of Mr. DeSaulnier follows:]
        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. DeSaulnier. I might add that the CBO also did a report
    on the--on the tax cuts, and their analysis showed that over 85
    percent of the benefits did not trickle down to Americans, it
    went to the top 1 percent, so in an age where we have the
    highest concentration of wealth in the history of the country,
    this tax cut actually made it worse. That is according to the
    CBO.
        I challenge my colleagues from across the aisle to hold
    town halls and listen to what their constituents say. I have
    had four in 3 months say about how much they rely on Medicaid.
    Constituents like Alisa Rosillo who lives in my district, proud
    to represent, and is a parent to children with disabilities.
    She would be irreparably harmed, and her children by reckless
    cuts to Medicaid.
        One in five Americans are covered by Medicaid, and they are
    understandably furious and afraid that their health is being
    sacrificed to pay for billionaires' tax cuts. Our priorities
    have never been clearer. Republicans are fighting to slash
    Medicaid for millions of people. I hope they change their mind,
    and I hope their constituents are telling them not to do that.
        Raise taxes for consumers in ACA plans and dismantle
    Federal agencies that combat--combat corporate greed, all in
    order to fund 4 and a half trillion dollars in tax cuts for
    billionaires and large corporations. They have just cut the
    National Institutes for Health, including serious cuts to the
    American Cancer Institute, which we will talk about further
    with Ms. Lilly.
        On the other hand, Democrats have solutions to take on big
    pharma insurance companies and large corporations. Not all of
    them, we support corporations that have social responsibility
    and want to work with us and expect to profit from those
    contributions and their efficiencies.
        Unfortunately, too many corporations are driving to the
    lowest common denominator in terms of return on investment
    without any kind of long-term strategy for the quality of the
    product they offer.
        Last week, we celebrated the 15th anniversary of the
    Affordable Care Act, which dramatically expanded millions of
    Americans' access to affordable healthcare. Congressional
    Democrats continued to build on this progress with the American
    Rescue Plan Act and the Inflation Reduction Act.
        Much more work needs to be done to improve health care in
    this country, and make it more affordable. However, axing the
    services and coverage that so many people, so many Americans
    rely on is not the way to accomplish those goals. I look
    forward to us working together to increase efficiency, and the
    quality of care in our health care system.
        Nothing, I think, should be more bipartisan. In spite of
    our differences of our approach, in order to extend people's
    lives and the quality of lives for all Americans, irrespective
    of where they live, or what their party affiliation is. Thank
    you Mr. Chairman, I yield back.
        [The statement of Ranking Member DeSaulnier follows:]
        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Allen. Thank you, Mr. DeSaulnier. Pursuant to
    Committee Rule 8-C, all members who wish to insert written
    statements into the record may do so by submitting them in
    Microsoft Word format to the Committee Clerk within 14 days of
    the date of this hearing.
        Without objection, the hearing record will remain open for
    14 days to allow such statements and other extraneous materials
    noted during the hearing to be submitted for the official
    hearing record.
        Now, I would like to introduce our witnesses. I will now
    turn to the introduction of our three distinguished witnesses.
    Our first witness is Ms. Angela Shields, the Chief Executive
    Officer for Tennessee REALTORS in Nashville Tennessee, a great
    State and a great city. Ms. Shields is testifying on behalf of
    the National Association of REALTORS.
        Our second witness is Ms. Bethany Lilly, Executive Director
    for public policy at the Leukemia and Lymphoma Society in
    Washington, DC. Our last witness is Ms. Marcie Strouse, a
    Partner with Capitol Benefits Group in Des Moines, Iowa. Ms.
    Strouse is testifying on behalf of the National Federation of
    Independent Businesses.
        We thank the witnesses for being here today, and we look
    forward to your testimony. Pursuant to Committee rules, I would
    ask that you each limit your oral presentation to a 3-minute
    summary of your written statement. The clock will count down
    for 3 minutes, as Committee members have many questions for
    you, and we would like to spend as much time as possible on
    those questions.
        Pursuant to Committee Rule 8D and Committee practice,
    however, we will not cutoff your testimony until you reach the
    5-minute mark. I would also like to remind the witnesses to be
    aware of their responsibility to provide accurate information
    to the Subcommittee. I will first recognize Ms. Shields for
    your opening statement.

       STATEMENT OF MS. ANGELA SHIELDS, CHIEF EXECUTIVE OFFICER,
     TENNESSEE REALTORS, ON BEHALF OF THE NATIONAL ASSOCIATION OF
                    REALTORS, NASHVILLE, TENNESSEE.

        Ms. Shields. Thank you, Chairman Allen, Ranking Member
    DeSaulnier, and members of the Subcommittee. Thank you for the
    opportunity to testify on behalf of the National Association of
    REALTORS. My name is Angela Shields, and I am CEO for the
    Tennessee REALTORS.
        In 2019, Tennessee and other realtor associations created
    an association health plan to provide high-quality, low-cost
    health coverage options to our members. We succeeded. Realtor
    AHPs offered comprehensive health coverage for preexisting
    conditions in all ten ACA essential health benefits.
        Our AHPs also had lower deductibles, and broader provider
    networks than the ACA. We did not negatively affect the ACA
    markets. Our members are generally older, and most do not
    obtain their health insurance from the ACA, so there was no
    competition. Of the few who did leave the ACA, most were older,
    less healthy individuals, seeking the lower deductibles and
    broader networks our AHP offered.
        Unfortunately, a Federal District Court overturned the
    regulation, allowing our associations to offer the AHP. Forcing
    us to discontinue our plan. We were devastated. My leadership
    team and I cared deeply about our members and their families.
    For the past 5 years, I have fielded hundreds of calls and
    emails from members, many with serious preexisting conditions.
        I had to explain why we took away their affordable
    comprehensive healthcare plans. Chairman Walberg has introduced
    The Association Health Plan Act, which would allow our realtor
    associations to once again have comprehensive and affordable
    coverage.
        We support this bill because it provides a choice, which
    allows self-employed individuals and small businesses to shop
    around and decide which works best, the ACA or AHPs. I would
    like to end by saying this. The ACA has helped many of our
    members, and we will continue to support the ACA, but high
    deductibles and limited networks made the ACA unworkable for
    most NAR members.
        AHP health coverages offers a viable insurance option for
    those members who find the ACA does not work. We urge Congress
    to work together and build on the AHP Act to provide a choice
    to self-employed individuals and to small businesses. Once
    again, I would like to thank you for your time and your
    consideration, and I would be happy to answer any questions
    that you would like to ask.
        [The statement of Ms. Shields follows:]
        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Allen. Thank you, Ms. Shields. I now recognize Ms.
    Lilly for your testimony.

      STATEMENT OF MS. BETHANY LILLY, EXECUTIVE DIRECTOR, PUBLIC
      POLICY, THE LEUKEMIA AND LYMPHOMA SOCIETY, WASHINGTON, D.C.

        Ms. Lilly. Thank you and thank you for inviting me to be
    here today, Chairman Allen and Ranking Member DeSaulnier. It is
    also wonderful to see you, Chairman, Chairman Walberg and
    Ranking Member Scott. I am delighted to join you today to talk
    about health insurance, and how it does and does not work for
    patients with blood cancer.
        My name is Bethany Lilly, and I serve as the Executive
    Director of Public Policy at the Leukemia and Lymphoma Society
    where our mission is to cure blood cancers and improve the
    quality of life for patients and for their families. No one
    knows when they or someone they love will be diagnosed with a
    blood cancer.
        Once a diagnosis occurs, our patients must often
    immediately start treatment. For some, every additional day of
    delay can reduce their chances of long-term survival. For--
    unfortunately, this is often the moment when our patients
    discover that their insurance is far more limited than they
    expected it to be.
        The last thing anyone with cancer should have to think
    about while undergoing treatment is whether their insurance
    will or will not cover the health care that they need. It is
    also no longer tenable to ignore the unsustainable growth in
    the cost of care in this country. Regardless of whether someone
    has been diagnosed with cancer or not, the cost of health
    insurance is significantly impacting American pocketbooks.
        Costs that patients do not pay directly, in co-pays or
    deductibles are too often passed back to them in the form of
    higher premiums. Insurance companies and public officials
    respond to efforts to reduce costs by inventing new ways to
    shift costs back onto the patients who receive care.
        Higher deductibles, additional noncovered care, more prior
    authorizations and denials, increased coinsurance, rising
    premiums and more red tape. At LLS, we have focused on
    identifying ways to drive down the cost curve for blood cancer
    care without eroding the underlying quality of health insurance
    coverage, including policies mentioned in my written testimony
    that have been before the Committee in this and previous
    Congresses.
        We are excited to work with the Committee to address issues
    related to denials and appeals, to prevent anti-competitive
    contracting practices, to advance site neutral reforms, and to
    limit facility fees. I would be remiss if I did not mention two
    additional and deeply impactful issues related to coverage
    before Congress this year.
        The reauthorization of the ACA's enhanced premium tax
    credits, and preserving access to the Medicaid Program. LLS
    urges the Congress to take action to extend the tax credits
    that make ACA coverage more affordable, and similarly we are
    deeply concerned about proposals to cut the Medicaid Program
    that will result in coverage losses.
        Now is the time for policymakers to stand up for patients,
    survivors, and caregivers by advancing solutions that bend the
    cost curve without sacrificing patient care. We need bold
    action in order to make the system sustainable for patients
    today and in the future. We need to ensure that every one of
    the approximately 188,000 people who will be diagnosed with a
    blood cancer this year, and every year after that, have access
    to comprehensive, high-quality and affordable health coverage.
        Thank you all for your time and attention to these
    important issues today. LLS looks forward to working with all
    of you to improve health care coverage for blood cancer
    patients, and I look forward to taking your questions.
        [The statement of Ms. Lilly follows:]
       [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Allen. Thank you, Ms. Lilly. I now recognize Ms.
    Strouse for your testimony.

      STATEMENT OF MS. MARCIE STROUSE, PARTNER, CAPITOL BENEFITS
      GROUP, ON BEHALF OF THE NATIONAL FEDERATION OF INDEPENDENT
                       BUSINESS, DES MOINES, IOWA

        Ms. Strouse. Chairman Allen, Ranking Member DeSaulnier, and
    members of the Subcommittee, thank you for the opportunity to
    testify today. My name is Marcie Strouse. I am a small business
    owner and benefits consultant in Des Moines, Iowa, but more
    importantly, I am a mom of three amazing kids, including two
    who were diagnosed with a neuromuscular disease.
        That diagnosis turned my world upside down, and it changed
    how I see healthcare. It is just not policy issue for me, it is
    personal. It is about ensuring that people can access the care
    they need when it matters most. For over 20 years, I have
    worked directly with small employers across Iowa. I sit across
    from family run businesses, hearing their fears and
    frustrations.
        They want to take care of their people. They want to be
    competitive, but they are drowning in rising costs and limited
    choices. In Polk County where I live, family premiums for small
    group plans have gone up 85 percent in just 8 years. For my own
    family of five, we pay $1,100.00 a month for a pre-ACA plan.
        A comparable ACA plan today would cost my family more than
    $2,100.00 a month, almost double. That is simply not
    sustainable, and I can tell you I am not the exception. Most
    small business owners are feeling the strain of rising costs
    and thinking to themselves, how can we stay competitive, retain
    and attract employees, and support our teams when we are paying
    more for less coverage every day.
        According to the latest NFIB job survey, 38 percent of
    small employers could not fill open jobs this February.
    Offering health benefits is one of the only ways we can compete
    with big companies, but 94 percent of owners say it is getting
    harder to afford. What can Congress do?
        Small business owners are resilient and innovative, they
    just need the tools to succeed. Congress should empower small
    businesses with more choices, greater flexibility and better
    tools to support healthier teams and stronger communities. Pass
    the Self-Insurance Protection Act. Self-insurance gives small
    businesses the freedom to design smarter plans.
        Over the last 3 years, one of my two person clients saved
    $17,500.00 by moving to a level funded plan. Congress should
    protect small business access to vital tools like stop loss
    insurance, expand association health plans, letting small
    businesses pool together, regardless of industry, levels the
    playing field with big employes and provides more options.
        Promoting innovative models, such as direct primary care
    and reference-based pricing. I have employers who have saved
    over 40 percent by switching to a plan with DPC and reference-
    based pricing. The models lower costs and put consumers back in
    the driver's seat. Preserve and expand telehealth. Telehealth
    is a lifeline, especially in rural communities, and it saves
    time and money.
        Congress should pass the Telehealth Benefit Expansion for
    Workers Act to make this a permanent option under ERISA.
    Protect ERISA preemption and cut red tape. We need clear,
    uniform rules so we can focus on our people, not paperwork.
        Finally, promote transparency, market consolidation and
    hidden costs have driven prices up. Small employers deserve to
    know what they are paying and why. We want to take care of our
    teams, offer strong benefits, and build businesses we can be
    proud of, but we need Washington to give us the tools to do
    that.
        I look forward to working with the Committee to accomplish
    these goals. Thank you for the opportunity to testify today.
        [The statement of Ms. Strouse follows:]
        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Allen. Thanks to all the witnesses. Under
    Committee Rule 9, we will begin questioning the witnesses under
    the 5-minute rule. I will start with my questions first, and
    before I do, I would like to clarify just a few things for the
    witnesses and for everyone attending the hearing today. First,
    at least in my meetings with Elon Musk and his team, and our
    conference meetings, his team has no authority to hire and fire
    a single Federal employee.
        What they are doing is what I would do in my business. They
    are going in, they are analyzing it, they are running the
    algorithms, they are looking at production, how many people it
    should take, and what it takes to run the government. I would
    think that any organization would want someone to take a look
    at that.
        Unfortunately, Congress had not been able to do that, and
    that is seriously our responsibility, but for whatever reason
    politics gets in the way. He is providing a very valuable
    service to this country, and I think, you know, we should be
    ashamed of demonizing somebody that actually wants to help us
    get out of a serious, serious situation.
        The other thing I would say is this, there are two things
    that have to happen for us to sustain this country. First, is
    we have to--and all the analysts say this, we have to reduce
    government spending by 3 percent and grow the GDP by 3 percent.
    If we do not do this, it is unsustainable.
        We have run 2 trillion-dollar deficits long after COVID.
    COVID has been over for 3 years, and we are still running 2
    trillion-dollar deficit. That is unsustainable. No country
    can--our interest on our debt is a trillion dollars. The
    American people need to wake up to this fact. There is a way to
    deal with it.
        First, you have to have incentives. We have been told by
    analysts if we do not pass and extend the tax credits, that
    there will be, you know, we will lose incentives for businesses
    to grow their business and to hire more people. You have to
    have incentives to grow GDP.
        These are just business principles that I learned in my
    business, and I am sure other folks who have learned in
    business, this is the way to do business. Now, Ms. Shields,
    getting back to you and self-employed individuals. Like the
    realtors you represent that often struggle to find affordable
    healthcare coverage, what options do realtors have to obtain
    coverage?
        Ms. Shields. Thank you, Mr. Chairman. My members, when we
    were offering our healthcare plan, they had some options
    available, obviously. They had the ACA. They did have our plan
    at the time that they no longer have. Many of them that were
    married were able to obtain through their spouse, and then
    frankly, we have 15 percent nationwide that are not insured at
    all.
        That is our biggest concern. What we did find was that when
    we offered our plan, they were comparing our plan to the ACA,
    so some did stay in the ACA. The ones that we attracted were
    the ones that the ACA was just too expensive for them, they
    could not afford it. We were able to save them some cost. They
    also found our deductibles were a little better, and so they
    made the change for that particular reason.
        Again, back to the spouses, they were able to save money
    sometimes because they were having to pay for their spouse that
    might not have been insured as well.
        Chairman Allen. Why are AHPs so important for self-employed
    individuals like realtors?
        Ms. Shields. Thank you again for that question. It is so
    important because, for many reasons and I can talk to you all
    day about it, but the ones I would highlight is again, the
    deductible savings. In many cases we are able to keep them with
    the doctors they are already using.
        We do take preexisting conditions, and it just gives them
    good, high-quality coverage. We are a plan that was ACA
    compliant. We had all ten of the key essential programs that is
    required by ACA, so we were offering them good coverage.
        Chairman Allen. Yes. I cannot understand why anybody would
    object to that. Ms. Strouse, if all employers with fewer than
    50 employees are not required to offer health coverage to their
    employees, but many choose to do so. Can you discuss the
    reasons why small employers choose to offer health coverage?
        Ms. Strouse. Yes, that is a great question, and one that I
    get a lot. It is because they want to take care of their
    people. They want to take care of their communities. They want
    to be also competitive to the large employers that are out
    there. Right now, they pay twice as much as a large employer
    does for healthcare costs, however, they are employing the
    people that they see at church on Sundays, that they see on the
    soccer field, and so these are not just employees to them, they
    are their community.
        They want to make sure that they have that opportunity to
    provide benefits, and just as mentioned, you know, the ACA in
    Iowa specifically limits the access to network. We only have
    HMO options within our marketplace in Iowa, which is like most
    states. In order to offer a group plan you have more
    flexibility, and you can offer more of those national PPO
    networks that then have that broader network, so people are not
    losing their coverage.
        Chairman Allen. Right. You know there was a promise made in
    ACA that your premiums would go down. What we have done,
    employer-based health insurance has become so expensive it is
    actually driving people to Medicaid.
        Ms. Strouse. Yes.
        Chairman Allen. Which is, you know, the problem we have
    with the mandatory spending issue. If we can customize it, make
    it more affordable obviously, we can get these people on great
    plans and obviously the company has--and the impact of this
    coverage has got to be positive.
        In other words, the idea is it is coming from the employer
    and not from the Federal Government. Would that be a--yes?
        Ms. Strouse. Absolutely, yes.
        Chairman Allen. Your written testimony, and I have got
    about a minute, notes how innovative coverage models, such as
    direct contracts and direct primary care allow businesses to
    lower costs, and improve quality. What barriers do small
    employers face in using these innovative models? What can
    Congress do to make it easier for small employers to use these
    models?
        Ms. Strouse. Yes, so currently when you use direct primary
    care, there is a subscription or a membership fee that is
    included for access for those plans, and they are not HSA
    qualified, so if you have an FSA plan in, or an HAS plan in,
    you do not receive those tax benefits on those plans.
        Direct primary care also has a huge impact on outcome of
    healthcare, so typically those employees that are using direct
    primary care have a much higher level of direct access to their
    provider, and so in the case of maybe diagnosing a chronic
    disease earlier, those things are going to be caught.
        There is a lot more advocacy on that side of things, so
    that, for me, is a big piece of it is just making sure that
    those employees and employers can afford to offer those direct
    primary care options.
        Chairman Allen. Right. Thank you so much, and I yield my
    time now, and I recognize Mr. Courtney for your questions.
        Mr. Courtney. Thank you, Mr. Chairman, and thank you to the
    witnesses for your thoughtful testimony. Again, I am also
    somebody who can say that I spent 20 years as a small employer,
    and like the Chairman and the Ranking Member, you know,
    definitely acknowledge that there are realities there in terms
    of that end of the market that we should always be focused and
    working on.
        Last Congress, as Mr. DeSaulnier mentioned, you know, we
    actually came together on a bipartisan basis to have the
    transparency in the pharmacy benefit managers, which again,
    small business communities supported strongly because that
    black box of how prescription drugs are negotiated, is
    unacceptable in terms of really trying to make sure that the
    customer, which is businesses who are buying these health plans
    understand, you know, where their dollars are going.
        Large companies like Boeing, as part of their contracts
    with PBMs, required full transparency. Because of that, a lot
    of them did not bid on their offering, and as a--but the ones
    that did, Boeing saved millions of dollars because of just the
    fact that they could be able to see what happened.
        Unfortunately, the bill was pulled during the lame duck
    session at the behest of the Trump transition team, and again,
    Speaker Johnson had signed off in terms of the legislation and
    unfortunately it got withdrawn.
        We are going to start again because that is--getting to the
    core costs of health care has got to be part of the plan here
    in terms of how you lower premiums. If you do not do that, then
    you know, everything you are doing is just cost shifting. It is
    whack-a-mole, and that is just not going to work.
        Speaking of moles, Mr. DeSaulnier mentioned the 880 billion
    dollar cut to Medicaid, which is not a mole, that is like a
    gorilla that is going to again, have ripple effects to the
    employer community.
        Mr. Chairman, I have a list of the 50 major health care
    provider groups that have come out opposed to the 880 billion
    dollar cut, and again, it deals with the high end providers,
    the American Hospital Association, Catholic Hospital
    Association, Children's Health Association, physician groups,
    patient groups that have all come forward and recognize the
    devastating impact this is going to have for access to care.
        I ask that this list be unanimous consent to be added to
    the record.
        Chairman Allen. Without objection.
        [The information of Mr. Courtney follows:]
        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Courtney. Again, if that goes through, you know, we are
    looking again at, you know, a program that provides 40 percent
    of the live birth coverage in America for babies and mothers.
    Again, it is about 40/45 percent of children are covered. Some
    are actually working families because Medicaid provides for
    coverage.
        Again, Ms. Lilly, maybe you can talk about that, that you
    know, that is part of the solution in terms of helping with
    small, with employers to have options.
        Ms. Lilly. I will say just to start off that I think having
    cancer is incredibly expensive. Anyone in our community who has
    had cancer can tell you that, and for a lot of kids as you have
    said, Medicaid is one, either their source of coverage, or it
    comes in as a secondary source of coverage when their parents
    realize exactly how expensive this is going to be.
        Children's hospitals across the United States, I am sure
    they are on your list because they are one of the largest
    recipients of Medicaid funding. When our kids end up in these
    children's hospitals that have the necessary specialized care,
    Medicaid is often the program that is picking up the tab there.
        I will say, you know, I also think a lot about caregivers.
    If you are, say, a mom or a dad who has had a kid diagnosed
    with cancer, and that kid is in the hospital for months or
    weeks on end, you may not be able to maintain your job. You may
    not have access to paid leave, you may not be able to do that.
        You also need health insurance. If something additionally
    awful were to happen you would also need that health insurance,
    and Medicaid also picks up those families. Medicaid is also
    incredibly important for people with disabilities, and many
    people deal with the long-term implications of having a cancer.
        For instance, I know you have personal experience with
    this, sir, but if you have been through that chemo, if you have
    been through that radiation, if you have been through frankly
    the treatments that we still need to develop better options
    for, those can have really long-term implications on your
    health, and you may need access to long-term services and
    supports, which are only available through the Medicaid
    Program.
        Really, Medicaid kind of comes around all cancer patients,
    and really helps all of that. I will add that I think in
    addition to caregivers and kids, and people with disabilities,
    you also have a lot of older adults on Medicaid, and that is
    actually one of the biggest populations of people with blood
    cancer are older adults.
        Mr. Courtney. 60 percent, right. Thank you. I yield back.
        Chairman Allen. Next, we turn to the Chairman of the
    Committee, Mr. Walberg.
        Mr. Walberg. Thank you, Mr. Chairman, and I want to say
    thank you to you, and Ranking Member DeSaulnier for your
    flexibility and continuing this hearing today, starting a
    little earlier than we had planned as the schedules changed,
    but thank you. I think it is an important hearing.
        I would also say I look forward to the apologies that will
    come out from my Democrat colleagues when we find it all worked
    out that there were no Medicaid benefit cuts. The unfettered,
    fear mongering that is going on that the people with cancer and
    everyone else are concerned with unnecessarily.
        I look forward to that, and again, the conscious effort to
    try to declare before the American people that 880 billion
    dollars for cuts, which will cut the entire Medicaid funding is
    intended, so we will see.
        I look forward to that when in fact the President and
    leadership and Congress have said no Medicaid cuts. I hope that
    gets out. Ms. Shields, thank you for being here. The
    Congressional Budget Office estimates that expanding
    association health plans will result in 400,000 uninsured
    individuals gaining coverage.
        What are the additional advantages of allowing small
    businesses to band together to offer coverage to AHPs?
        Ms. Shields. Thank you. Again, there are many benefits to
    allowing these programs. One, you do pick up additional people
    who had not been insured. We have had--not to repeat myself,
    but 15 percent that were uninsured across the entire nation
    with NAR, so we are picking them up.
        Second, we have a comprehensive plan that is offering great
    benefits to our members that they were otherwise unable to get.
    The cost savings, the deductible that is lower, and we were
    able to lower the deductibles for our members where they were
    paying for a family $11,000. We were able to bring that down
    significantly anywhere from $4,000 to $6,000, depending on
    which plan they picked.
        These are high-quality plans that were ACA compliant and
    had all ten essential pieces in it. They are able to keep their
    doctors. We were allowing them to choose--these plans allowed
    them to choose their doctors. We also had where we were
    allowing pre-existing conditions.
        It was everything that we were able to provide. It was as
    if you were going to work for a large employer, but it was a
    plan that they were able to do as self-employed, which for us,
    our job is to offer our members benefits. This was one of the
    biggest benefits they were asking for.
        Mr. Walberg. Yes. The disruption of the Tennessee REALTORS
    AHP ultimately put people on the Unaffordable Care Act again.
        Ms. Shields. Absolutely, or uninsured.
        Mr. Walberg. Or uninsured, which was basically the same in
    many cases. You had an insurance policy under the Unaffordable
    Care Act, but you could not use it in so many cases.
        Ms. Shields. Right. We heard terrible stories from members,
    particularly when we had to tell them that we had to cancel the
    program. I had a member who, unfortunately, has passed since
    that time, who had everything from heart conditions to
    diabetes, and ended up dying from Lou Gehrig's disease.
        To have to tell somebody like that that we finally got you
    on a plan, and then have to tell him we are so sorry, but now
    we have to take it away.
        Mr. Walberg. Yes, the cruelty of the Courts in the Biden
    administration, taking people off of plans that worked for
    them, which provides insurance coverage when you figure across
    the Nation, for 85 percent potentially of our workforce in
    small business. Thank you.
        Ms. Shields. Thank you.
        Mr. Walberg. Ms. Strouse, use of telehealth drastically
    increased during the pandemic, and as a result we saw new and
    innovative ways of delivering care. What feedback did you
    receive from workers about increased access to telehealth
    benefits?
        Ms. Strouse. Yes, the telehealth benefit was actually
    pretty significant during that time, and then going forward
    people got used to it, and the access to care through
    telehealth. For us, what we saw in the State of Iowa was more
    access to behavioral health providers during that time because
    Iowa, like many states, have challenges with providers and
    access to providers, especially in rural communities like Iowa
    has.
        That telehealth piece actually helps to keep people from
    running into the doctor for things and incurring a cost--a
    claims cost to that. A lot of these things can be done at no
    cost to the employee, depending on plans, and how these are set
    up. What also happened was it actually encouraged people to
    actually seek that care because maybe that barrier of getting
    in to see a provider face to face is gone, so telehealth is
    very significant.
        We would love to see that continue forward, especially on
    the health savings account qualified plans.
        Mr. Walberg. Right, which saves costs as well, and helps
    healthcare. Thank you.
        Ms. Strouse. Absolutely.
        Mr. Walberg. I yield back.
        Mr. Onder [presiding]. The Chairman yields back. The Chair
    next recognizes Ms. Lee from Pennsylvania.
        Ms. Lee. Thank you, Mr. Chair. I think I might take just a
    slightly different route, and I would like to start by saying
    that I do not think that we should have health care that is
    tied to employment in the first place. The United States has
    the largest economy on Earth, but we are one of the only
    wealthy countries where getting sick can bankrupt you and your
    access to care depends on what kind of job you have, or whether
    you have one at all. Our current health care system tells
    people that their worth and their health depends on their
    specific employment status. In the wake of the Trump
    administration and DOGE's reckless mass firings across the
    Federal Government, it is now clearer than ever why trying
    something as, or excuse me, as tying something as essential as
    health care to a paycheck is harmful.
        We are hearing heartbreaking stories after heartbreaking
    story about the tens of thousands of people who are waking up
    one day suddenly unemployed, and also suddenly without health
    care. A woman about to give birth to twins, a man in the middle
    of chemotherapy. We have heard from a senior desperately
    needing hip surgery.
        Let us also not forget, even those with employer-sponsored
    insurance can still struggle with health care access and
    affordability. Often, I hear from working families who are
    underinsured, burdened by high out-of-pocket costs, skipping
    appointments, or drowning in debt for care that barely meets
    their needs.
        If they even have coverage, it often does not go far
    enough, and many are forced to choose between rent and
    groceries or paying thousands for their life-saving medication.
    Ms. Lilly, based on what you have seen in the blood cancer
    community, can you speak to the personal and financial effects
    on patients when they are denied coverage for lifesaving care,
    not because of medical judgment, but because it is being too
    costly or not profitable?
        Ms. Lilly. Yes. I would say that this is unfortunately a
    call we often get to our information and referral center is,
    hi, I have insurance, but they are saying they are not going to
    cover this particular service. Unfortunately, you know, the
    U.S. has led in biomedical research. We have amazing cell and
    gene therapies, and those therapies are probably the calls we
    get the most now, is folks being unable to access these
    services because they are so expensive.
        I will also add that this is one of the reasons why
    Medicaid is so important. If we look at Deanne, who was
    diagnosed with blood cancer many years ago, she ended up on
    Medicaid because she could no longer work. A similar situation
    for Amanda, who lives in Michigan. Many of our patients end up
    not being able to work, not being able to maintain the
    coverage, and then end up accessing the Medicaid Program
    because they are literally too sick to work.
        Ms. Lee. Thank you. Unfortunately, being denied life-saving
    care based on cost is not an exception, it is baked into the
    system. Investigations have uncovered troubling practices by
    health plans and their corporate service providers to conduct
    arbitrary, improper and mass denials of claims.
        A ProPublica investigation found that Cigna built a system
    allowing doctors to instantly reject claims without opening the
    patient's file. Another investigation found how EviCore a
    company contracted by insurers that cover over 100 million
    Americans, uses a secretive algorithm to drive up denial rates.
        One employee described executives directing staff to keep a
    closer eye on guidelines because we are not showing savings.
    Ms. Lilly, since private insurers often have a duty to maximize
    profit for shareholders, would you agree that a health system
    designed to maximize care and access for the public would help
    prevent these kinds of abusive denial practices, and better
    protect patients?
        Ms. Lilly. I think it would, and I think having that
    transparency that has really been a theme of this hearing so
    far, around what algorithms are being used? What are they based
    on? Are they being doublechecked? Is there a human actually
    reading the results and saying OK, no, this is all right, this
    makes sense?
        Does that human have the right expertise? Are they, for my
    patients, an oncologist, or are they someone else?
        Ms. Lee. I--just to say, I think this is exactly why we
    need universal health care. We have spent decades trying to
    patch a broken system. The Affordable Care Act expanded access
    and curbed some of the worst abuses, but to be honest, it was a
    compromise.
        Since then both Democratic and Republican administrations
    have doubled down on market-based models that hand over more
    power and profit to corporate actors, allowing private equity
    firms and hospital conglomerates to tighten their grips on the
    health care system.
        Where do these profits go? Straight into lobbying and
    political campaigns that block meaningful reform. That is
    exactly why we know this Republican Congress, this
    administration, and the billionaires and corporate lackeys will
    not support the policies working people actually need.
        That is why, instead of seeking to bolster our health
    system, they are seeking to cut at least 800 million in funding
    for Medicaid, a lifesaving program for our most vulnerable
    populations, including those who found themselves, or find
    themselves recently unemployed. We do not need more tweaks. We
    need a system that treats health care as a human right, not a
    job perk.
        One that prioritizes savings lives, not shareholder values,
    we deserve universal, guaranteed health care for all. I thank
    you all so much for your time today, and I yield back.
        Mr. Onder. The gentlelady yields back. The Chair next
    recognizes himself for 5 minutes. You know, we have been
    hearing a lot today about Medicaid. That was not the purpose of
    this hearing, but Id like to echo the sentiments of Chairman
    Walberg.
        Our Democratic colleagues insist on mis--and repeating
    their misrepresentations about Medicaid. There are no Medicaid
    cuts. Where do they get the 880 billion dollar figure they keep
    repeating? They get that because that is the total amount that
    the Energy and Commerce Committee is tasked with savings, as we
    desperately attempt to get our Federal budget deficit and debt
    under control.
        Not all of that savings will come, of course, from the
    Medicaid Program, much of it will come from the EV mandate, and
    so on. Even if, even if 800 billion dollars came from savings
    from reforming Medicaid, according to the CBO instead of
    Medicaid spending over the next decade increasing by 2.5
    trillion dollars, it would increase by 1.7 trillion dollars,
    only in this city. Only in Washington, DC, is a 1.7 trillion
    dollar increase a cut.
        In many ways--there are many ways, without cutting
    coverage, that we can save money on the Medicaid Program, and
    we do badly need to do so. We can check eligibility, that alone
    can save hundreds of billions of dollars. Work requirements can
    save over 100 billion dollars.
        We know the Democrat states spend twice as much per capita
    on Medicaid as Republican states. We could reform gimmicks used
    by states to juice their take from the Medicaid dollar. We can
    eliminate some of these gimmicks. No, there are no Medicaid
    cuts, but if we are to preserve Medicaid for the most needy,
    and the most vulnerable, we badly need to reform the Medicaid
    Program.
        Ms. Strouse, I appreciated your testimony in support of the
    Self-Insurance Protection Act to self-insurance, it allows
    employers to offer an alternative to costly, one size fits all
    traditional insurance plans and Obamacare plan. It can produce
    long-term financial savings for employers, give flexibility to
    tailor coverage to the needs of their employees, and invest in
    employee wellness programs.
        Reinsurance, or stop loss insurance, which empowers self-
    insured employers to enter into these agreements is critical.
    Reinsurance is a financial risk management tool that protects
    self-insurance employers from catastrophic expenses. We know
    that in 2022, 103 million Americans relied on self-insurance
    for their healthcare coverage.
        Since the Obama administration, this alternative has been
    under attack at the State and Federal levels. That is why this
    week of course, I introduced the Self-Insurance Protection Act.
    This bill will protect self-insurance by clarifying that
    Federal regulators cannot define stop loss insurance as
    traditional health insurance, which common sense dictates it is
    not.
        It also prohibits states from regulating stop loss
    insurance if those regulations make it inaccessible to
    employers. Essentially, it prevents the regulation of self-
    insurance out of business. Ms. Strouse, in your written
    testimony you mentioned that a two-employee small business was
    able to save over $3,500 annually by transforming--or,
    transitioning to a level funded plan by purchasing stop loss
    insurance.
        How does this work and how does this lead to cost savings?
        Ms. Strouse. Yes. Again, through innovation what we are
    seeing here is new opportunities coming to the table. When you
    look at the small group market, that self-funded space is a
    little different than it would be for these large employers
    that, you know, essentially are hundreds of employees.
        There are a lot more protections built around the small
    employer, so then that way, you know, if for some reason they
    come into a self-funded plan, and let us say they do have
    situations where they have multiple employees dealing with
    cancer or chronic diseases that might increase those costs,
    they still have protections so there is no run out.
        There is nothing that is going to catch them on the back
    end. These have really been put together to make sure that it
    not only protects those employers and employees, but it does
    also put them in the driver's seat for their healthcare. These
    plans, typically what they can do is lower deductibles, out of
    pocket maximums, lower those cost shares for office visits.
        It also again gives those employees the opportunity to
    drive their own health experience and their own health journey.
    When you have skin in the game and it directly impacts your
    paycheck, you tend to be a little bit more engaged with what is
    going on, so we are seeing, you know, things being diagnosed a
    lot sooner, and better outcomes for employees in these
    situations.
        Mr. Onder. Well, thank you, Ms. Strouse. I yield back. The
    Chair recognizes Ranking Member Scott of Virginia.
        Mr. Scott. Thank you, Mr. Chairman. Mr. Chairman, we have
    heard a lot about the deficit. I would just point out that the
    Republican budget increases the deficit, and adds on to the
    debt as opposed--compared to doing nothing, and remind people
    that every Democratic president since Kennedy has improved the
    deficit that they inherited, compared to what they handed over
    to the Republicans.
        Every Republican president since Nixon has handed over to
    the Democrats a worse deficit than the one, they inherited all
    without exception. For fearmongering, CBO said you cannot cut
    Energy and Commerce 880 billion dollars, programs under that
    Committee, without touching Medicaid. If they want to end the
    fearmongering, all they have to do is identify 880 billion
    dollars within the jurisdiction of that Committee that does not
    include Medicaid, and that would put an end to the discussion.
        Ms. Shields, you indicated that under your plans you
    covered all of the essential benefits that were required under
    the Affordable Care Act. Is that right?
        Ms. Shields. Yes, sir.
        Mr. Scott. That is not required for associated health
    plans? Is that right?
        Ms. Shields. We made a point of making sure that we were
    covering everything, so that we wanted to be----
        Mr. Scott. It was--it was not required under associated
    health plans?
        Ms. Shields. I honestly would have to defer that to my
    consultant, so I could get back to you on that.
        Mr. Scott. Your plan--it is not required under associated
    health plans, but you did voluntarily. Now, your plans were
    done before the--before the American Rescue Plan Act eliminated
    the cliff at four times poverty that eliminated any subsidies
    after I guess about $60,000 income for an individual.
        When we eliminated that cliff, what did that do to the
    competitiveness of your plans?
        Ms. Shields. Congressman Scott, I am not sure that I have
    the information available to answer that.
        Mr. Scott. What was the typical policy premium under your
    plan?
        Ms. Shields. The typical--again, they had several plans
    that they could pick from, so it might range $1,200 a month,
    depending on if they were getting family added to it. It might
    add just a little bit more to it, but I am going to say average
    they were probably around $1,000 to $1,100, $1,200 depending on
    which plan they picked.
        Mr. Scott. That would be over $10,000, $12,000 a year.
    That--when we eliminated the cliff it meant that the maximum
    you would pay for a family policy would be 8 and 1/2 percent of
    your income, which at $100,000 would be $8,500.00, which would
    be very difficult for you to compete with.
        I think the problem we had was that cliff, which we
    eliminated in the American Rescue Plan, and extended in the
    Inflation Reduction Act, which made insurance much more
    affordable for the people in the income range that realtors
    would probably find themselves in, the 60,000 to 100,000, maybe
    a little more, would be much more affordable.
        Can--could--could businesses buy into the Affordable Care
    Act, Ms. Shields?
        Ms. Shields. Again, I am not familiar with the Affordable
    Care Act, and as far as could businesses buy in, but I am happy
    to get the information that you need and get that back to you.
        Mr. Scott. Can anybody on the panel answer that?
        Ms. Strouse.
        Ms. Strouse. Can you just repeat it really quick, so I can
    make sure I am understanding it?
        Mr. Scott. Can businesses buy into--small businesses buy
    into the Affordable Care Act?
        Ms. Strouse. Yes.
        Mr. Scott. How does that work, because I--we understand
    most businesses do not take advantage of that.
        Ms. Strouse. There was the shop market opportunity, and it
    was not sustainable in most situations, and so what was
    happening was employers were looking at that as an option and
    recognizing that they have better options outside of that.
        Those subsidies that have been increased, some of these
    people that have--coming from employer plans to get into the
    marketplace with those subsidies are recognizing that in that
    case they actually have less access to providers in the
    marketplace, so they are giving something up to get lower
    premiums.
        The premiums have significantly increased from the very
    beginning of the market, the marketplace.
        Mr. Scott. Mr. Chairman, the--Ms. Shields indicated that
    the benefits--essential benefits were not required. I would ask
    unanimous consent to enter into the record a Washington Post
    article entitled, ``He Had Short Term Health Insurance. His
    Colonoscopy Cost Him $7,000'' because it was not included.
        A statement on behalf of members of a partnership, a
    coalition of organizations who are opposing the association
    health plans, the telehealth benefit expansion, and the Self-
    Insurance Protection Act for the record.
        Mr. Onder. Without objection, so ordered.
        [The information of Mr. Scott follows:]
        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Onder. The Chair recognizes Mr. Mackenzie of
    Pennsylvania.
        Mr. Mackenzie. Thank you, Mr. Chair. For Ms. Shields,
    participants in your program had a choice to enter into these
    plans. Is that correct?
        Ms. Shields. That is correct. They would do their research
    to determine if our plan fit them best, or if they wanted to go
    to the ACA or anywhere else.
        Mr. Mackenzie. What they experienced was lower premiums and
    deductibles in this option?
        Ms. Shields. That is correct. They had better prices, lower
    deductibles, and as pointed out earlier, it may not be
    necessarily that the price was lower, but they had a better
    plan that fit their needs.
        Mr. Mackenzie. What you are saying is that they were
    satisfied with their access to the care through their use
    programs?
        Ms. Shields. Absolutely, especially the fact that they were
    able to come in. We covered the previous existing conditions
    that they had, or that they were able to keep their doctors, or
    for whatever the necessary reason was.
        Mr. Mackenzie. What I am hearing is that this is a choice
    that these individuals are choosing. They were potentially able
    to get lower premiums and deductibles, and they were satisfied
    with the care that they were receiving?
        Ms. Shields. 100 percent. Our whole point was to offer it
    as a benefit, so that they had options because many of them
    again, were not insured, and did not feel that they had
    anywhere that they could get the insurance that they needed.
        Mr. Mackenzie. When you see that pattern, it is astounding
    that people would be opposed to giving people a choice to get
    lower cost healthcare that they are satisfied with. That is
    astounding to me that somebody would go on the record and say I
    want to take away choice from people to get low-cost healthcare
    that meets their needs.
        I will just leave it right there. The next thing is I want
    to talk to Ms. Strouse, and ask about small businesses, a
    particularly challenging environment for healthcare in our
    economy today is making sure that small businesses can offer
    affordable healthcare to their individuals.
        Can you tell me about additional innovative options that
    you are seeing in this space that meet those needs?
        Ms. Strouse. Yes, so we routinely talk about the level
    funded, which is the self-funded plans in that small group
    market, with most of our groups. There is a little bit more
    flexibility in that. However, there are things coming into the
    market around direct primary care that actually again, puts
    those employees in the driver's seat.
        We have a program that we can offer to employers at a
    minimum, just a minimal fee on a monthly basis, and employees
    have direct access to a provider team that they can call, text,
    email at any time. This team not only advocates for them in
    situations where maybe a claim has been denied, which agents do
    all the time. I just had one of those this week.
        Sometimes those denied claims are lack of documentation
    that needs to just be put together. When we look at these
    things, the whole experience, which I think Mr. DeSaulnier had
    mentioned, the quality of care, is very challenging.
        A lot of times somebody might get diagnosed with something,
    and just accessing the next step is very difficult. When you
    have these advocacy programs in place, you actually have a team
    that is not only helping you to navigate that process.
        A lot of times they have success in getting appointments
    sooner for these people. They have the ability to look at
    prescriptions, and so they can look at a wide variety of
    prescriptions in case somebody got prescribed something that is
    very expensive or not covered.
        They can do that medical management with them, and they
    also just have a little bit more of a person in their corner,
    so they know that they can contact this provider team, and that
    team already knows them. They know their family members, and
    they do not have to take the time out to go to a doctor that
    they might only see for 15 minutes, to then be sent to a
    specialist, or you know, just out into the healthcare system.
        Again, these are providing that really high level of touch
    to the employees, and it is bringing the claims cost down
    because these programs do not run then through the insurance
    program.
        For these basic needs that they have, those claims do not
    run through. When you partner that with a level funded plan, or
    a high-deductible health plan, the out-of-pocket costs go down
    significantly for those members that are participating in that.
        Mr. Mackenzie. Great. Well, thank you for sharing that with
    me. What I would like to close on is that we know we have a
    broken healthcare system in this country. I think everybody up
    here agrees with that. The question is where do you go next?
    For me, the clear answer is that we want people to innovate.
        We want new options, more options available for these
    individuals. It could be association health plans. It could be
    self-insurance. It could be telehealth. It could be direct
    primary care, it could be anything that we are not even aware
    of at this time, but the way that we are going to get those
    solutions is by getting government out of the way.
        Instead of having a one size fits all approach, which is
    failing people in many instances, I think we need to allow the
    free market to innovate, allow these new options to come
    online, and they can work in tandem with things like Medicare
    or Medicaid. It is not a one size fits all option.
        I think we need an all of the above solution here, and so I
    again, thank you for your testimony today and these new
    alternatives that you have presented that I think we should be
    in support of. Thank you, and I yield back.
        Chairman Allen. The gentleman yields. I now recognize Mr.
    DeSaulnier, our Ranking Member for his questions for 5 minutes.
        Mr. DeSaulnier. Thank you, Mr. Chairman. I hope we are
    still friends, and the comments that have been made by my
    colleagues about Medicaid, I--I welcome. We can stop talking
    about it if we all have an agreement that what is in the
    Republican approved budget, in terms of the number, is not
    going to happen the way it is described in that.
        I think apologies are not the right word for my friend, Mr.
    Walberg. I think there is a recognition that the end product
    hopefully will be what we can all agree on, much like the
    starting product was from the Senate and through the budget
    process until a certain point, we were reaching consensus.
        Ms. Lilly, I am a survivor of stage 4 chronic lymphocytic
    leukemia. I like to tell my friends that I was perfectly
    healthy until I became a Member of Congress when I was
    diagnosed with stage 4 cancer.
        Then after that because of my decreased immune system, just
    running on the mall I took a freak fall 5 years ago at the
    beginning of COVID, was rushed to George Washington, and my
    doctors there told my kids when they flew out from California
    that I would die in the next 48 hours. I am--have some
    expertise, not because I chose to, but because I am a survivor
    of the American health care system.
        We do agree that the United States has--we pay the most of
    any developed country for our health care, a fifth of the
    economy. Looking at people who help pay for that, and from a
    business perspective, clearly this is broken, and we have the
    worst outcomes of any developed country.
        I mean that is a simple statement. If I ran a restaurant, I
    was losing money, and I kept borrowing money to prop it up, I
    would not be in business very long. If I said I was going to
    cut my prices by 25 percent, and I was also going to cut a
    third of my kitchen staff, I do not think people would believe
    me.
        Ms. Lilly, denials first, and then I want to talk about the
    cuts at NIH and ACI. I have got an example that is not an
    anomaly where a gentleman, and again, as a consumer, I could
    not have done this without help as you have said, Ms. Strouse.
        Having been a small business member, I was a member of NFIB
    back when I was a Republican, many years ago, I can barely
    remember sometimes. Having had--trying to negotiate that. There
    are denials, and as you alluded to, there are the denials
    before the denials, just trying to negotiate the system, which
    is not just conspiracies, or incompetence.
        I had a friend who used to say I used to believe in
    conspiracies until I discovered incompetence. In this instance
    I think it was a combination of both, that you alluded to. In
    the case of denials, one case that stands out to me is a
    gentleman named Tracy Pike from Illinois, father of three, he
    had stomach cancer stage 4.
        He had all kinds of cases and precedents and let us see
    Blue Shield of Illinois and Blue Cross of approving the
    operation. Then when he was getting ready to go, they denied
    his--the approval. He died because he was denied. Is that an
    anomaly, or is that what we are seeing more and more?
        Ms. Lilly. Unfortunately, it is not. I think it is
    something that we are seeing more and more as the cost of
    health care is increasing. I will add that, you know, I think
    we had a--we testified before the ERISA Advisory Committee on
    this exact issue around denials recently, and that is part of
    my written testimony, so I would refer everyone to that.
        I will say I think we do not know how many denials occur in
    employer-sponsored insurance. We do not have a lot of
    information, and that transparency is kind of the first step in
    that direction. The Office of Inspector General has looked at
    denials in both Medicaid Managed Care and in Medicare
    Advantage, where they are incredibly high.
        Folks do not know they can appeal denials. I mean, I think
    that the lack of consumer knowledge is also an incredibly
    important piece of this. Kaiser Family Foundation, KFF, does
    sponsor a regular survey of health consumers, and more than 50
    percent of people had no idea they could appeal a denial.
        Mr. DeSaulnier. I want to ask you about the cuts to NIH and
    ACI. I, as a survivor of leukemia, I would not be here if it
    was not for investments over the last 70 years in research in
    the Department of Defense first off, and at NIH and ACI. What
    is going to happen, chronic--CLL is the most common leukemia,
    affects everyone.
        Doctor told me if I was diagnosed with this 15 years ago, I
    would be dead. Now, I have a normal life expectancy, times
    hundreds of thousands of Americans. What will these cuts that
    the administration has just done to the department and NIH, how
    will that affect life expectancy?
        Ms. Lilly. Half of cancer treatments in use today were
    developed by the NCI, the National Institute of Cancer. We need
    that research to advance the ball to make sure that we have new
    treatments. With cuts to that, we do not know. America has led
    in biomedical research for decades and decades, and that is
    why, sir, you are still alive with us today, and I do not know
    what will happen.
        We are monitoring this very carefully and very concerned.
        Mr. DeSaulnier. The pill I have in my pocket that I will
    take at 3 in the afternoon was paid for from American
    taxpayers. It is now covered by Johnson & Johnson. They charge
    $500 a pill in this country. In Australia it was 37, in the EU
    it was 90. When the Biden administration with us in leadership
    negotiated those prices, it is now $90.
        Free market is great, but there has got to be some
    parameters to free market. We live in a mixed market. Thank
    you, Mr. Chairman, I yield back.
        Chairman Allen. The gentlemen yields, and now I will
    recognize our former Chairman and current Chairman of the Rules
    Committee, Ms. Foxx, for her questions.
        Mrs. Foxx. Thank you, Mr. Chairman. Ms. Strouse, we often
    talk of ERISA preemption as being important for large employers
    to avoid the complexity of dealing with a patchwork of
    different insurance regulations across State lines. Why is
    ERISA preemption also important for small employers?
        Ms. Strouse. Yes, that is a great question. Again, it comes
    down to being treated equally, so small employers are already
    at a disadvantage. Offering them plans that are regulated by
    ERISA, like the self-funded plans, those are just crucial. It
    is just another option, another opportunity for them, again, to
    be innovative.
        We do not want regulations to get in the way when something
    is working, which ERISA has worked for a long time.
        Mrs. Foxx. Thank you very much. Ms. Strouse, last Congress
    the House passed the Lower Cost More Transparency Act, which
    among other things, would have required hospitals and insurance
    companies to publicly list the prices they charge patients.
        How would additional price transparency allow agents in the
    benefits industry like you, to better assist employers and
    employees as they make healthcare coverage decisions?
        Ms. Strouse. Transparency is vital. I think we all can
    agree on that, and right now the healthcare system has gotten
    so complicated that it makes it very hard for people to
    actually be able to manage their healthcare journey. PBMs
    continue to get brought up, and I will tell you it is not only
    PBMs in the pharmacy space. There are quite a few stakeholders
    that actually impact pharmacy costs.
        We need to make sure that we are not only targeting one
    situation and asking for them to be transparent. We need
    transparency across the board.
        When we look at things like site neutral payments, you
    know, those are the things that we are looking at in that space
    as far as the hospitals and all of the consolidation that has
    happened in the rural communities across the country.
        Mrs. Foxx. You know, it is intriguing to me that there is
    this battle not to have transparency, price transparency.
    Obviously, we must be on to something if the people who should
    be giving us transparency are not giving us transparency
    because it is the right thing to do.
        Ms. Shields, as you mentioned in your testimony, you were
    responsible for setting up the association health plan for the
    realtors. Can you discuss in more detail the participation in
    the AHP you set up, and how did this participation compare to
    the participation in ACA plans?
        Ms. Shields. Thank you for that question. Our members were
    participating in the ACA. We had many that were not insured at
    all, and then we had many members that were getting their
    insurance from their spouses. If that person happened to be
    working, and of course, we did have some on Medicare or
    Medicaid.
        When we offered the plan, we had done many, many surveys,
    and this is something that was a benefit that our members had
    asked us to offer to them. When we set up the plan, we did not
    find that it took away necessarily from the ACA. What we found
    is it was a choice that our members were able to look at to see
    if it was a benefit for them and their family.
        We did have a lot that came to our program because they
    found that it was either saving them money, it was a better
    deductible rate for them, or they were able to have a pre-
    existing condition that was covered, or they were able to keep
    their doctors, or for any other number of reasons.
        The problem that we found back to Mr. Scott's point with
    the ACA was that the ones that were in there were the realtor,
    we were talking earlier about people that are unemployed. Well,
    if you know a realtor, they are going to tell you they are
    unemployed every day. They have to get up every day and go find
    their work.
        With that, you might have an average price, or an average
    income that they make, but it is not necessarily something they
    are going to keep year after year after year. They do not get
    raises like an employee does. What happens is that their income
    is fluctuated.
        The subsidies we were being told is that they would take a
    subsidy maybe and then end up having to pay it back at the end
    of the year. They do not necessarily always qualify for those
    subsidies. The costs of the ACA did not always fit them with
    the lower cost.
        Mrs. Foxx. Well, thank you very much. I think you have done
    a great job of describing that situation with realtors from
    ones I have talked to. Mr. Chairman, I have a question for Mr.
    Coleman that I will enter into the record.
        Chairman Allen. Thank you. The gentlelady yields back, and
    now I will call on Mr. Casar from Texas for his questions for 5
    minutes.
        Mr. Casar. Thank you. I want to focus my time today on
    something you will not hear much about from my Republican
    colleagues, and frankly, I do not think we are hearing enough
    about in the news, but it is what I believe is Donald Trump's
    most dangerous attack on the rights of working people thus far.
        Last Thursday night President Trump signed an executive
    order that fundamentally undercuts union and labor rights that
    Americans have counted on for 100 years. The executive order
    strips the rights to organize and to bargain away from one and
    a half million Federal employees, and that is just where he
    wants to start.
        For over 100 years, Americans have joined together in
    unions to fight to win everything from child labor laws to the
    minimum wage, to the 40-hour work week. For over 100 years,
    unions have protected their members and lifted up all American
    workers.
        For more than 100 years, our unions have empowered
    Americans to stand up against the greedy and the ultra-rich
    that tried to use our government to take away your money.
        They have stood up against people like Elon Musk who think
    everyone else was put on Earth to just make them richer. Again,
    Donald Trump at the behest of the ultra-rich, has signed this
    executive order robbing one and a half million Americans of the
    fundamental right to come together alongside their coworkers to
    fight for better wages and better working conditions.
        If the President is allowed to exploit a loophole in order
    to end the Federal right to bargain, that is not where he is
    going to stop. He will be coming for your right to bargain and
    to organize next. This attack will not end with these Federal
    workers unless we put a stop to it.
        Let us discuss who Donald Trump is starting with by trying
    to take away their rights. These Federal workers are people
    dedicated to serving the public, doctors at the VA, food safety
    inspectors at the Department of Agriculture, IRS employees who
    go after corporations who cheat on their taxes.
        This includes our janitors, food service workers,
    administrative employees, all losing the right to organize and
    bargain that workers have fought and bled for and marched for,
    for over 100 years. This executive order is illegal, full stop.
    Trump does not have the authority to take bargaining rights
    away from these workers, and it is already being challenged in
    court.
        The president is trying to see what he can get away with
    after stacking the Supreme Court with not just right-wing
    Justices, but Justices picked by some of the richest people and
    biggest corporations in the country. This committee should be
    talking about this.
        It should really be the only thing that this committee on
    ``The Workforce'' is discussing this week. Right now, instead,
    we have had kind of a business as usual committee hearing on
    health care, so let us talk about how Trump taking away
    collective bargaining rights impacts health care.
        Federal employees will continue to be fired without due
    process because they do not have union representation. They
    will lose their health care. CDC employees that are protecting
    us from the next pandemic can be fired without the security of
    a collective bargaining agreement.
        Justice Department lawyers prosecuting things like health
    care fraud could lose their jobs because they are not Trump's
    political lackeys, but they have lost protections in collective
    bargaining. These are real impacts, and we should be talking
    about them.
        My question, Mr. Chairman, is whether we can hold a hearing
    on President Trump's executive order to strip bargaining rights
    away from 1.5 million Americans?
        Chairman Allen. This hearing is about employer healthcare
    plans. We will take your question under consideration.
        Mr. Casar. I appreciate that. It would be good for us to
    talk about since we are the folks here that talk about
    education and the workforce, one and a half million Americans
    losing their right to bargain. I cannot think of another moment
    in American history where in just 1 day that many Americans
    have lost that basic labor right.
        I would request that we have that hearing. If we can have
    it at the next meeting, or we can have a hearing about how a
    Trump executive order has gotten rid of the minimum wage for
    Federal contractors, or the firing of Equal Employment
    Opportunity Commissioners who are tasked with stopping
    discrimination in employment.
        Mr. Chairman, thank you for taking it under consideration,
    and I will continue to bring up this issue if we do not have a
    hearing on the fact that one and a half million Americans just
    lost their bargaining rights.
        I will be interested in whether the Republican majority is
    trying to take away bargaining rights from even more union
    workers, or whether they are thinking about giving those
    bargaining rights back.
        We know union members vote both Democratic and Republican,
    as they always have, and I just think it is really important
    for those union members to know whether the Republican majority
    and President Trump wants to take away their bargaining rights
    that they have had for over 100 years. Thank you.
        Chairman Allen. The gentleman yields. Now I will--let us
    see, yes, OK. I now call Mr. DeSaulnier for a closing
    statement, yes.
        Mr. DeSaulnier. All right. I want to thank the Chairman,
    and I really look forward to--I am happy to work with my
    colleagues. Clearly, the system has worked. I think if we as
    people, those of us who have owned businesses, really looked at
    this in private, we could find a solution, we could--if we were
    driven by efficiency.
        As I said, it is very clear we pay the highest cost in
    terms of a percentage of GDP, a fifth of the U.S. GDP compared
    to the rest of the developed world with worse outcomes, life
    expectancy, and that is in spite of these huge investments. We
    know there are inefficiencies. We know that PBMs no longer
    serve as any kind of efficient delivery of services.
        We know that taking over hospitals and closing them so that
    we are restricting competition does not help with the quality
    of care. If we want competition, we have got to help
    incentivize to have that hard infrastructure. We need to get
    young people to be able to go into the field.
        All of those things I really have hope. On the Medicaid, I
    take--I take my friends at their word. However, I have to say
    that in addition to CBO, the Kaiser Foundation did an analysis
    of CBO's analysis and let me just read some of what they said.
        This is from Kaiser Family Foundation, a nonprofit,
    probably the most respected nonprofit when it comes to health
    care in the United States, and I am proud of the fact that
    Henry Kaiser started it in the East Bay of California as a
    major employer during World War II because he wanted--he was
    really the starter of employer-employee based health care.
        Kaiser Family Foundation, ``The math is conclusive. Major
    cuts to Medicaid are the only way to meet the House's budget
    resolution requirements.'' The analysis goes on to say, ``The
    CBO letter confirms early expectations, finding that over the
    next 10 years 93 percent of Non-Medicare spending in the Energy
    and Commerce jurisdiction is from the Federal share of Medicaid
    spending.
        8.2 trillion out of 8.9 trillion. An additional 200 billion
    of Federal spending comes from the Children's Health Insurance
    Program, CHIP. Some of the committee's remaining spending in
    budget neutral, and there is--and therefore won't cut toward
    deficit reduction, even if Energy and Commerce eliminated all
    Non-Medicaid and CHIP spending, the committee would need to cut
    Federal spending on Medicaid and CHIP by well over 700 billion
    dollars.''
        Mr. Chairman, I would like to ask unanimous consent to
    submit the Kaiser Family Foundation analysis for the record.
        Chairman Allen. Without objection.
        [The information of Mr. DeSaulnier follows:]
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        Mr. DeSaulnier. If I could continue just briefly, in terms
    of efficiencies, as two people who met payrolls. If we were
    interested in efficiencies, I have often sat here and thought
    if we just, on a bipartisan level, followed the recommendations
    of the Inspector Generals, how much more efficient would
    government be?
        We pay for them. They are experts. They are bipartisan.
    They have come in with great recommendations. What did this
    administration do as one of its first acts? It fired the
    Inspector Generals. Why would we not just listen to them, and
    act with the seriousness of implementing those plans?
        The problem is not the analysis of the IG, it is our
    failure to act, the Congress, on efficiencies. Elon Musk, I
    have known for a good deal of time. 20 years ago, I was
    visiting the Palo Alto campus talking to the people who ran
    Tesla. I thought it was a good idea. I was a Republican
    appointed by Governor Pete Wilson regulator.
        In those days we wanted to improve under the California
    waiver, the Clean Air Act signed by Richard Nixon, and then the
    California Clean Air Act signed by Governor Ronald Reagan. We
    wanted to incentivize this kind of delivery of services. The
    original conception and the brilliant minds behind Tesla, the
    computerized system and the battery, was not Elon Musk.
        If you want to read a good analysis of this, read
    Ludicrous, it is a book about how Tesla got formed. I have met
    with Mr. Musk. He once asked me when I was a Chair of the
    Transportation Committee in the State Senate, he wanted to know
    why in California we could not be like Oregon and not have a
    sales tax on cars that cost $100,000, so he could get more of
    it out.
        At the time, I was Chair of the Budget Committee on Health
    and Human Services. We were--during the recession we were
    cutting our social safety net by billions of dollars,
    Democrats, with Republicans. I told him, it was a funny
    exchange, I said I cannot comprehend of writing a bill like
    that.
        I have had long relationships, off and on with the company.
    The plant--is many of the people who work in Fremont work, live
    in my district. I have been there multiple times. There is a
    genius, I suppose, to what is happening there, but you have to
    look under the hood so to speak, to the corporate culture.
        The corporate culture does not work. The companies that are
    coming online internationally, Ford, GM, who are providing that
    product are doing it in a competitive way. They were late, and
    I wish they had been earlier, but in terms of efficiency, just
    because somebody has a lot of money does not mean they are the
    messenger of efficiency, particularly when you are coming from
    a business model like that to a completely different model.
        I am completely committed to working with my colleagues to
    look at efficiencies. There is no excuse for the Federal
    Government to have inefficient delivery of services. With that,
    Mr. Chairman, for all of our differences, for you and the
    chairman of the full committee, it is in our best interest to
    respect one another, and I know we do, even when we get heated
    about some of these things.
        I think we can fix this system in this subcommittee if we
    take that approach. The cuts to Medicaid, putting it in the
    budget where responsibility goes, inevitably, since you are in
    the majority, what the final numbers are I will respect that
    division, but I think it is completely accurate for us to bring
    the subject up aggressively because it is in the budget. Thank
    you, Mr. Chairman, and I yield back.
        Chairman Allen. I thank the Ranking Member. gain, I agree
    with Chairman Walberg. I cannot wait to shine a light on it and
    show the people of this country where the money is going. You
    know, I served on the Healthy Future Task Force, and I asked
    all the experts to give me a breakdown of where every
    healthcare dollar is going.
        They could not give it to me. You know, we have talked
    about how complex healthcare is, they could not give it to me.
    We spend 4 trillion dollars in this country on healthcare. If
    you think about what Elon Musk said, he said we are sending
    money out that we do not know--that there is no
    characterization on it is what he calls it. I call it code. OK,
    what is this for?
        I am talking about here we are talking about B's and T's,
    not millions. I am talking about billions. Who actually
    approved this, or appropriate this to be spent? Maybe that is
    the reason the Inspector Generals got fired. Maybe they were
    not, you know, doing their job. You know, I mean we have all--
    we are all seeing the list of waste, fraud and abuse that is
    coming out of this exercise.
        We should be embarrassed about it, not defend it. I mean we
    are dealing, I mean a public company would not get away with
    this. Their shareholders--are the taxpayer's shareholders in
    the Federal Government. They have got the stock. They have got
    ownership.
        That is the reason they pay taxes is to be secure, and to
    make sure that their dollars are being spent in a wise way,
    which is frankly the only way we are going to survive. Like I
    said earlier, we are running 2 trillion-dollar deficits after
    COVID. If we were at pre-COVID spending today, we would have a
    balanced budget.
        Like CBO said, revenues would not increase under our Tax
    and Jobs Act, or revenues are up a trillion dollars. You grow
    the economy, you grow revenues. You grow GDP, you grow
    revenues. Folks, there is a way to do this, and there is a way
    not to do it, and somehow, we have got to convince each other
    that OK, this is how you get the job done.
        I am looking forward to that. I really am. We have learned
    a lot today. You know, one thing is small businesses need
    flexibility and as many tools as possible to combat years of
    rising healthcare costs, to continue to offer high-quality and
    affordable healthcare benefits to their employees.
        You know, a former President promised the American people
    if we pass this, your premiums are going to go down. What
    happened? There should be alarm about that, and we are just
    sitting here paying the bill. Guess who is paying the bill? Our
    children and our grandchildren, and future generations.
        We should be ashamed of that. Democrats and Republicans can
    share the goal of expanding assets to the affordable and high-
    quality healthcare to all Americans, and there is a way to do
    it. Have you heard from our witnesses doubling down big
    government healthcare is the wrong approach because it takes
    away choices and increases healthcare costs for employers and
    employees.
        The government is not the answer. The people are the
    answer. We give this to the people, they will fix it. I look
    forward to continuing to work with all the members of the
    Committee on the innovative free market care solutions we
    discussed today, and with that, this hearing is adjourned.
        [Whereupon, at 11:49 a.m., the Subcommittee was adjourned.]

        [Additional submissions from Chairman Allen follows:]
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        [Additional submission from Rep. Foxx follows:]
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        [Additional submissions from Rep. Scott follows:]
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        [Additional submission from Rep. Walberg follows:]
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        [Questions and responses submitted for the record by Ms.
    Bethany Lilly follows:]
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