[Congressional Record Volume 163, Number 12 (Monday, January 23, 2017)]
[Senate]
[Pages S400-S403]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. CASSIDY (for himself, Ms. Collins, Mrs. Capito, and Mr. 
        Isakson):
  S. 191. A bill to improve patient choice by allowing States to adopt 
market-based alternatives to the Affordable Care Act that increase 
access to affordable health insurance and reduce costs while ensuring 
important consumer protections and improving patient care; to the 
Committee on Finance.
  Mr. CASSIDY. Mr. President, today I have the privilege, with Senator 
Collins, to introduce a replacement bill for ObamaCare, with her 
experience as an insurance commissioner and mine as a physician caring 
for the insured and the underinsured. Let me also give due credit to 
Pete Sessions in the House, who has introduced a very similar bill to 
come up with something that we think works not just for the people we 
represent but for the entire country. That is our goal.
  I wish to speak on the Patient Freedom Act of 2017. Our goal, if you 
will--I tell my staff to imagine a woman who voted for Donald Trump and 
doesn't like ObamaCare, but she has breast cancer. Her coverage has a 
$6,000 deductible, but she has coverage. On the other hand, she wants 
to see something different. If we just view our efforts through the 
prism of her care, I think we will do right by the American people.
  Let me say something else. Again, our goal is not to come up with a 
Republican plan; it is not to come up with an anti-ObamaCare plan; our 
goal is to come up with an American patient plan where, whoever she or 
he is, they can feel comfortable that, as a Senate, we are trying to do 
right by the American people.
  Let's go to first principles. First principles is, we in the 
Republican Party think that if you like your insurance, you should be 
able to keep it. I will come to that later. President Obama was rightly 
criticized because he pledged that, and it turns out it wasn't true. 
That is one of our first principles, and we mean it.
  Secondly, we think the States should have the power, not the Federal 
Government. When you speak to Americans, they want their State capital 
to be the kind of principal force behind how their insurance is 
administered, not our Nation's Capital, so we return power to both the 
States and to patients.
  Lastly, I will say that we are truly reaching out to Democrats. One 
of the criticisms of ObamaCare is that it was rammed through on a 
partisan vote with hardly a consideration given of Republicans. Senator 
Collins and I are absolutely open to working with Democrats for this 
solution.
  How do we begin?
  We first begin by repealing the ObamaCare mandates and penalties. The 
American people do not like Washington telling them how to live their 
lives. We take those mandates and penalties from both the individual 
and the employer and we take them off.
  Secondly, we work to make health care truly affordable. We do this by 
giving States a choice to put in what we call the State alternative. I 
think we are going to begin calling it the better choice. In the better 
choice, we would use tax credits which would go to those who are 
eligible and which would go into an account. If the patient did 
nothing, she would have a

[[Page S401]]

health savings account, which will be pre funded. The money would go 
in, actually put money into the account--catastrophic coverage and a 
pharmacy benefit.
  It is important to note that she would have power over this account. 
If she wished, she could combine it with her family's, these different 
tax credits, and they could buy a richer family policy, or she could 
assign it to her employer as the employee's contribution for an 
employer-sponsored plan.
  If each member of the family decided to keep their own HPSA account 
and one of them got a terrible illness and went into the cash portion 
and exhausted their health savings account, we would allow family 
members to donate their health savings account balance to each other to 
help cover that cash exposure.
  We do different things, but the goal is to give the patient the 
power.
  Since we are going to these health savings accounts under the better 
choice model, in the better choice model, we give these tax credits 
that go into a health savings account. The individual can donate their 
own money, or the employer can contribute theirs. These are some of the 
options they have, but whichever options they have, we institute price 
transparency. That is to say that when the patient goes to have her 
blood test, she will know the cost of the blood test before she has it 
done as opposed to finding out later.
  This came to mind this past Sunday. I had a friend in town for the 
inauguration. She is a physician, and she went for a vitamin D level. 
When she went for the vitamin D level and got the bill, it was $290. 
She called the hospital and said: I order these all the time. Am I 
really getting a $290 charge on each of these?
  They said: Oh, yes, ma'am. That is what we bill patients.
  So she went to different labs and found out the cash price for the 
panels of labs she typically orders.
  She had a patient who was from out of town and was paying cash. She 
said: Pay me $38; it will cover the labs. Here is the slip; go to the 
lab.
  The patient paid $38 but went to the wrong laboratory. She was from 
out of town and not quite sure where to go. She went to the wrong 
laboratory. The bill she got, which in one lab would be $38, in the 
other lab was $690.
  My physician friend called the hospital and said: You have to be 
kidding--$690?
  They reduced it to $380. There is a tenfold difference in the cash 
price for labs. If the patient had known that, she probably would have 
paid more attention to the directions. But certainly if the price of 
the labs were posted when she went, even if she went to the wrong 
place, she could have looked at the fee schedule and decided she needed 
to go someplace else.
  One of the young men who work with me said: Yes, I get it, price 
transparency. Who would buy a car without knowing the price beforehand? 
It would be great for the car dealer but really lousy for you. That is 
how we purchase health care now. It is great for the folks selling the 
service; it is pretty lousy for the person paying the cash.
  By this, we think we begin to use market forces to reduce costs. By 
the way, this is not only about saving the patient money, which is very 
important, but here is another example.

  John Fleming is a physician who until recently was a Member of the 
House of Representatives. He tells the story of when their office went 
to a health savings account, a woman who worked with him came to him 
and said: Dr. Fleming, I don't like these health savings accounts. 
Previously I had a pharmacy benefit that paid for my inhaler, and now I 
don't have the same pharmacy benefit.
  He said: Well, under their plan, at least, you can use the health 
savings account to pay for your inhaler, and, by the way, if you 
stopped smoking, you wouldn't need the inhaler.
  Then he walks away.
  Six months later she says to him: Dr. Fleming, you were right.
  He didn't remember the conversation. He turns around and she says: 
Remember when you told me if I stopped smoking, I wouldn't need an 
inhaler? I stopped smoking and I don't need an inhaler.
  So what this does is it activates the patient. It gets her or him 
engaged in their health care, and between that--not only do we protect 
the patient's pocketbook, but we also do something positive for their 
health care.
  Let me also point this out. We think most States would go for the 
better choice. It is possible, though, that a State will reject 
everything and say: We don't want Medicaid expansion dollars and we 
don't want any extra help for those who have lower incomes. We would 
give States that choice. This is not Washington, DC, forcing something 
on people.
  Let me also point out something else. Republicans believe that if you 
like your health care, you can keep it; if you like your health 
insurance, you can keep it, and we mean it. If a State decided they 
wished to stay on ObamaCare--I think it is a terrible decision--but 
this legislation would allow a State to do so.
  I was so disappointed. I saw that the minority leader, Mr. Schumer, 
criticized our bill and said things that weren't true--fake news, if 
you will. He said we didn't cover preexisting conditions. We do. He 
said the deductibles and copays would be too high, which is not true, 
but what was striking is that he hasn't read our legislation yet.
  This is what is wrong with Washington, DC. Here we have something 
which in good faith would allow New York to stay in ObamaCare if the 
people of New York decided they wished to--but we can look at double- 
and even triple-digit premium increases in other States. Without 
reading our bill, other States are going to be condemned to these 
double- and triple-digit premium increases because folks don't want to 
consider something different. This is not a Republican plan. It is not 
a Democratic plan. We want it to be an American plan where States can 
decide the best system for their State, and if it is working for New 
York, it can stay in New York. It is not working for Louisiana so our 
State would go with the better choice, I am confident.
  That said, please don't criticize the plan before you even look at 
it, and please allow those on the Democratic side who are down to one 
insurance company on their exchanges, with double-digit premium 
increases, to at least consider an option that would be good for their 
State.
  Now, folks say: Well, you don't have a mandate. We don't think 
Washington, DC, should be telling people how to live their lives. So 
how do we, under our better choice, get the kind of big insurance pool 
without a mandate? We give States the option to do what we call 
automatic enrollment. If someone is eligible, they would be enrolled. 
The tax credit they receive would be adequate for their premium. They 
would never have to pay anything out-of-pocket to have this health 
savings account--high-deductible health plan and pharmacy benefit. It 
would be covered with the tax credit they receive. By doing so, all 
these young males who haven't signed up for ObamaCare because they are 
paying too much would actually be enrolled in an insurance plan. For 
those who get ill or have chronic conditions, they are spreading the 
cost of their expensive illness over the many healthy and not just over 
the few sick. It restores the law of big numbers.
  We had an insurance plan model this, and they said they think just by 
doing our method of enrollment, it would lower premiums by 20 percent. 
That is without an individual mandate.
  By the way, think of the folks who will never sign up for an 
ObamaCare exchange policy. The mentally ill person living beneath a 
bridge is not going to go to a public library. If he has his W-2 form, 
he doesn't know where it is. He is not going to fill out a 16-page, 
long-line form and sign up for ObamaCare. Under our policy, he could be 
automatically enrolled. So if he goes to the urgent care center with 
cellulitis, he has coverage. If something terrible happens--if he is 
hit by a car, and goes to the emergency room and is admitted to the 
hospital, society is protected from major expenses. If he gets his life 
together enough, he has a pharmacy benefit providing those 
antipsychotics. So we actually think we would increase the number who 
truly need health care to the number of those who are covered.
  Let me finish up by speaking about our timeline. We hope that over 
this next year, Republicans and Democrats can come together. I 
understand Democrats will not vote for a reconciliation

[[Page S402]]

bill that begins the repeal process of ObamaCare, but that almost 
certainly will pass. What we hope is that sometime within this year, 
Democrats who live in States with only one insurance company on their 
exchanges, in which premiums are increasing by double--and maybe even 
at that time in their States triple digits--will come together to vote 
with us to give their State an option for our better choice. So we 
would pass that legislation in 2017, giving their State legislatures 
and Governors the option to choose this pathway in 2018; and in 2019, 
the States would implement their option of choice; and by 2020, it has 
all been done.
  That is our hope.
  Folks say Senator Collins and I are naive; that the Senate cannot 
overcome its partisanship; that inevitably it will be so partisan, 
people, without reading the bill, will criticize our legislation, 
saying things about it that are not true.
  I go back to where I started, to that woman who didn't go to college, 
working hard, voted for Trump, doesn't like ObamaCare but has breast 
cancer. She needs coverage, and she wants something done for her. We 
want to give her the power. We want to give her that coverage. My goal 
is that when this finishes, as she goes from cancer to health, the only 
thing she knows about her coverage is that the decisions about her 
health care are made in her State Capitol and around her kitchen table, 
and that as her breast cancer is treated, her health coverage improves. 
That is our goal. It is not a Democratic plan or a Republican plan. It 
is not a partisan plan. It is a plan for her. That is our goal.
  Ms. COLLINS. Mr. President, first, let me commend the Senator from 
Louisiana for his extraordinary work on this bill. It has been a great 
pleasure to work so closely with him as we have made a genuine effort 
to put together a bill that would be a reasonable replacement for 
ObamaCare that would help to bring people together.
  I wish to commend the Senator from Louisiana for his expertise. As a 
physician, Senator Cassidy brings an important perspective to this 
debate, particularly since he has practiced for so many years in 
hospitals in Louisiana that serve the uninsured. So I wish to 
personally thank him for the privilege of working together to craft 
this bill.
  There has been much debate recently on the best approach to replacing 
and reforming the Affordable Care Act. Considerable confusion and 
anxiety exists about the current status of the law and about the future 
of health care in our country. However, what is often overlooked in 
this discussion is that while the ACA provides valuable assistance for 
some people who were previously uninsured, the system created by the 
law is under tremendous financial strain.
  ObamaCare exchanges are on the verge of collapse in many States. The 
reality is that significant changes must be made. Doing nothing is not 
an option.
  I am, therefore, both surprised and disappointed by the remarks of 
the Democratic leader to the press and on the floor today about the 
genuine effort that Senator Cassidy and I have put forward in 
introducing the Patient Freedom Act.
  First of all, let me point out that the Democratic leader could not 
possibly have read our bill since we haven't introduced it yet, and it 
is evident that he has misunderstood many of its provisions.
  For example, in a press statement, he said we gutted the preexisting 
condition protections that we strongly support and that are codified in 
our bill in section 101(b). Again, that is section 101(b). It ensures 
that insurers cannot discriminate against individuals with preexisting 
conditions who pay their premiums.
  I guess what disappoints me most is that the Democratic leader's 
response really represents what is wrong with Washington, DC. The 
American people want us to come together. They want Democrats and 
Republicans to work as a team to solve the problems facing our Nation. 
If we are going to have a leader on the other side of the aisle 
denounce to the press and come to the Senate floor to criticize a bill 
that has not even been introduced yet, where are we? I really hope this 
is an aberration and that we can work together and that the compromises 
we put in the bill are recognized as a good-faith effort to bring both 
sides of the aisle together in the interests of the American people and 
in providing access to affordable health care. That is our goal.
  We are not saying our bill is perfect. We are open to refinements. We 
have made a good-faith effort, and to hear it described inaccurately 
and as other than a genuine effort to solve a problem truly disappoints 
me.
  The fact is, the ACA has been in effect for years. Yet nearly 30 
million Americans still do not have health insurance coverage. Many of 
those who do have coverage through the ACA exchanges are experiencing 
large spikes in premiums, deductibles, and copays, increasing costs to 
consumers and taxpayers alike. Contrary to the predictions made by the 
early supporters of the ACA, premiums are increasing in nearly every 
State, with an average increase of 25 percent nationally.
  In New York State, the average increase on the exchange is 16.6 
percent. I don't know, but perhaps the Democratic leader thinks that is 
an acceptable rate of increase. It strikes me as pretty high, and even 
though it is below the national average, it is still in double digits. 
The situation is even more dire in some States like Arizona, where 
premiums have increased by 116 percent. In many counties throughout our 
country, there are only one or two health insurers offering plans on 
the exchanges, severely limiting consumer choice.

  In my State of Maine, premiums for the individual market for 2017 
have soared by 22 percent, on average, and plan options have become 
more limited. Now, while subsidies do cushion the blow for those 
consumers who are eligible for them, others have had to shoulder the 
full increase, and of course taxpayers have borne a greater burden. 
Moreover, individuals and families with incomes exceeding 250 percent 
of the poverty rate are not shielded from the dramatic increases in 
deductibles and copays. That is important to remember. The premium 
subsidy applies to incomes up to 400 percent of the poverty rate. It 
then drops off the cliff, and you are eligible for no subsidy 
whatsoever--there is no orderly phaseout. For help with copays and 
deductibles under the Affordable Care Act, the threshold is 250 percent 
of the poverty rate. These huge premium spikes and increases in 
deductibles and larger copays are having an effect on families and 
individuals--who are by no means wealthy--all over this Nation.
  Millions with coverage under the ACA are also facing increasingly 
narrow networks, which means they may find their preferred doctors are 
not in their networks. This can be particularly difficult for rural 
States that may have few specialists and whose citizens rely on major 
medical centers in nearby States. If patients want to continue to see 
these doctors, they can be faced with enormous costs that are not 
covered by their ACA insurance. As one Mainer put it, ``[President] 
Obama said I could keep my doctor, and the insurance company says I 
can't.''
  The co-ops created under the ACA to help provide health insurance 
coverage have been failing at an alarming rate. In fact, only 5 of the 
23 remain operational. It is also important to carefully consider the 
effects that ObamaCare's Medicare cuts have had on providers like rural 
hospitals and home health agencies, many of whom are struggling.
  In sum, prices are skyrocketing, coverage is narrowing, and the 
individual market is likely in a death spiral if Congress fails to act.
  I know many Members of this Chamber share the goal of expanding 
access to affordable health care. Over the years, I have collaborated 
with colleagues on both sides of the aisle on a number of initiatives. 
Today I am pleased to join my colleague, Senator and Doctor Bill 
Cassidy, in introducing the Patient Freedom Act of 2017 to help ensure 
that Americans have access to affordable health care that improves 
choices and helps to restrain costs.
  Let me emphasize again that our bill is a work in progress. It is not 
perfect. However, what it does--and it is virtually unique in this 
regard, in this Chamber--is it puts specific proposals on the table as 
we seek to craft bills to repair and improve the Affordable Care Act. 
Other legislation being discussed,

[[Page S403]]

such as those designed to help small businesses pool risks so they can 
better afford to provide insurance to their employees, also deserves 
consideration. Let's get a lot of ideas on the table.
  We have to start, and we have been willing to step forward and 
propose a specific bill. To be criticized for that by the Democratic 
leader is just so disappointing, particularly since the leader is well 
aware that I work across the aisle all the time to try to find 
solutions for our country.
  The Patient Freedom Act is built on the premise that giving people 
more choices is superior to the one-size-fits-all approach that defined 
the Affordable Care Act. We recognize that what works best for people 
in Maine or New Hampshire may not be right for people in New York or 
California. Our bill respects those differences by giving States 
options to choose the path that works best for their citizens.
  Now, option one would allow a State to choose to continue operating 
its insurance markets pursuant to all the rules of the Affordable Care 
Act. So if New York State wants to keep with the status quo, despite 
the 16.6-percent increase, on average, in the premiums for the 
individual market, New York State can make that choice. If a State 
chooses to remain covered by the ACA, exchange policies will continue 
to be eligible for cost-sharing subsidies and advanced premium tax 
credits, and the insurance markets will still be subject to ACA 
requirements. The individual mandate and the employer mandate will also 
remain in place for that State. Medicaid expansion States will continue 
to receive Federal funding. So if a State is happy with the status 
quo--with spiraling costs, with limited choices, with a market that is 
broken--fine, keep the ACA. In some States, maybe it is working well. 
States should have that option, and they would under the Cassidy-
Collins bill.
  More appealing to many States, however, would be what we call the 
better choice option in the Patient Freedom Act that would allow a 
State to waive many of the requirements of the ACA, except for vital 
consumer protections, and still receive Federal funding to help its 
residents purchase affordable health insurance. Senator Cassidy has 
explained how it would work so I will not go through that all again.
  Let me just say that eligible individuals in States selecting this 
option would receive Federal funding deposited into their Roth health 
savings accounts. The aggregate funding for these per-beneficiary 
deposits would be determined based on the total amount of funding that 
the Federal Government would have provided in the form of ACA subsidies 
in each State, plus any funding each State would have received had it 
chosen to expand its Medicaid Program--even if, like my State, it has 
chosen not to do so. These deposits in the Roth health savings accounts 
would be phased out for higher income beneficiaries.
  States selecting this option for every resident who does not have 
health insurance coverage through his or her employer or through public 
programs like Medicare or the VA or the Federal Employees Health 
Benefits Program--in those States, the option would be a standard 
health insurance plan that would include first-dollar coverage through 
the Roth health savings account, basic prescription drug coverage, and 
a high-deductible health plan. States could automatically enroll their 
residents who are uninsured in this standard plan, unless an individual 
opted to use his or her health savings account to purchase more 
comprehensive coverage or opted out of coverage altogether. I can't 
imagine someone making the choice of opting out altogether when they 
would receive this generous subsidy.
  In addition to Federal funds, individuals and employers could make 
contributions to these health savings accounts, and the balances would 
grow tax-free. The bill also provides for a partial tax credit for very 
low-income individuals who do receive employer-based coverage to help 
these workers pay for their deductibles and their copays.
  Here is another important provision of our bill: Health care 
providers receiving payments from the Roth health savings accounts 
would be required to publish cash prices for their services. That would 
add transparency that is sorely lacking in our current system and that 
we need to move toward a more patient-directed health care future. For 
example, if your physician has suggested that you have a colonoscopy, 
you would know whether one hospital or one clinic would charge more 
than another so you can make the right decision for you.
  Health care reform should be about expanding affordable choices, and 
that is what our legislation aims to do by allowing States to structure 
their individual health insurance markets and to do so without the 
burdensome individual mandate, the employer mandate, or many of the 
other restrictive requirements in the ACA that have substantially 
driven up costs and forced millions of Americans to buy coverage that 
is more than they want, need, or can afford. Americans should have the 
choice to purchase more affordable coverage, if that is what works best 
for them.
  Let me again emphasize, since misinformation was given to the press 
about the consumer protections in our bill, the Patient Freedom Act 
would retain several important consumer protections, contrary to what 
was said earlier today by a colleague who hadn't read our bill. 
Dependents will be able to remain on their parents' health insurance 
policies until age 26. Insurance companies will still not be able to 
exclude coverage for preexisting conditions or discriminate based on 
health status. In fact, there is no medical underwriting for the 
standard plan offered under the better choice option. Insurance 
companies cannot cap benefits by including lifetime or annual limits in 
their policies, and they must offer to renew policies as long as 
enrollees continue to pay premiums. Insurance companies must also 
continue to cover mental health and substance use disorder benefits for 
individuals, a particularly important benefit given the nationwide 
scope of the opioid crisis that has seriously affected my State of 
Maine and so many other States throughout our country, ruining the 
lives of individuals, their families, and their communities.
  Provisions like these vital consumer protections should be retained. 
However, the Washington centric approach of the ACA must be changed if 
we are ever to truly reform our broken health care system.
  I am pleased to see a growing consensus among Members of both the 
Senate and the House that we must fix the Affordable Care Act and 
provide reforms at nearly the same time as we repeal the law. This will 
help protect the families who rely on the program and give insurers 
time to transition to a new marketplace that is based on more choices 
for consumers. That is what we are trying to do here. Reforms in the 
way we provide health insurance must ensure that individuals relying on 
the current system do not experience a needless and avoidable gap in 
coverage.
  If we are going to reform the system, we must begin to put specific 
proposals on the table for our colleagues to debate, refine, amend, and 
enact. That is why the criticism is so disappointing. This is an 
attempt to put forth a possible solution that would appeal to Members 
on both sides of the aisle.
  As we continue our work to find a responsible path to repealing and 
repairing the ACA, we should give the States the freedom to choose what 
they believe works best for their citizens, whether that means staying 
with the Affordable Care Act or selecting a different path--in my view, 
a better path--that will lead to patient-directed reforms that contain 
costs and provide more choice. The Patient Freedom Act does exactly 
that, and I commend my colleague Senator Cassidy for his leadership on 
this legislation. I also want to thank our cosponsors, including 
Senator Isakson and Senator Capito for their support as well.

                          ____________________