Congressional Record, Volume 163 Issue 52 (Friday, March 24, 2017)

[Congressional Record Volume 163, Number 52 (Friday, March 24, 2017)]
[House]
[Pages H2393-H2441]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

AMERICAN HEALTH CARE ACT OF 2017

Mrs. BLACK. Mr. Speaker, pursuant to House Resolution 228, I call up
the bill (H.R. 1628) to provide for reconciliation pursuant to title II
of the concurrent resolution on the budget for fiscal year 2017, and
ask for its immediate consideration.
The Clerk read the title of the bill.
The SPEAKER pro tempore (Mr. Simpson). Pursuant to House Resolution
228, the amendments specified in section 2 of House Resolution 228
shall be considered as adopted, and the bill, as amended, is considered
read.
The text of the bill, as amended, is as follows:

H.R. 1628

Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the ``American Health Care Act of
2017''.

SEC. 2. TABLE OF CONTENTS.

The table of contents of this Act is as follows:

Sec. 1. Short title.
Sec. 2. Table of contents.

TITLE I--ENERGY AND COMMERCE

Subtitle A--Patient Access to Public Health Programs

Sec. 101. The Prevention and Public Health Fund.
Sec. 102. Community health center program.
Sec. 103. Federal payments to States.

Subtitle B--Medicaid Program Enhancement

Sec. 111. Repeal of Medicaid provisions.
Sec. 112. Repeal of Medicaid expansion.
Sec. 113. Elimination of DSH cuts.
Sec. 114. Reducing State Medicaid costs.
Sec. 115. Safety net funding for non-expansion States.
Sec. 116. Providing incentives for increased frequency of eligibility
redeterminations.

Subtitle C--Per Capita Allotment for Medical Assistance

Sec. 121. Per capita allotment for medical assistance.

Subtitle D--Patient Relief and Health Insurance Market Stability

Sec. 131. Repeal of cost-sharing subsidy.
Sec. 132. Patient and State Stability Fund.
Sec. 133. Continuous health insurance coverage incentive.
Sec. 134. Increasing coverage options.
Sec. 135. Change in permissible age variation in health insurance
premium rates.

TITLE II--COMMITTEE ON WAYS AND MEANS

Subtitle A--Repeal and Replace of Health-Related Tax Policy

Sec. 201. Recapture excess advance payments of premium tax credits.
Sec. 202. Additional modifications to premium tax credit.
Sec. 203. Premium tax credit.
Sec. 204. Small business tax credit.
Sec. 205. Individual mandate.
Sec. 206. Employer mandate.
Sec. 207. Repeal of the tax on employee health insurance premiums and
health plan benefits.
Sec. 208. Repeal of tax on over-the-counter medications.
Sec. 209. Repeal of increase of tax on health savings accounts.
Sec. 210. Repeal of limitations on contributions to flexible spending
accounts.
Sec. 211. Repeal of medical device excise tax.
Sec. 212. Repeal of elimination of deduction for expenses allocable to
medicare part D subsidy.
Sec. 213. Repeal of increase in income threshold for determining
medical care deduction.
Sec. 214. Repeal of Medicare tax increase.
Sec. 215. Refundable tax credit for health insurance coverage.
Sec. 216. Maximum contribution limit to health savings account
increased to amount of deductible and out-of-pocket
limitation.
Sec. 217. Allow both spouses to make catch-up contributions to the same
health savings account.
Sec. 218. Special rule for certain medical expenses incurred before
establishment of health savings account.

Subtitle B--Repeal of Certain Consumer Taxes

Sec. 221. Repeal of tax on prescription medications.
Sec. 222. Repeal of health insurance tax.

Subtitle C--Repeal of Tanning Tax

Sec. 231. Repeal of tanning tax.

Subtitle D--Remuneration From Certain Insurers

Sec. 241. Remuneration from certain insurers.

Subtitle E--Repeal of Net Investment Income Tax

Sec. 251. Repeal of net investment income tax.

TITLE I--ENERGY AND COMMERCE

Subtitle A--Patient Access to Public Health Programs

SEC. 101. THE PREVENTION AND PUBLIC HEALTH FUND.

(a) In General.--Subsection (b) of section 4002 of the
Patient Protection and Affordable Care Act (42 U.S.C. 300u-
11), as amended by

[[Page H2394]]

section 5009 of the 21st Century Cures Act, is amended--
(1) in paragraph (2), by adding ``and'' at the end;
(2) in paragraph (3)--
(A) by striking ``each of fiscal years 2018 and 2019'' and
inserting ``fiscal year 2018''; and
(B) by striking the semicolon at the end and inserting a
period; and
(3) by striking paragraphs (4) through (8).
(b) Rescission of Unobligated Funds.--Of the funds made
available by such section 4002, the unobligated balance at
the end of fiscal year 2018 is rescinded.

SEC. 102. COMMUNITY HEALTH CENTER PROGRAM.

Effective as if included in the enactment of the Medicare
Access and CHIP Reauthorization Act of 2015 (Public Law 114-
10, 129 Stat. 87), paragraph (1) of section 221(a) of such
Act is amended by inserting ``, and an additional
$422,000,000 for fiscal year 2017'' after ``2017''.

SEC. 103. FEDERAL PAYMENTS TO STATES.

(a) In General.--Notwithstanding section 504(a),
1902(a)(23), 1903(a), 2002, 2005(a)(4), 2102(a)(7), or
2105(a)(1) of the Social Security Act (42 U.S.C. 704(a),
1396a(a)(23), 1396b(a), 1397a, 1397d(a)(4), 1397bb(a)(7),
1397ee(a)(1)), or the terms of any Medicaid waiver in effect
on the date of enactment of this Act that is approved under
section 1115 or 1915 of the Social Security Act (42 U.S.C.
1315, 1396n), for the 1-year period beginning on the date of
the enactment of this Act, no Federal funds provided from a
program referred to in this subsection that is considered
direct spending for any year may be made available to a State
for payments to a prohibited entity, whether made directly to
the prohibited entity or through a managed care organization
under contract with the State.
(b) Definitions.--In this section:
(1) Prohibited entity.--The term ``prohibited entity''
means an entity, including its affiliates, subsidiaries,
successors, and clinics--
(A) that, as of the date of enactment of this Act--
(i) is an organization described in section 501(c)(3) of
the Internal Revenue Code of 1986 and exempt from tax under
section 501(a) of such Code;
(ii) is an essential community provider described in
section 156.235 of title 45, Code of Federal Regulations (as
in effect on the date of enactment of this Act), that is
primarily engaged in family planning services, reproductive
health, and related medical care; and
(iii) provides for abortions, other than an abortion--

(I) if the pregnancy is the result of an act of rape or
incest; or
(II) in the case where a woman suffers from a physical
disorder, physical injury, or physical illness that would, as
certified by a physician, place the woman in danger of death
unless an abortion is performed, including a life-endangering
physical condition caused by or arising from the pregnancy
itself; and

(B) for which the total amount of Federal and State
expenditures under the Medicaid program under title XIX of
the Social Security Act in fiscal year 2014 made directly to
the entity and to any affiliates, subsidiaries, successors,
or clinics of the entity, or made to the entity and to any
affiliates, subsidiaries, successors, or clinics of the
entity as part of a nationwide health care provider network,
exceeded $350,000,000.
(2) Direct spending.--The term ``direct spending'' has the
meaning given that term under section 250(c) of the Balanced
Budget and Emergency Deficit Control Act of 1985 (2 U.S.C.
900(c)).

Subtitle B--Medicaid Program Enhancement

SEC. 111. REPEAL OF MEDICAID PROVISIONS.

The Social Security Act is amended--
(1) in section 1902 (42 U.S.C. 1396a)--
(A) in subsection (a)(47)(B), by inserting ``and provided
that any such election shall cease to be effective on January
1, 2020, and no such election shall be made after that date''
before the semicolon at the end; and
(B) in subsection (l)(2)(C), by inserting ``and ending
December 31, 2019,'' after ``January 1, 2014,'';
(2) in section 1915(k)(2) (42 U.S.C. 1396n(k)(2)), by
striking ``during the period described in paragraph (1)'' and
inserting ``on or after the date referred to in paragraph (1)
and before January 1, 2020''; and
(3) in section 1920(e) (42 U.S.C. 1396r-1(e)), by striking
``under clause (i)(VIII), clause (i)(IX), or clause (ii)(XX)
of subsection (a)(10)(A)'' and inserting ``under clause
(i)(VIII) or clause (ii)(XX) of section 1902(a)(10)(A) before
January 1, 2020, section 1902(a)(10)(A)(i)(IX),''.

SEC. 112. REPEAL OF MEDICAID EXPANSION.

(a) In General.--Title XIX of the Social Security Act (42
U.S.C. 1396 et seq.) is amended--
(1) in section 1902 (42 U.S.C. 1396a)--
(A) in subsection (a)(10)(A)--
(i) in clause (i)(VIII), by inserting ``and ending December
31, 2019,'' after ``2014,'';
(ii) in clause (ii)(XX), by inserting ``and ending December
31, 2017,'' after ``2014,''; and
(iii) in clause (ii), by adding at the end the following
new subclause:
``(XXIII) beginning January 1, 2020--

``(aa) who are expansion enrollees (as defined in
subsection (nn)(1)); or
``(bb) who are grandfathered expansion enrollees (as
defined in subsection (nn)(2));''; and

(B) by adding at the end the following new subsection:
``(nn) Expansion Enrollees.--In this title:
``(1) In general.--The term `expansion enrollee' means an
individual--
``(A) who is under 65 years of age;
``(B) who is not pregnant;
``(C) who is not entitled to, or enrolled for, benefits
under part A of title XVIII, or enrolled for benefits under
part B of title XVIII;
``(D) who is not described in any of subclauses (I) through
(VII) of subsection (a)(10)(A)(i); and
``(E) whose income (as determined under subsection (e)(14))
does not exceed 133 percent of the poverty line (as defined
in section 2110(c)(5)) applicable to a family of the size
involved.
``(2) Grandfathered expansion enrollees.--The term
`grandfathered expansion enrollee' means an expansion
enrollee who--
``(A) was enrolled under the State plan under this title
(or under a waiver of such plan) as of December 31, 2019; and
``(B) does not have a break in eligibility for medical
assistance under such State plan (or waiver) for more than
one month after such date.
``(3) Application of related provisions.--Any reference in
subsection (a)(10)(G), (k), or (gg) of this section or in
section 1903, 1905(a), 1920(e), or 1937(a)(1)(B) to
individuals described in subclause (VIII) of subsection
(a)(10)(A)(i) shall be deemed to include a reference to
expansion enrollees (including grandfathered expansion
enrollees).''; and
(2) in section 1905 (42 U.S.C. 1396d)--
(A) in subsection (y)(1), in the matter preceding
subparagraph (A)--
(i) by inserting ``and that has elected to cover newly
eligible individuals before March 1, 2017'' after ``that is
one of the 50 States or the District of Columbia''; and
(ii) by inserting after ``subclause (VIII) of section
1902(a)(10)(A)(i)'' the following: ``who, for periods after
December 31, 2019, are grandfathered expansion enrollees (as
defined in section 1902(nn)(2))''; and
(B) in subsection (z)(2)--
(i) in subparagraph (A), by inserting after ``section
1937'' the following: ``and, for periods after December 31,
2019, who are grandfathered expansion enrollees (as defined
in section 1902(nn)(2))''; and
(ii) in subparagraph (B)(ii)--

(I) in subclause (III), by adding ``and'' at the end; and
(II) by striking subclauses (IV), (V), and (VI) and
inserting the following new subclause:

``(IV) 2017 and each subsequent year is 80 percent.''.
(b) Sunset of Essential Health Benefits Requirement.--
Section 1937(b)(5) of the Social Security Act (42 U.S.C.
1396u-7(b)(5)) is amended by adding at the end the following:
``This paragraph shall not apply after December 31, 2019.''.

SEC. 113. ELIMINATION OF DSH CUTS.

Section 1923(f) of the Social Security Act (42 U.S.C.
1396r-4(f)) is amended--
(1) in paragraph (7)--
(A) in subparagraph (A)--
(i) in clause (i)--

(I) in the matter preceding subclause (I), by striking
``2025'' and inserting ``2019''; and

(ii) in clause (ii)--

(I) in subclause (I), by adding ``and'' at the end;
(II) in subclause (II), by striking the semicolon at the
end and inserting a period; and
(III) by striking subclauses (III) through (VIII); and

(B) by adding at the end the following new subparagraph:
``(C) Exemption from reduction for non-expansion states.--
``(i) In general.--In the case of a State that is a non-
expansion State for a fiscal year, subparagraph (A)(i) shall
not apply to the DSH allotment for such State and fiscal
year.
``(ii) No change in reduction for expansion states.--In the
case of a State that is an expansion State for a fiscal year,
the DSH allotment for such State and fiscal year shall be
determined as if clause (i) did not apply.
``(iii) Non-expansion and expansion state defined.--

``(I) The term `expansion State' means with respect to a
fiscal year, a State that, as of July 1 of the preceding
fiscal year, provides for eligibility under clause (i)(VIII)
or (ii)(XX) of section 1902(a)(10)(A) for medical assistance
under this title (or a waiver of the State plan approved
under section 1115).
``(II) The term `non-expansion State' means, with respect
to a fiscal year, a State that is not an expansion State.'';
and

(2) in paragraph (8), by striking ``fiscal year 2025'' and
inserting ``fiscal year 2019''.

SEC. 114. REDUCING STATE MEDICAID COSTS.

(a) Letting States Disenroll High Dollar Lottery Winners.--
(1) In general.--Section 1902 of the Social Security Act
(42 U.S.C. 1396a) is amended--
(A) in subsection (a)(17), by striking ``(e)(14), (e)(14)''
and inserting ``(e)(14), (e)(15)''; and
(B) in subsection (e)--
(i) in paragraph (14) (relating to modified adjusted gross
income), by adding at the end the following new subparagraph:
``(J) Treatment of certain lottery winnings and income
received as a lump sum.--
``(i) In general.--In the case of an individual who is the
recipient of qualified lottery winnings (pursuant to
lotteries occurring on or after January 1, 2020) or qualified
lump sum income (received on or after such

[[Page H2395]]

date) and whose eligibility for medical assistance is
determined based on the application of modified adjusted
gross income under subparagraph (A), a State shall, in
determining such eligibility, include such winnings or income
(as applicable) as income received--

``(I) in the month in which such winnings or income (as
applicable) is received if the amount of such winnings or
income is less than $80,000;
``(II) over a period of 2 months if the amount of such
winnings or income (as applicable) is greater than or equal
to $80,000 but less than $90,000;
``(III) over a period of 3 months if the amount of such
winnings or income (as applicable) is greater than or equal
to $90,000 but less than $100,000; and
``(IV) over a period of 3 months plus 1 additional month
for each increment of $10,000 of such winnings or income (as
applicable) received, not to exceed a period of 120 months
(for winnings or income of $1,260,000 or more), if the amount
of such winnings or income is greater than or equal to
$100,000.

``(ii) Counting in equal installments.--For purposes of
subclauses (II), (III), and (IV) of clause (i), winnings or
income to which such subclause applies shall be counted in
equal monthly installments over the period of months
specified under such subclause.
``(iii) Hardship exemption.--An individual whose income, by
application of clause (i), exceeds the applicable eligibility
threshold established by the State, may continue to be
eligible for medical assistance to the extent that the State
determines, under procedures established by the State under
the State plan (or in the case of a waiver of the plan under
section 1115, incorporated in such waiver), or as otherwise
established by such State in accordance with such standards
as may be specified by the Secretary, that the denial of
eligibility of the individual would cause an undue medical or
financial hardship as determined on the basis of criteria
established by the Secretary.
``(iv) Notifications and assistance required in case of
loss of eligibility.--A State shall, with respect to an
individual who loses eligibility for medical assistance under
the State plan (or a waiver of such plan) by reason of clause
(i), before the date on which the individual loses such
eligibility, inform the individual of the date on which the
individual would no longer be considered ineligible by reason
of such clause to receive medical assistance under the State
plan or under any waiver of such plan and the date on which
the individual would be eligible to reapply to receive such
medical assistance.
``(v) Qualified lottery winnings defined.--In this
subparagraph, the term `qualified lottery winnings' means
winnings from a sweepstakes, lottery, or pool described in
paragraph (3) of section 4402 of the Internal Revenue Code of
1986 or a lottery operated by a multistate or
multijurisdictional lottery association, including amounts
awarded as a lump sum payment.
``(vi) Qualified lump sum income defined.--In this
subparagraph, the term `qualified lump sum income' means
income that is received as a lump sum from one of the
following sources:

``(I) Monetary winnings from gambling (as defined by the
Secretary and including monetary winnings from gambling
activities described in section 1955(b)(4) of title 18,
United States Code).
``(II) Income received as liquid assets from the estate (as
defined in section 1917(b)(4)) of a deceased individual.'';
and

(ii) by striking ``(14) Exclusion'' and inserting ``(15)
Exclusion''.
(2) Rules of construction.--
(A) Interception of lottery winnings allowed.--Nothing in
the amendment made by paragraph (1)(B)(i) shall be construed
as preventing a State from intercepting the State lottery
winnings awarded to an individual in the State to recover
amounts paid by the State under the State Medicaid plan under
title XIX of the Social Security Act for medical assistance
furnished to the individual.
(B) Applicability limited to eligibility of recipient of
lottery winnings or lump sum income.--Nothing in the
amendment made by paragraph (1)(B)(i) shall be construed,
with respect to a determination of household income for
purposes of a determination of eligibility for medical
assistance under the State plan under title XIX of the Social
Security Act (42 U.S.C. 1396 et seq.) (or a waiver of such
plan) made by applying modified adjusted gross income under
subparagraph (A) of section 1902(e)(14) of such Act (42
U.S.C. 1396a(e)(14)), as limiting the eligibility for such
medical assistance of any individual that is a member of the
household other than the individual (or the individual's
spouse) who received qualified lottery winnings or qualified
lump-sum income (as defined in subparagraph (J) of such
section 1902(e)(14), as added by paragraph (1)(B)(i) of this
subsection).
(b) Repeal of Retroactive Eligibility.--
(1) In general.--
(A) State plan requirements.--Section 1902(a)(34) of the
Social Security Act (42 U.S.C. 1396a(a)(34)) is amended by
striking ``in or after the third month before the month in
which he made application'' and inserting ``in or after the
month in which the individual made application''.
(B) Definition of medical assistance.--Section 1905(a) of
the Social Security Act (42 U.S.C. 1396d(a)) is amended by
striking ``in or after the third month before the month in
which the recipient makes application for assistance'' and
inserting ``in or after the month in which the recipient
makes application for assistance''.
(2) Effective date.--The amendments made by paragraph (1)
shall apply to medical assistance with respect to individuals
whose eligibility for such assistance is based on an
application for such assistance made (or deemed to be made)
on or after October 1, 2017.
(c) Updating Allowable Home Equity Limits in Medicaid.--
(1) In general.--Section 1917(f)(1) of the Social Security
Act (42 U.S.C. 1396p(f)(1)) is amended--
(A) in subparagraph (A), by striking ``subparagraphs (B)
and (C)'' and inserting ``subparagraph (B)'';
(B) by striking subparagraph (B);
(C) by redesignating subparagraph (C) as subparagraph (B);
and
(D) in subparagraph (B), as so redesignated, by striking
``dollar amounts specified in this paragraph'' and inserting
``dollar amount specified in subparagraph (A)''.
(2) Effective date.--
(A) In general.--The amendments made by paragraph (1) shall
apply with respect to eligibility determinations made after
the date that is 180 days after the date of the enactment of
this section.
(B) Exception for state legislation.--In the case of a
State plan under title XIX of the Social Security Act that
the Secretary of Health and Human Services determines
requires State legislation in order for the respective plan
to meet any requirement imposed by amendments made by this
subsection, the respective plan shall not be regarded as
failing to comply with the requirements of such title solely
on the basis of its failure to meet such an additional
requirement before the first day of the first calendar
quarter beginning after the close of the first regular
session of the State legislature that begins after the date
of the enactment of this Act. For purposes of the previous
sentence, in the case of a State that has a 2-year
legislative session, each year of the session shall be
considered to be a separate regular session of the State
legislature.

SEC. 115. SAFETY NET FUNDING FOR NON-EXPANSION STATES.

Title XIX of the Social Security Act is amended by
inserting after section 1923 (42 U.S.C. 1396r-4) the
following new section:

``adjustment in payment for services of safety net providers in non-
expansion states

``Sec. 1923A. (a) In General.--Subject to the limitations
of this section, for each year during the period beginning
with fiscal year 2018 and ending with fiscal year 2022, each
State that is one of the 50 States or the District of
Columbia and that, as of July 1 of the preceding fiscal year,
did not provide for eligibility under clause (i)(VIII) or
(ii)(XX) of section 1902(a)(10)(A) for medical assistance
under this title (or a waiver of the State plan approved
under section 1115) (each such State or District referred to
in this section for the fiscal year as a `non-expansion
State') may adjust the payment amounts otherwise provided
under the State plan under this title (or a waiver of such
plan) to health care providers that provide health care
services to individuals enrolled under this title (in this
section referred to as `eligible providers') so long as the
payment adjustment to such an eligible provider does not
exceed the provider's costs in furnishing health care
services (as determined by the Secretary and net of payments
under this title, other than under this section, and by
uninsured patients) to individuals who either are eligible
for medical assistance under the State plan (or under a
waiver of such plan) or have no health insurance or health
plan coverage for such services.
``(b) Increase in Applicable FMAP.--Notwithstanding section
1905(b), the Federal medical assistance percentage applicable
with respect to expenditures attributable to a payment
adjustment under subsection (a) for which payment is
permitted under subsection (c) shall be equal to--
``(1) 100 percent for calendar quarters in fiscal years
2018, 2019, 2020, and 2021; and
``(2) 95 percent for calendar quarters in fiscal year 2022.
``(c) Annual Allotment Limitation.--Payment under section
1903(a) shall not be made to a State with respect to any
payment adjustment made under this section for all calendar
quarters in a fiscal year in excess of the $2,000,000,000
multiplied by the ratio of--
``(1) the population of the State with income below 138
percent of the poverty line in 2015 (as determined based the
table entitled `Health Insurance Coverage Status and Type by
Ratio of Income to Poverty Level in the Past 12 Months by
Age' for the universe of the civilian noninstitutionalized
population for whom poverty status is determined based on the
2015 American Community Survey 1-Year Estimates, as published
by the Bureau of the Census), to
``(2) the sum of the populations under paragraph (1) for
all non-expansion States.
``(d) Disqualification in Case of State Coverage
Expansion.--If a State is a non-expansion for a fiscal year
and provides eligibility for medical assistance described in
subsection (a) during the fiscal year, the State shall no
longer be treated as a non-expansion State under this section
for any subsequent fiscal years.''.

SEC. 116. PROVIDING INCENTIVES FOR INCREASED FREQUENCY OF
ELIGIBILITY REDETERMINATIONS.

(a) In General.--Section 1902(e)(14) of the Social Security
Act (42 U.S.C. 1396a(e)(14))

[[Page H2396]]

(relating to modified adjusted gross income), as amended by
section 114(a)(1), is further amended by adding at the end
the following:
``(K) Frequency of eligibility redeterminations.--Beginning
on October 1, 2017, and notwithstanding subparagraph (H), in
the case of an individual whose eligibility for medical
assistance under the State plan under this title (or a waiver
of such plan) is determined based on the application of
modified adjusted gross income under subparagraph (A) and who
is so eligible on the basis of clause (i)(VIII) or clause
(ii)(XX) of subsection (a)(10)(A), a State shall redetermine
such individual's eligibility for such medical assistance no
less frequently than once every 6 months.''.
(b) Increased Administrative Matching Percentage.--For each
calendar quarter during the period beginning on October 1,
2017, and ending on December 31, 2019, the Federal matching
percentage otherwise applicable under section 1903(a) of the
Social Security Act (42 U.S.C. 1396b(a)) with respect to
State expenditures during such quarter that are attributable
to meeting the requirement of section 1902(e)(14) (relating
to determinations of eligibility using modified adjusted
gross income) of such Act shall be increased by 5 percentage
points with respect to State expenditures attributable to
activities carried out by the State (and approved by the
Secretary) to increase the frequency of eligibility
redeterminations required by subparagraph (K) of such section
(relating to eligibility redeterminations made on a 6-month
basis) (as added by subsection (a)).

SEC. 117. PERMITTING STATES TO APPLY A WORK REQUIREMENT FOR
NONDISABLED, NONELDERLY, NONPREGNANT ADULTS
UNDER MEDICAID.

(a) In General.--Section 1902 of the Social Security Act
(42 U.S.C. 1396a), as previously amended, is further amended
by adding at the end the following new subsection:
``(oo) Work Requirement Option for Nondisabled, Nonelderly,
Nonpregnant Adults.--
``(1) In general.--Beginning October 1, 2017, subject to
paragraph (3), a State may elect to condition medical
assistance to a nondisabled, nonelderly, nonpregnant
individual under this title upon such an individual's
satisfaction of a work requirement (as defined in paragraph
(2)).
``(2) Work requirement defined.--In this section, the term
`work requirement' means, with respect to an individual, the
individual's participation in work activities (as defined in
section 407(d)) for such period of time as determined by the
State, and as directed and administered by the State.
``(3) Required exceptions.--States administering a work
requirement under this subsection may not apply such
requirement to--
``(A) a woman during pregnancy through the end of the month
in which the 60-day period (beginning on the last day of her
pregnancy) ends;
``(B) an individual who is under 19 years of age;
``(C) an individual who is the only parent or caretaker
relative in the family of a child who has not attained 6
years of age or who is the only parent or caretaker of a
child with disabilities; or
``(D) an individual who is married or a head of household
and has not attained 20 years of age and who--
``(i) maintains satisfactory attendance at secondary school
or the equivalent; or
``(ii) participates in education directly related to
employment.''.
(b) Increase in Matching Rate for Implementation.--Section
1903 of the Social Security Act (42 U.S.C. 1396b) is amended
by adding at the end the following:
``(aa) The Federal matching percentage otherwise applicable
under subsection (a) with respect to State administrative
expenditures during a calendar quarter for which the State
receives payment under such subsection shall, in addition to
any other increase to such Federal matching percentage, be
increased for such calendar quarter by 5 percentage points
with respect to State expenditures attributable to activities
carried out by the State (and approved by the Secretary) to
implement subsection (oo) of section 1902.''.

Subtitle C--Per Capita Allotment for Medical Assistance

SEC. 121. PER CAPITA ALLOTMENT FOR MEDICAL ASSISTANCE.

Title XIX of the Social Security Act is amended--
(1) in section 1903 (42 U.S.C. 1396b)--
(A) in subsection (a), in the matter before paragraph (1),
by inserting ``and section 1903A(a)'' after ``except as
otherwise provided in this section''; and
(B) in subsection (d)(1), by striking ``to which'' and
inserting ``to which, subject to section 1903A(a),''; and
(2) by inserting after such section 1903 the following new
section:

``SEC. 1903A. PER CAPITA-BASED CAP ON PAYMENTS FOR MEDICAL
ASSISTANCE.

``(a) Application of Per Capita Cap on Payments for Medical
Assistance Expenditures.--
``(1) In general.--If a State has excess aggregate medical
assistance expenditures (as defined in paragraph (2)) for a
fiscal year (beginning with fiscal year 2020), the amount of
payment to the State under section 1903(a)(1) for each
quarter in the following fiscal year shall be reduced by \1/
4\ of the excess aggregate medical assistance payments (as
defined in paragraph (3)) for that previous fiscal year. In
this section, the term `State' means only the 50 States and
the District of Columbia.
``(2) Excess aggregate medical assistance expenditures.--In
this subsection, the term `excess aggregate medical
assistance expenditures' means, for a State for a fiscal
year, the amount (if any) by which--
``(A) the amount of the adjusted total medical assistance
expenditures (as defined in subsection (b)(1)) for the State
and fiscal year; exceeds
``(B) the amount of the target total medical assistance
expenditures (as defined in subsection (c)) for the State and
fiscal year.
``(3) Excess aggregate medical assistance payments.--In
this subsection, the term `excess aggregate medical
assistance payments' means, for a State for a fiscal year,
the product of--
``(A) the excess aggregate medical assistance expenditures
(as defined in paragraph (2)) for the State for the fiscal
year; and
``(B) the Federal average medical assistance matching
percentage (as defined in paragraph (4)) for the State for
the fiscal year.
``(4) Federal average medical assistance matching
percentage.--In this subsection, the term `Federal average
medical assistance matching percentage' means, for a State
for a fiscal year, the ratio (expressed as a percentage) of--
``(A) the amount of the Federal payments that would be made
to the State under section 1903(a)(1) for medical assistance
expenditures for calendar quarters in the fiscal year if
paragraph (1) did not apply; to
``(B) the amount of the medical assistance expenditures for
the State and fiscal year.
``(b) Adjusted Total Medical Assistance Expenditures.--
Subject to subsection (g), the following shall apply:
``(1) In general.--In this section, the term `adjusted
total medical assistance expenditures' means, for a State--
``(A) for fiscal year 2016, the product of--
``(i) the amount of the medical assistance expenditures (as
defined in paragraph (2)) for the State and fiscal year,
reduced by the amount of any excluded expenditures (as
defined in paragraph (3)) for the State and fiscal year
otherwise included in such medical assistance expenditures;
and
``(ii) the 1903A FY16 population percentage (as defined in
paragraph (4)) for the State; or
``(B) for fiscal year 2019 or a subsequent fiscal year, the
amount of the medical assistance expenditures (as defined in
paragraph (2)) for the State and fiscal year that is
attributable to 1903A enrollees, reduced by the amount of any
excluded expenditures (as defined in paragraph (3)) for the
State and fiscal year otherwise included in such medical
assistance expenditures and includes non-DSH supplemental
payments (as defined in subsection (d)(4)(A)(ii)) and
payments described in subsection (d)(4)(A)(iii) but shall not
be construed as including any expenditures attributable to
the program under section 1928. In applying subparagraph (B),
non-DSH supplemental payments (as defined in subsection
(d)(4)(A)(ii)) and payments described in subsection
(d)(4)(A)(iii) shall be treated as fully attributable to
1903A enrollees.
``(2) Medical assistance expenditures.--In this section,
the term `medical assistance expenditures' means, for a State
and fiscal year, the medical assistance payments as reported
by medical service category on the Form CMS-64 quarterly
expense report (or successor to such a report form, and
including enrollment data and subsequent adjustments to any
such report, in this section referred to collectively as a
`CMS-64 report') for which payment is (or may otherwise be)
made pursuant to section 1903(a)(1).
``(3) Excluded expenditures.--In this section, the term
`excluded expenditures' means, for a State and fiscal year,
expenditures under the State plan (or under a waiver of such
plan) that are attributable to any of the following:
``(A) DSH.--Payment adjustments made for disproportionate
share hospitals under section 1923.
``(B) Medicare cost-sharing.--Payments made for medicare
cost-sharing (as defined in section 1905(p)(3)).
``(C) Safety net provider payment adjustments in non-
expansion states.--Payment adjustments under subsection (a)
of section 1923A for which payment is permitted under
subsection (c) of such section.
``(4) 1903A fy 16 population percentage.--In this
subsection, the term `1903A FY16 population percentage'
means, for a State, the Secretary's calculation of the
percentage of the actual medical assistance expenditures, as
reported by the State on the CMS-64 reports for calendar
quarters in fiscal year 2016, that are attributable to 1903A
enrollees (as defined in subsection (e)(1)).
``(c) Target Total Medical Assistance Expenditures.--
``(1) Calculation.--In this section, the term `target total
medical assistance expenditures' means, for a State for a
fiscal year and subject to paragraph (4), the sum of the
products, for each of the 1903A enrollee categories (as
defined in subsection (e)(2)), of--
``(A) the target per capita medical assistance expenditures
(as defined in paragraph (2)) for the enrollee category,
State, and fiscal year; and
``(B) the number of 1903A enrollees for such enrollee
category, State, and fiscal year, as determined under
subsection (e)(4).
``(2) Target per capita medical assistance expenditures.--
In this subsection, the term `target per capita medical
assistance expenditures' means, for a 1903A enrollee category
and State--

[[Page H2397]]

``(A) for fiscal year 2020, an amount equal to--
``(i) the provisional FY19 target per capita amount for
such enrollee category (as calculated under subsection
(d)(5)) for the State; increased by
``(ii) the applicable annual inflation factor (as defined
in paragraph (3)) for fiscal year 2020; and
``(B) for each succeeding fiscal year, an amount equal to--
``(i) the target per capita medical assistance expenditures
(under subparagraph (A) or this subparagraph) for the 1903A
enrollee category and State for the preceding fiscal year,
increased by
``(ii) the applicable annual inflation factor for that
succeeding fiscal year.
``(3) Applicable annual inflation factor.--In paragraph
(2), the term `applicable annual inflation factor' means, for
a fiscal year--
``(A) for each of the 1903A enrollee categories described
in subparagraphs (C), (D), and (E) of subsection (e)(2), the
percentage increase in the medical care component of the
consumer price index for all urban consumers (U.S. city
average) from September of the previous fiscal year to
September of the fiscal year involved; and
``(B) for each of the 1903A enrollee categories described
in subparagraphs (A) and (B) of subsection (e)(2), the
percentage increase described in subparagraph (A) plus 1
percentage point.
``(4) Decrease in target expenditures for required
expenditures by certain political subdivisions.--
``(A) In general.--In the case of a State that had a DSH
allotment under section 1923(f) for fiscal year 2016 that was
more than 6 times the national average of such allotments for
all the States for such fiscal year and that requires
political subdivisions within the State to contribute funds
towards medical assistance or other expenditures under the
State plan under this title (or under a waiver of such plan)
for a fiscal year (beginning with fiscal year 2020), the
target total medical assistance expenditures for such State
and fiscal year shall be decreased by the amount that
political subdivisions in the State are required to
contribute under the plan (or waiver) without reimbursement
from the State for such fiscal year, other than contributions
described in subparagraph (B).
``(B) Exceptions.--The contributions described in this
subparagraph are the following:
``(i) Contributions required by a State from a political
subdivision that, as of the first day of the calendar year in
which the fiscal year involved begins--

``(I) has a population of more than 5,000,000, as estimated
by the Bureau of the Census; and
``(II) imposes a local income tax upon its residents.

``(ii) Contributions required by a State from a political
subdivision for administrative expenses if the State required
such contributions from such subdivision without
reimbursement from the State as of January 1, 2017.
``(d) Calculation of FY19 Provisional Target Amount for
Each 1903A Enrollee Category.--Subject to subsection (g), the
following shall apply:
``(1) Calculation of base amounts for fiscal year 2016.--
For each State the Secretary shall calculate (and provide
notice to the State not later than April 1, 2018, of) the
following:
``(A) The amount of the adjusted total medical assistance
expenditures (as defined in subsection (b)(1)) for the State
for fiscal year 2016.
``(B) The number of 1903A enrollees for the State in fiscal
year 2016 (as determined under subsection (e)(4)).
``(C) The average per capita medical assistance
expenditures for the State for fiscal year 2016 equal to--
``(i) the amount calculated under subparagraph (A); divided
by
``(ii) the number calculated under subparagraph (B).
``(2) Fiscal year 2019 average per capita amount based on
inflating the fiscal year 2016 amount to fiscal year 2019 by
cpi-medical.--The Secretary shall calculate a fiscal year
2019 average per capita amount for each State equal to--
``(A) the average per capita medical assistance
expenditures for the State for fiscal year 2016 (calculated
under paragraph (1)(C)); increased by
``(B) the percentage increase in the medical care component
of the consumer price index for all urban consumers (U.S.
city average) from September, 2016 to September, 2019.
``(3) Aggregate and average expenditures per capita for
fiscal year 2019.--The Secretary shall calculate for each
State the following:
``(A) The amount of the adjusted total medical assistance
expenditures (as defined in subsection (b)(1)) for the State
for fiscal year 2019.
``(B) The number of 1903A enrollees for the State in fiscal
year 2019 (as determined under subsection (e)(4)).
``(4) Per capita expenditures for fiscal year 2019 for each
1903a enrollee category.--The Secretary shall calculate (and
provide notice to each State not later than January 1, 2020,
of) the following:
``(A)(i) For each 1903A enrollee category, the amount of
the adjusted total medical assistance expenditures (as
defined in subsection (b)(1)) for the State for fiscal year
2019 for individuals in the enrollee category, calculated by
excluding from medical assistance expenditures those
expenditures attributable to expenditures described in clause
(iii) or non-DSH supplemental expenditures (as defined in
clause (ii)).
``(ii) In this paragraph, the term `non-DSH supplemental
expenditure' means a payment to a provider under the State
plan (or under a waiver of the plan) that--
``(I) is not made under section 1923;
``(II) is not made with respect to a specific item or
service for an individual;
``(III) is in addition to any payments made to the provider
under the plan (or waiver) for any such item or service; and
``(IV) complies with the limits for additional payments to
providers under the plan (or waiver) imposed pursuant to
section 1902(a)(30)(A), including the regulations specifying
upper payment limits under the State plan in part 447 of
title 42, Code of Federal Regulations (or any successor
regulations).
``(iii) An expenditure described in this clause is an
expenditure that meets the criteria specified in subclauses
(I), (II), and (III) of clause (ii) and is authorized under
section 1115 for the purposes of funding a delivery system
reform pool, uncompensated care pool, a designated state
health program, or any other similar expenditure (as defined
by the Secretary).
``(B) For each 1903A enrollee category, the number of 1903A
enrollees for the State in fiscal year 2019 in the enrollee
category (as determined under subsection (e)(4)).
``(C) For fiscal year 2016, the State's non-DSH
supplemental and pool payment percentage is equal to the
ratio (expressed as a percentage) of--
``(i) the total amount of non-DSH supplemental expenditures
(as defined in subparagraph (A)(ii)) and payments described
in subparagraph (A)(iii) for the State for fiscal year 2016;
to
``(ii) the amount described in subsection (b)(1)(A) for the
State for fiscal year 2016.
``(D) For each 1903A enrollee category an average medical
assistance expenditures per capita for the State for fiscal
year 2019 for the enrollee category equal to--
``(i) the amount calculated under subparagraph (A) for the
State, increased by the non-DSH supplemental and pool payment
percentage for the State (as calculated under subparagraph
(C)); divided by
``(ii) the number calculated under subparagraph (B) for the
State for the enrollee category.
``(5) Provisional fy19 per capita target amount for each
1903a enrollee category.--Subject to subsection (f)(2), the
Secretary shall calculate for each State a provisional FY19
per capita target amount for each 1903A enrollee category
equal to the average medical assistance expenditures per
capita for the State for fiscal year 2019 (as calculated
under paragraph (4)(D)) for such enrollee category multiplied
by the ratio of--
``(A) the product of--
``(i) the fiscal year 2019 average per capita amount for
the State, as calculated under paragraph (2); and
``(ii) the number of 1903A enrollees for the State in
fiscal year 2019, as calculated under paragraph (3)(B); to
``(B) the amount of the adjusted total medical assistance
expenditures for the State for fiscal year 2019, as
calculated under paragraph (3)(A).
``(e) 1903A Enrollee; 1903A Enrollee Category.--Subject to
subsection (g), for purposes of this section, the following
shall apply:
``(1) 1903A enrollee.--The term `1903A enrollee' means,
with respect to a State and a month and subject to subsection
(i)(1)(B), any Medicaid enrollee (as defined in paragraph
(3)) for the month, other than such an enrollee who for such
month is in any of the following categories of excluded
individuals:
``(A) CHIP.--An individual who is provided, under this
title in the manner described in section 2101(a)(2), child
health assistance under title XXI.
``(B) IHS.--An individual who receives any medical
assistance under this title for services for which payment is
made under the third sentence of section 1905(b).
``(C) Breast and cervical cancer services eligible
individual.--An individual who is entitled to medical
assistance under this title only pursuant to section
1902(a)(10)(A)(ii)(XVIII).
``(D) Partial-benefit enrollees.--An individual who--
``(i) is an alien who is entitled to medical assistance
under this title only pursuant to section 1903(v)(2);
``(ii) is entitled to medical assistance under this title
only pursuant to subclause (XII) or (XXI) of section
1902(a)(10)(A)(ii) (or pursuant to a waiver that provides
only comparable benefits);
``(iii) is a dual eligible individual (as defined in
section 1915(h)(2)(B)) and is entitled to medical assistance
under this title (or under a waiver) only for some or all of
medicare cost-sharing (as defined in section 1905(p)(3)); or
``(iv) is entitled to medical assistance under this title
and for whom the State is providing a payment or subsidy to
an employer for coverage of the individual under a group
health plan pursuant to section 1906 or section 1906A (or
pursuant to a waiver that provides only comparable benefits).
``(2) 1903A enrollee category.--The term `1903A enrollee
category' means each of the following:

[[Page H2398]]

``(A) Elderly.--A category of 1903A enrollees who are 65
years of age or older.
``(B) Blind and disabled.--A category of 1903A enrollees
(not described in the previous subparagraph) who are eligible
for medical assistance under this title on the basis of being
blind or disabled.
``(C) Children.--A category of 1903A enrollees (not
described in a previous subparagraph) who are children under
19 years of age.
``(D) Expansion enrollees.--A category of 1903A enrollees
(not described in a previous subparagraph) for whom the
amounts expended for medical assistance are subject to an
increase or change in the Federal medical assistance
percentage under subsection (y) or (z)(2), respectively, of
section 1905.
``(E) Other nonelderly, nondisabled, non-expansion
adults.--A category of 1903A enrollees who are not described
in any previous subparagraph.
``(3) Medicaid enrollee.--The term `Medicaid enrollee'
means, with respect to a State for a month, an individual who
is eligible for medical assistance for items or services
under this title and enrolled under the State plan (or a
waiver of such plan) under this title for the month.
``(4) Determination of number of 1903a enrollees.--The
number of 1903A enrollees for a State and fiscal year, and,
if applicable, for a 1903A enrollee category, is the average
monthly number of Medicaid enrollees for such State and
fiscal year (and, if applicable, in such category) that are
reported through the CMS-64 report under (and subject to
audit under) subsection (h).
``(f) Special Payment Rules.--
``(1) Application in case of research and demonstration
projects and other waivers.--In the case of a State with a
waiver of the State plan approved under section 1115, section
1915, or another provision of this title, this section shall
apply to medical assistance expenditures and medical
assistance payments under the waiver, in the same manner as
if such expenditures and payments had been made under a State
plan under this title and the limitations on expenditures
under this section shall supersede any other payment
limitations or provisions (including limitations based on a
per capita limitation) otherwise applicable under such a
waiver.
``(2) Treatment of states expanding coverage after fiscal
year 2016.--In the case of a State that did not provide for
medical assistance for the 1903A enrollee category described
in subsection (e)(2)(D) during fiscal year 2016 but which
provides for such assistance for such category in a
subsequent year, the provisional FY19 per capita target
amount for such enrollee category under subsection (d)(5)
shall be equal to the provisional FY19 per capita target
amount for the 1903A enrollee category described in
subsection (e)(2)(E).
``(3) In case of state failure to report necessary data.--
If a State for any quarter in a fiscal year (beginning with
fiscal year 2019) fails to satisfactorily submit data on
expenditures and enrollees in accordance with subsection
(h)(1), for such fiscal year and any succeeding fiscal year
for which such data are not satisfactorily submitted--
``(A) the Secretary shall calculate and apply subsections
(a) through (e) with respect to the State as if all 1903A
enrollee categories for which such expenditure and enrollee
data were not satisfactorily submitted were a single 1903A
enrollee category; and
``(B) the growth factor otherwise applied under subsection
(c)(2)(B) shall be decreased by 1 percentage point.
``(g) Recalculation of Certain Amounts for Data Errors.--
The amounts and percentage calculated under paragraphs (1)
and (4)(C) of subsection (d) for a State for fiscal year
2016, and the amounts of the adjusted total medical
assistance expenditures calculated under subsection (b) and
the number of Medicaid enrollees and 1903A enrollees
determined under subsection (e)(4) for a State for fiscal
year 2016, fiscal year 2019, and any subsequent fiscal year,
may be adjusted by the Secretary based upon an appeal (filed
by the State in such a form, manner, and time, and containing
such information relating to data errors that support such
appeal, as the Secretary specifies) that the Secretary
determines to be valid, except that any adjustment by the
Secretary under this subsection for a State may not result in
an increase of the target total medical assistance
expenditures exceeding 2 percent.
``(h) Required Reporting and Auditing of CMS-64 Data;
Transitional Increase in Federal Matching Percentage for
Certain Administrative Expenses.--
``(1) Reporting.--In addition to the data required on form
Group VIII on the CMS-64 report form as of January 1, 2017,
in each CMS-64 report required to be submitted (for each
quarter beginning on or after October 1, 2018), the State
shall include data on medical assistance expenditures within
such categories of services and categories of enrollees
(including each 1903A enrollee category and each category of
excluded individuals under subsection (e)(1)) and the numbers
of enrollees within each of such enrollee categories, as the
Secretary determines are necessary (including timely guidance
published as soon as possible after the date of the enactment
of this section) in order to implement this section and to
enable States to comply with the requirement of this
paragraph on a timely basis.
``(2) Auditing.--The Secretary shall conduct for each State
an audit of the number of individuals and expenditures
reported through the CMS-64 report for fiscal year 2016,
fiscal year 2019, and each subsequent fiscal year, which
audit may be conducted on a representative sample (as
determined by the Secretary).
``(3) Temporary increase in federal matching percentage to
support improved data reporting systems for fiscal years 2018
and 2019.--For amounts expended during calendar quarters
beginning on or after October 1, 2017, and before October 1,
2019--
``(A) the Federal matching percentage applied under section
1903(a)(3)(A)(i) shall be increased by 10 percentage points
to 100 percent;
``(B) the Federal matching percentage applied under section
1903(a)(3)(B) shall be increased by 25 percentage points to
100 percent; and
``(C) the Federal matching percentage applied under section
1903(a)(7) shall be increased by 10 percentage points to 60
percent but only with respect to amounts expended that are
attributable to a State's additional administrative
expenditures to implement the data requirements of paragraph
(1).
``(i) Flexible Block Grant Option for States.--
``(1) In general.--In the case of a State that elects the
option of applying this subsection for a 10-fiscal-year
period (beginning no earlier than fiscal year 2020 and, at
the State option, for any succeeding 10-fiscal-year period)
and that has a plan approved by the Secretary under paragraph
(2) to carry out the option for such period--
``(A) the State shall receive, instead of amounts otherwise
payable to the State under this title for medical assistance
for block grant individuals within the applicable block grant
category (as defined in paragraph (6)) for the State during
the period in which the election is in effect, the amount
specified in paragraph (4);
``(B) the previous provisions of this section shall be
applied as if--
``(i) block grant individuals within the applicable block
grant category for the State and period were not section
1903A enrollees for each 10-fiscal year period for which the
State elects to apply this subsection; and
``(ii) if such option is not extended at the end of a 10-
fiscal-year-period, the per capita limitations under such
previous provisions shall again apply after such period and
such limitations shall be applied as if the election under
this subsection had never taken place;
``(C) the payment under this subsection may only be used
consistent with the State plan under paragraph (2) for block
grant health care assistance (as defined in paragraph (7));
and
``(D) with respect to block grant individuals within the
applicable block grant category for the State for which block
grant health care assistance is made available under this
subsection, such assistance shall be instead of medical
assistance otherwise provided to the individual under this
title.
``(2) State plan for administering block grant option.--
``(A) In general.--No payment shall be made under this
subsection to a State pursuant to an election for a 10-
fiscal-year period under paragraph (1) unless the State has a
plan, approved under subparagraph (B), for such period that
specifies--
``(i) the applicable block grant category with respect to
which the State will apply the option under this subsection
for such period;
``(ii) the conditions for eligibility of block grant
individuals within such applicable block grant category for
block grant health care assistance under the option, which
shall be instead of other conditions for eligibility under
this title, except that in the case of a State that has
elected the applicable block grant category described in--

``(I) subparagraph (A) of paragraph (6), the plan must
provide for eligibility for pregnant women and children
required to be provided medical assistance under subsections
(a)(10)(A)(i) and (e)(4) of section 1902; or
``(II) subparagraph (B) of paragraph (6), the plan must
provide for eligibility for pregnant women required to be
provided medical assistance under subsection (a)(10)(A)(i);
and

``(iii) the types of items and services, the amount,
duration, and scope of such services, the cost-sharing with
respect to such services, and the method for delivery of
block grant health care assistance under this subsection,
which shall be instead of the such types, amount, duration,
and scope, cost-sharing, and methods of delivery for medical
assistance otherwise required under this title, except that
the plan must provide for assistance for--

``(I) hospital care;
``(II) surgical care and treatment;
``(III) medical care and treatment;
``(IV) obstetrical and prenatal care and treatment;
``(V) prescribed drugs, medicines, and prosthetic devices;
``(VI) other medical supplies and services; and
``(VII) health care for children under 18 years of age.

``(B) Review and approval.--A plan described in
subparagraph (A) shall be deemed approved by the Secretary
unless the Secretary determines, within 30 days after the
date of the Secretary's receipt of the plan, that the plan is
incomplete or actuarially unsound and, with respect to such
plan and its implementation under this subsection, the
requirements of paragraphs (1), (10)(B), (17), and (23) of
section 1902(a) shall not apply.
``(3) Amount of block grant funds.--

[[Page H2399]]

``(A) For initial fiscal year.--The block grant amount
under this paragraph for a State for the initial fiscal year
in the first 10-fiscal-year period is equal to the sum of the
products (for each applicable block grant category for such
State and period) of--
``(i) the target per capita medical assistance expenditures
for such State for such fiscal year (under subsection
(c)(2));
``(ii) the number of 1903A enrollees for such category and
State for fiscal year 2019, as determined under subsection
(e)(4); and
``(iii) the Federal average medical assistance matching
percentage (as defined in subsection (a)(4)) for the State
for fiscal year 2019.
``(B) For any subsequent fiscal year.--The block grant
amount under this paragraph for a State for each succeeding
fiscal year (in any 10-fiscal-year period) is equal to the
block grant amount under subparagraph (A) (or this
subparagraph) for the State for the previous fiscal year
increased by the annual increase in the consumer price index
for all urban consumers (all items; U.S. city average) for
the fiscal year involved.
``(C) Availability of rollover funds.--The block grant
amount under this paragraph for a State for a fiscal year
shall remain available to the State for expenditures under
this subsection for the succeeding fiscal year but only if an
election is in effect under this subsection for the State in
such succeeding fiscal year.
``(4) Federal payment and state responsibility.--The
Secretary shall pay to each State with an election in effect
under this subsection for a fiscal year, from its block grant
amount under paragraph (3) available for such fiscal year, an
amount for each quarter of such fiscal year equal to the
enhanced FMAP described in the first sentence of section
2105(b) of the total amount expended under the State plan
under this subsection during such quarter, and the State is
responsible for the balance of funds to carry out such plan.
``(5) Block grant individual defined.--In this subsection,
the term `block grant individual' means, with respect to a
State for a 10-fiscal-year period, an individual who is not
disabled (as defined for purposes of the State plan) and who
is within an applicable block grant category for the State
and such period.
``(6) Applicable block grant category defined.--In this
subsection, the term `applicable block grant category' means
with respect to a State for a 10-fiscal-year period, either
of the following as specified by the State for such period in
its plan under paragraph (2)(A)(i):
``(A) 2 enrollee categories.--Both of the following 1903A
enrollee categories:
``(i) Children.--The 1903A enrollee category specified in
subparagraph (C) of subsection (e)(2).
``(ii) Other nonelderly, nondisabled, non-expansion
adults.--The 1903A enrollee category specified in
subparagraph (E) of such subsection.
``(B) Other nonelderly, nondisabled, non-expansion
adults.--Only the 1903A enrollee category specified in
subparagraph (E) of subsection (e)(2).
``(7) Block grant health care assistance.--In this
subsection, the term `block grant health care assistance'
means assistance for health-care-related items and medical
services for block grant individuals within the applicable
block grant category for the State and 10-fiscal-year period
involved who are low-income individuals (as defined by the
State).
``(8) Auditing.--As a condition of receiving funds under
this subsection, a State shall contract with an independent
entity to conduct audits of its expenditures made with
respect to activities funded under this subsection for each
fiscal year for which the State elects to apply this
subsection to ensure that such funds are used consistent with
this subsection and shall make such audits available to the
Secretary upon the request of the Secretary.''.

Subtitle D--Patient Relief and Health Insurance Market Stability

SEC. 131. REPEAL OF COST-SHARING SUBSIDY.

(a) In General.--Section 1402 of the Patient Protection and
Affordable Care Act is repealed.
(b) Effective Date.--The repeal made by subsection (a)
shall apply to cost-sharing reductions (and payments to
issuers for such reductions) for plan years beginning after
December 31, 2019.

SEC. 132. PATIENT AND STATE STABILITY FUND.

The Social Security Act (42 U.S.C. 301 et seq.) is amended
by adding at the end the following new title:

``TITLE XXII--PATIENT AND STATE STABILITY FUND

``SEC. 2201. ESTABLISHMENT OF PROGRAM.

``There is hereby established the `Patient and State
Stability Fund' to be administered by the Secretary of Health
and Human Services, acting through the Administrator of the
Centers for Medicare & Medicaid Services (in this section
referred to as the `Administrator'), to provide funding, in
accordance with this title, to the 50 States and the District
of Columbia (each referred to in this section as a `State')
during the period, subject to section 2204(c), beginning on
January 1, 2018, and ending on December 31, 2026, for the
purposes described in section 2202.

``SEC. 2202. USE OF FUNDS.

``(a) In General.--Subject to subsection (b), a State may
use the funds allocated to the State under this title for any
of the following purposes:
``(1) Helping, through the provision of financial
assistance, high-risk individuals who do not have access to
health insurance coverage offered through an employer enroll
in health insurance coverage in the individual market in the
State, as such market is defined by the State (whether
through the establishment of a new mechanism or maintenance
of an existing mechanism for such purpose).
``(2) Providing incentives to appropriate entities to enter
into arrangements with the State to help stabilize premiums
for health insurance coverage in the individual market, as
such markets are defined by the State.
``(3) Reducing the cost for providing health insurance
coverage in the individual market and small group market, as
such markets are defined by the State, to individuals who
have, or are projected to have, a high rate of utilization of
health services (as measured by cost) and to individuals who
have high costs of health insurance coverage due to the low
density population of the State in which they reside.
``(4) Promoting participation in the individual market and
small group market in the State and increasing health
insurance options available through such market.
``(5) Promoting access to preventive services; dental care
services (whether preventive or medically necessary); vision
care services (whether preventive or medically necessary); or
any combination of such services.
``(6) Maternity coverage and newborn care.
``(7) Prevention, treatment, or recovery support services
for individuals with mental or substance use disorders,
focused on either or both of the following:
``(A) Direct inpatient or outpatient clinical care for
treatment of addiction and mental illness.
``(B) Early identification and intervention for children
and young adults with serious mental illness.
``(8) Providing payments, directly or indirectly, to health
care providers for the provision of such health care services
as are specified by the Administrator.
``(9) Providing assistance to reduce out-of-pocket costs,
such as copayments, coinsurance, premiums, and deductibles,
of individuals enrolled in health insurance coverage in the
State.
``(b) Required Use of Increase in Allotment.--A State shall
use the additional allocation provided to the State from the
funds appropriated under the second sentence of section
2204(b) for each year only for the purposes described in
paragraphs (6) and (7) of subsection (a).

``SEC. 2203. STATE ELIGIBILITY AND APPROVAL; DEFAULT
SAFEGUARD.

``(a) Encouraging State Options for Allocations.--
``(1) In general.--To be eligible for an allocation of
funds under this title for a year during the period described
in section 2201 for use for one or more purposes described in
section 2202, a State shall submit to the Administrator an
application at such time (but, in the case of allocations for
2018, not later than 45 days after the date of the enactment
of this title and, in the case of allocations for a
subsequent year, not later than March 31 of the previous
year) and in such form and manner as specified by the
Administrator and containing--
``(A) a description of how the funds will be used for such
purposes;
``(B) a certification that the State will make, from non-
Federal funds, expenditures for such purposes in an amount
that is not less than the State percentage required for the
year under section 2204(e)(1); and
``(C) such other information as the Administrator may
require.
``(2) Automatic approval.--An application so submitted is
approved unless the Administrator notifies the State
submitting the application, not later than 60 days after the
date of the submission of such application, that the
application has been denied for not being in compliance with
any requirement of this title and of the reason for such
denial.
``(3) One-time application.--If an application of a State
is approved for a year, with respect to a purpose described
in section 2202, such application shall be treated as
approved, with respect to such purpose, for each subsequent
year through 2026.
``(4) Treatment as a state health care program.--Any
program receiving funds from an allocation for a State under
this title, including pursuant to subsection (b), shall be
considered to be a `State health care program' for purposes
of sections 1128, 1128A, and 1128B.
``(b) Default Federal Safeguard.--
``(1) In general.--
``(A) 2018.--For allocations made under this title for
2018, in the case of a State that does not submit an
application under subsection (a) by the 45-day submission
date applicable to such year under subsection (a)(1) and in
the case of a State that does submit such an application by
such date that is not approved, subject to section 2204(e),
the Administrator, in consultation with the State insurance
commissioner, shall use the allocation that would otherwise
be provided to the State under this title for such year, in
accordance with paragraph (2), for such State.
``(B) 2019 through 2026.--In the case of a State that does
not have in effect an approved application under this section
for 2019 or a subsequent year beginning during the period
described in section 2201, subject to

[[Page H2400]]

section 2204(e), the Administrator, in consultation with the
State insurance commissioner, shall use the allocation that
would otherwise be provided to the State under this title for
such year, in accordance with paragraph (2), for such State.
``(2) Required use for market stabilization payments to
issuers.--Subject to section 2204(a), an allocation for a
State made pursuant to paragraph (1) for a year shall be used
to carry out the purpose described in section 2202(2) in such
State by providing payments to appropriate entities described
in such section with respect to claims that exceed $50,000
(or, with respect to allocations made under this title for
2020 or a subsequent year during the period specified in
section 2201, such dollar amount specified by the
Administrator), but do not exceed $350,000 (or, with respect
to allocations made under this title for 2020 or a subsequent
year during such period, such dollar amount specified by the
Administrator), in an amount equal to 75 percent (or, with
respect to allocations made under this title for 2020 or a
subsequent year during such period, such percentage specified
by the Administrator) of the amount of such claims.

``SEC. 2204. ALLOCATIONS.

``(a) Appropriation.--For the purpose of providing
allocations for States (including pursuant to section
2203(b)) under this title there is appropriated, out of any
money in the Treasury not otherwise appropriated--
``(1) for 2018, $15,000,000,000;
``(2) for 2019, $15,000,000,000;
``(3) for 2020, $10,000,000,000;
``(4) for 2021, $10,000,000,000;
``(5) for 2022, $10,000,000,000;
``(6) for 2023, $10,000,000,000;
``(7) for 2024, $10,000,000,000;
``(8) for 2025, $10,000,000,000; and
``(9) for 2026, $10,000,000,000.
The amount otherwise appropriated under the previous sentence
for 2020 shall be increased by $15,000,000,000, to be used
and available under subsection (d) only for the purposes
described in paragraphs (6) and (7) of section 2202(a).
``(b) Allocations.--
``(1) Payment.--
``(A) In general.--From amounts appropriated under
subsection (a) for a year, the Administrator shall, with
respect to a State and not later than the date specified
under subparagraph (B) for such year, allocate, subject to
subsection (e), for such State (including pursuant to section
2203(b)) the amount determined for such State and year under
paragraph (2).
``(B) Specified date.--For purposes of subparagraph (A),
the date specified in this subparagraph is--
``(i) for 2018, the date that is 45 days after the date of
the enactment of this title; and
``(ii) for 2019 and subsequent years, January 1 of the
respective year.
``(2) Allocation amount determinations.--
``(A) For 2018 and 2019.--
``(i) In general.--For purposes of paragraph (1), the
amount determined under this paragraph for 2018 and 2019 for
a State is an amount equal to the sum of--

``(I) the relative incurred claims amount described in
clause (ii) for such State and year; and
``(II) the relative uninsured and issuer participation
amount described in clause (iv) for such State and year.

``(ii) Relative incurred claims amount.--For purposes of
clause (i), the relative incurred claims amount described in
this clause for a State for 2018 and 2019 is the product of--

``(I) 85 percent of the amount appropriated under
subsection (a) for the year; and
``(II) the relative State incurred claims proportion
described in clause (iii) for such State and year.

``(iii) Relative state incurred claims proportion.--The
relative State incurred claims proportion described in this
clause for a State and year is the amount equal to the ratio
of--

``(I) the adjusted incurred claims by the State, as
reported through the medical loss ratio annual reporting
under section 2718 of the Public Health Service Act for the
third previous year; to
``(II) the sum of such adjusted incurred claims for all
States, as so reported, for such third previous year.

``(iv) Relative uninsured and issuer participation
amount.--For purposes of clause (i), the relative uninsured
and issuer participation amount described in this clause for
a State for 2018 and 2019 is the product of--

``(I) 15 percent of the amount appropriated under
subsection (a) for the year; and
``(II) the relative State uninsured and issuer
participation proportion described in clause (v) for such
State and year.

``(v) Relative state uninsured and issuer participation
proportion.--The relative State uninsured and issuer
participation proportion described in this clause for a State
and year is--

``(I) in the case of a State not described in clause (vi)
for such year, 0; and
``(II) in the case of a State described in clause (vi) for
such year, the amount equal to the ratio of--

``(aa) the number of individuals residing in such State who
for the third preceding year were not enrolled in a health
plan or otherwise did not have health insurance coverage
(including through a Federal or State health program) and
whose income is below 100 percent of the poverty line
applicable to a family of the size involved; to
``(bb) the sum of the number of such individuals for all
States described in clause (vi) for the third preceding year.
``(vi) States described.--For purposes of clause (v), a
State is described in this clause, with respect to 2018 and
2019, if the State satisfies either of the following
criterion:

``(I) The ratio described in subclause (II) of clause (v)
that would be determined for such State by substituting
`2015' for each reference in such subclause to `the third
preceding year' and by substituting `all such States' for the
reference in item (bb) of such subclause to `all States
described in clause (vi)' is greater than the ratio described
in such subclause that would be determined for such State by
substituting `2013' for each reference in such subclause to
`the third preceding year' and by substituting `all such
States' for the reference in item (bb) of such subclause to
`all States described in clause (vi)'.
``(II) The State has fewer than three health insurance
issuers offering qualified health plans through the Exchange
for 2017.

``(B) For 2020 through 2026.--For purposes of paragraph
(1), the amount determined under this paragraph for a year
(beginning with 2020) during the period described in section
2201 for a State is an amount determined in accordance with
an allocation methodology specified by the Administrator
which--
``(i) takes into consideration the adjusted incurred claims
of such State, the number of residents of such State who for
the previous year were not enrolled in a health plan or
otherwise did not have health insurance coverage (including
through a Federal or State health program) and whose income
is below 100 percent of the poverty line applicable to a
family of the size involved, and the number of health
insurance issuers participating in the insurance market in
such State for such year;
``(ii) is established after consultation with health care
consumers, health insurance issuers, State insurance
commissioners, and other stakeholders and after taking into
consideration additional cost and risk factors that may
inhibit health care consumer and health insurance issuer
participation; and
``(iii) reflects the goals of improving the health
insurance risk pool, promoting a more competitive health
insurance market, and increasing choice for health care
consumers.
``(c) Annual Distribution of Previous Year's Remaining
Funds.-- In carrying out subsection (b), the Administrator
shall, with respect to a year (beginning with 2020 and ending
with 2027), not later than March 31 of such year--
``(1) determine the amount of funds, if any, from the
amounts appropriated under subsection (a) for the previous
year but not allocated for such previous year; and
``(2) if the Administrator determines that any funds were
not so allocated for such previous year, allocate such
remaining funds, in accordance with the allocation
methodology specified pursuant to subsection (b)(2)(B)--
``(A) to States that have submitted an application approved
under section 2203(a) for such previous year for any purpose
for which such an application was approved; and
``(B) for States for which allocations were made pursuant
to section 2203(b) for such previous year, to be used by the
Administrator for such States, to carry out the purpose
described in section 2202(2) in such States by providing
payments to appropriate entities described in such section
with respect to claims that exceed $1,000,000;
with, respect to a year before 2027, any remaining funds
being made available for allocations to States for the
subsequent year.
``(d) Availability.--Amounts appropriated under subsection
(a) for a year and allocated to States in accordance with
this section shall remain available for expenditure through
December 31, 2027.
``(e) Conditions for and Limitations on Receipt of Funds.--
The Secretary may not make an allocation under this title for
a State, with respect to a purpose described in section
2202--
``(1) in the case of an allocation that would be made to a
State pursuant to section 2203(a), if the State does not
agree that the State will make available non-Federal
contributions towards such purpose in an amount equal to--
``(A) for 2020, 7 percent of the amount allocated under
this subsection to such State for such year and purpose;
``(B) for 2021, 14 percent of the amount allocated under
this subsection to such State for such year and purpose;
``(C) for 2022, 21 percent of the amount allocated under
this subsection to such State for such year and purpose;
``(D) for 2023, 28 percent of the amount allocated under
this subsection to such State for such year and purpose;
``(E) for 2024, 35 percent of the amount allocated under
this subsection to such State for such year and purpose;
``(F) for 2025, 42 percent of the amount allocated under
this subsection to such State for such year and purpose; and
``(G) for 2026, 50 percent of the amount allocated under
this subsection to such State for such year and purpose;
``(2) in the case of an allocation that would be made for a
State pursuant to section 2203(b), if the State does not
agree that the State will make available non-Federal
contributions towards such purpose in an amount equal to--
``(A) for 2020, 10 percent of the amount allocated under
this subsection to such State for such year and purpose;

[[Page H2401]]

``(B) for 2021, 20 percent of the amount allocated under
this subsection to such State for such year and purpose; and
``(C) for 2022, 30 percent of the amount allocated under
this subsection to such State for such year and purpose;
``(D) for 2023, 40 percent of the amount allocated under
this subsection to such State for such year and purpose;
``(E) for 2024, 50 percent of the amount allocated under
this subsection to such State for such year and purpose;
``(F) for 2025, 50 percent of the amount allocated under
this subsection to such State for such year and purpose; and
``(G) for 2026, 50 percent of the amount allocated under
this subsection to such State for such year and purpose; or
``(3) if such an allocation for such purpose would not be
permitted under subsection (c)(7) of section 2105 if such
allocation were payment made under such section.''.

SEC. 133. CONTINUOUS HEALTH INSURANCE COVERAGE INCENTIVE.

Subpart I of part A of title XXVII of the Public Health
Service Act is amended--
(1) in section 2701(a)(1)(B), by striking ``such rate'' and
inserting ``subject to section 2710A, such rate'';
(2) by redesignating the second section 2709 as section
2710; and
(3) by adding at the end the following new section:

``SEC. 2710A. ENCOURAGING CONTINUOUS HEALTH INSURANCE
COVERAGE.

``(a) Penalty Applied.--
``(1) In general.--Notwithstanding section 2701, subject to
the succeeding provisions of this section, a health insurance
issuer offering health insurance coverage in the individual
market shall, in the case of an individual who is an
applicable policyholder of such coverage with respect to an
enforcement period applicable to enrollments for a plan year
beginning with plan year 2019 (or, in the case of enrollments
during a special enrollment period, beginning with plan year
2018), increase the monthly premium rate otherwise applicable
to such individual for such coverage during each month of
such period, by an amount determined under paragraph (2).
``(2) Amount of penalty.--The amount determined under this
paragraph for an applicable policyholder enrolling in health
insurance coverage described in paragraph (1) for a plan
year, with respect to each month during the enforcement
period applicable to enrollments for such plan year, is the
amount that is equal to 30 percent of the monthly premium
rate otherwise applicable to such applicable policyholder for
such coverage during such month.
``(b) Definitions.--For purposes of this section:
``(1) Applicable policyholder.--The term `applicable
policyholder' means, with respect to months of an enforcement
period and health insurance coverage, an individual who--
``(A) is a policyholder of such coverage for such months;
``(B) cannot demonstrate that (through presentation of
certifications described in section 2704(e) or in such other
manner as may be specified in regulations, such as a return
or statement made under section 6055(d) or 36B of the
Internal Revenue Code of 1986), during the look-back period
that is with respect to such enforcement period, there was
not a period of at least 63 continuous days during which the
individual did not have creditable coverage (as defined in
paragraph (1) of section 2704(c) and credited in accordance
with paragraphs (2) and (3) of such section); and
``(C) in the case of an individual who had been enrolled
under dependent coverage under a group health plan or health
insurance coverage by reason of section 2714 and such
dependent coverage of such individual ceased because of the
age of such individual, is not enrolling during the first
open enrollment period following the date on which such
coverage so ceased.
``(2) Look-back period.--The term `look-back period' means,
with respect to an enforcement period applicable to an
enrollment of an individual for a plan year beginning with
plan year 2019 (or, in the case of an enrollment of an
individual during a special enrollment period, beginning with
plan year 2018) in health insurance coverage described in
subsection (a)(1), the 12-month period ending on the date the
individual enrolls in such coverage for such plan year.
``(3) Enforcement period.--The term `enforcement period'
means--
``(A) with respect to enrollments during a special
enrollment period for plan year 2018, the period beginning
with the first month that is during such plan year and that
begins subsequent to such date of enrollment, and ending with
the last month of such plan year; and
``(B) with respect to enrollments for plan year 2019 or a
subsequent plan year, the 12-month period beginning on the
first day of the respective plan year.''.

SEC. 134. INCREASING COVERAGE OPTIONS.

Section 1302 of the Patient Protection and Affordable Care
Act (42 U.S.C. 18022) is amended--
(1) in subsection (a)(3), by inserting ``and with respect
to a plan year before plan year 2020'' after ``subsection
(e)''; and
(2) in subsection (d), by adding at the end the following:
``(5) Sunset.--The provisions of this subsection shall not
apply after December 31, 2019, and after such date any
reference to this subsection or level of coverage or plan
described in this subsection and any requirement under law
applying such a level of coverage or plan shall have no force
or effect (and such a requirement shall be applied as if this
section had been repealed).''.

SEC. 135. CHANGE IN PERMISSIBLE AGE VARIATION IN HEALTH
INSURANCE PREMIUM RATES.

Section 2701(a)(1)(A)(iii) of the Public Health Service Act
(42 U.S.C. 300gg(a)(1)(A)(iii)), as inserted by section
1201(4) of the Patient Protection and Affordable Care Act, is
amended by inserting after ``(consistent with section
2707(c))'' the following: ``or, for plan years beginning on
or after January 1, 2018, as the Secretary may implement
through interim final regulation, 5 to 1 for adults
(consistent with section 2707(c)) or such other ratio for
adults (consistent with section 2707(c)) as the State
involved may provide''.

SEC. 136. ESSENTIAL HEALTH BENEFITS DEFINED BY THE STATES.

Section 1302 of the Patient Protection and Affordable Care
Act (42 U.S.C. 18022) is amended--
(1) in subsection (a)(1), by striking ``by the Secretary'';
and
(2) in subsection (b)--
(A) in paragraph (1), by striking ``paragraph (2)'' and
inserting ``paragraphs (2) and (6)''; and
(B) by adding at the end the following new paragraph:
``(6) Essential health benefits for plan and taxable years
beginning on or after january 1, 2018.--For plan years and
taxable years beginning on or after January 1, 2018, each
State shall define the essential health benefits with respect
to health plans offered in such State, for the purposes of
section 36B of the Internal Revenue Code of 1986.''.

Subtitle E--Implementation Funding

SEC. 141. AMERICAN HEALTH CARE IMPLEMENTATION FUND.

(a) In General.--There is hereby established an American
Health Care Implementation Fund (referred to in this section
as the ``Fund'') within the Department of Health and Human
Services to carry out sections 121, 132, 202, and 214
(including the amendments made by such sections).
(b) Funding.--There is appropriated to the Fund, out of any
funds in the Treasury not otherwise appropriated,
$1,000,000,000 for Federal administrative expenses to carry
out the sections described in subsection (a) (including the
amendments made by such sections).

TITLE II--COMMITTEE ON WAYS AND MEANS

Subtitle A--Repeal and Replace of Health-Related Tax Policy

SEC. 201. RECAPTURE EXCESS ADVANCE PAYMENTS OF PREMIUM TAX
CREDITS.

Subparagraph (B) of section 36B(f)(2) of the Internal
Revenue Code of 1986 is amended by adding at the end the
following new clause:
``(iii) Nonapplicability of limitation.--This subparagraph
shall not apply to taxable years beginning after December 31,
2017, and before January 1, 2020.''.

SEC. 202. ADDITIONAL MODIFICATIONS TO PREMIUM TAX CREDIT.

(a) Modification of Definition of Qualified Health Plan.--
(1) In general.--Section 36B(c)(3)(A) of the Internal
Revenue Code of 1986 is amended--
(A) by inserting ``(determined without regard to
subparagraphs (A), (C)(ii), and (C)(iv) of paragraph (1)
thereof and without regard to whether the plan is offered on
an Exchange)'' after ``1301(a) of the Patient Protection and
Affordable Care Act'', and
(B) by striking ``shall not include'' and all that follows
and inserting ``shall not include any health plan that--
``(i) is a grandfathered health plan or a grandmothered
health plan, or
``(ii) includes coverage for abortions (other than any
abortion necessary to save the life of the mother or any
abortion with respect to a pregnancy that is the result of an
act of rape or incest).''.
(2) Definition of grandmothered health plan.--Section
36B(c)(3) of such Code is amended by adding at the end the
following new subparagraph:
``(C) Grandmothered health plan.--
``(i) In general.--The term `grandmothered health plan'
means health insurance coverage which is offered in the
individual health insurance market as of October 1, 2013, and
is permitted to be offered in such market after January 1,
2014, as a result of CCIIO guidance.
``(ii) CCIIO guidance defined.--The term `CCIIO guidance'
means the letter issued by the Centers for Medicare &
Medicaid Services on November 14, 2013, to the State
Insurance Commissioners outlining a transitional policy for
non-grandfathered coverage in the individual health insurance
market, as subsequently extended and modified (including by a
communication entitled `Insurance Standards Bulletin Series--
INFORMATION--Extension of Transitional Policy through
Calendar Year 2017' issued on February 29, 2016, by the
Director of the Center for Consumer Information & Insurance
Oversight of such Centers).
``(iii) Individual health insurance market.--The term
`individual health insurance market' means the market for
health insurance coverage (as defined in section 9832(b))
offered to individuals other than in connection with a group
health plan (within the meaning of section 5000(b)(1)).''.
(3) Conforming amendment related to abortion coverage.--
Section 36B(c)(3) of

[[Page H2402]]

such Code, as amended by paragraph (2), is amended by adding
at the end the following new subparagraph:
``(D) Certain rules related to abortion.--
``(i) Option to purchase separate coverage or plan.--
Nothing in subparagraph (A) shall be construed as prohibiting
any individual from purchasing separate coverage for
abortions described in such subparagraph, or a health plan
that includes such abortions, so long as no credit is allowed
under this section with respect to the premiums for such
coverage or plan.
``(ii) Option to offer coverage or plan.--Nothing in
subparagraph (A) shall restrict any health insurance issuer
offering a health plan from offering separate coverage for
abortions described in such subparagraph, or a plan that
includes such abortions, so long as premiums for such
separate coverage or plan are not paid for with any amount
attributable to the credit allowed under this section (or the
amount of any advance payment of the credit under section
1412 of the Patient Protection and Affordable Care Act).
``(iii) Other treatments.--The treatment of any infection,
injury, disease, or disorder that has been caused by or
exacerbated by the performance of an abortion shall not be
treated as an abortion for purposes of subparagraph (A).''.
(4) Conforming amendments related to off-exchange
coverage.--
(A) Advance payment not applicable.--Section 1412 of the
Patient Protection and Affordable Care Act is amended by
adding at the end the following new subsection:
``(f) Exclusion of Off-Exchange Coverage.--Advance payments
under this section, and advance determinations under section
1411, with respect to any credit allowed under section 36B
shall not be made with respect to any health plan which is
not enrolled in through an Exchange.''.
(B) Reporting.--Section 6055(b) of the Internal Revenue
Code of 1986 is amended by adding at the end the following
new paragraph:
``(3) Information relating to off-exchange premium credit
eligible coverage.--If minimum essential coverage provided to
an individual under subsection (a) consists of a qualified
health plan (as defined in section 36B(c)(3)) which is not
enrolled in through an Exchange established under title I of
the Patient Protection and Affordable Care Act, a return
described in this subsection shall include--
``(A) a statement that such plan is a qualified health plan
(as defined in section 36B(c)(3)),
``(B) the premiums paid with respect to such coverage,
``(C) the months during which such coverage is provided to
the individual,
``(D) the adjusted monthly premium for the applicable
second lowest cost silver plan (as defined in section
36B(b)(3)) for each such month with respect to such
individual, and
``(E) such other information as the Secretary may
prescribe.''.
(C) Other conforming amendments.--
(i) Section 36B(b)(2)(A) of such Code is amended by
striking ``and which were enrolled'' and all that follows and
inserting ``, or''.
(ii) Section 36B(b)(3)(B)(i) of such Code is amended by
striking ``the same Exchange'' and all that follows and
inserting ``the Exchange through which such taxpayer is
permitted to obtain coverage, and''.
(iii) Section 36B(c)(2)(A)(i) of such Code is amended by
striking ``that was enrolled in through an Exchange
established by the State under section 1311 of the Patient
Protection and Affordable Care Act''.
(b) Modification of Applicable Percentage.--Section
36B(b)(3)(A) of such Code is amended to read as follows:
``(A) Applicable percentage.--
``(i) In general.--The applicable percentage for any
taxable year shall be the percentage such that the applicable
percentage for any taxpayer whose household income is within
an income tier specified in the following table shall
increase, on a sliding scale in a linear manner, from the
initial percentage to the final percentage specified in such
table for such income tier with respect to a taxpayer of the
age involved:

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
``In the case of Up to Age 29 Age 30-39 Age 40-49 Age 50-59 Over Age 59
household income ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(expressed as a
percent of the
poverty line)
within the Initial % Final % Initial % Final % Initial % Final % Initial % Final % Initial % Final %
following income
tier:
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Up to 133% 2............... 2............... 2............... 2.............. 2.............. 2.............. 2.............. 2.............. 2.............. 2
133%-150% 3............... 4............... 3............... 4.............. 3.............. 4.............. 3.............. 4.............. 3.............. 4
150%-200% 4............... 4.3............. 4............... 5.3............ 4.............. 6.3............ 4.............. 7.3............ 4.............. 8.3
200%-250% 4.3............. 4.3............. 5.3............. 5.9............ 6.3............ 8.05........... 7.3............ 9.............. 8.3............ 10
250%-300% 4.3............. 4.3............. 5.9............. 5.9............ 8.05........... 8.35........... 9.............. 10.5........... 10............. 11.5
300%-400% 4.3............. 4.3............. 5.9............. 5.9............ 8.35........... 8.35........... 10.5........... 10.5........... 11.5........... 11.5
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

``(ii) Age determinations.--

``(I) In general.--For purposes of clause (i), the age of
the taxpayer taken into account under clause (i) with respect
to any taxable year is the age attained by such taxpayer
before the close of such taxable year.
``(II) Joint returns.--In the case of a joint return, the
age of the older spouse shall be taken into account under
clause (i).

``(iii) Indexing.--In the case of any taxable year
beginning in calendar year 2019, the initial and final
percentages contained in clause (i) shall be adjusted to
reflect--

``(I) the excess (if any) of the rate of premium growth for
the period beginning with calendar year 2013 and ending with
calendar year 2018, over the rate of income growth for such
period, and
``(II) in addition to any adjustment under subclause (I),
the excess (if any) of the rate of premium growth for
calendar year 2018, over the rate of growth in the consumer
price index for calendar year 2018.

``(iv) Failsafe.--Clause (iii)(II) shall apply only if the
aggregate amount of premium tax credits under this section
and cost-sharing reductions under section 1402 of the Patient
Protection and Affordable Care Act for calendar year 2018
exceeds an amount equal to 0.504 percent of the gross
domestic product for such calendar year.''.
(c) Effective Date.--
(1) In general.--Except as otherwise provided in this
subsection, the amendments made by this section shall apply
to taxable years beginning after December 31, 2017.
(2) Advance payment not applicable to off-exchange
coverage.--The amendment made by subsection (a)(4)(A) shall
take effect on January 1, 2018.
(3) Reporting.--The amendment made by subsection (a)(4)(B)
shall apply to coverage provided for months beginning after
December 31, 2017.
(4) Modification of applicable percentage.--The amendment
made by subsection (b) shall apply to taxable years beginning
after December 31, 2018.

SEC. 203. SMALL BUSINESS TAX CREDIT.

(a) In General.--Section 45R of the Internal Revenue Code
of 1986 is amended by adding at the end the following new
subsection:
``(j) Shall Not Apply.--This section shall not apply with
respect to amounts paid or incurred in taxable years
beginning after December 31, 2019.''.
(b) Disallowance of Small Employer Health Insurance Expense
Credit for Plan Which Includes Coverage for Abortion.--
Subsection (h) of section 45R of the Internal Revenue Code of
1986 is amended--
(1) by striking ``Any term'' and inserting the following:
``(1) In general.--Any term''; and
(2) by adding at the end the following new paragraph:
``(2) Exclusion of health plans including coverage for
abortion.--
``(A) In general.--The term `qualified health plan' does
not include any health plan that includes coverage for
abortions (other than any abortion necessary to save the life
of the mother or any abortion with respect to a pregnancy
that is the result of an act of rape or incest) .
``(B) Certain rules related to abortion.--
``(i) Option to purchase separate coverage or plan.--
Nothing in subparagraph (A) shall be construed as prohibiting
any employer from purchasing for its employees separate
coverage for abortions described in such subparagraph, or a
health plan that includes such abortions, so long as no
credit is allowed under this section with respect to the
employer contributions for such coverage or plan.
``(ii) Option to offer coverage or plan.--Nothing in
subparagraph (A) shall restrict any health insurance issuer
offering a health plan from offering separate coverage for
abortions described in such subparagraph, or a plan that
includes such abortions, so long as such separate coverage or
plan is not paid for with any employer contribution eligible
for the credit allowed under this section.
``(iii) Other treatments.--The treatment of any infection,
injury, disease, or disorder that has been caused by or
exacerbated by the performance of an abortion shall not be
treated as an abortion for purposes of subparagraph (A).''.
(c) Effective Dates.--
(1) In general.--The amendment made by subsection (a) shall
apply to taxable years beginning after December 31, 2019.
(2) Disallowance of small employer health insurance expense
credit for plan which includes coverage for abortion.--The
amendments made by subsection (b)

[[Page H2403]]

shall apply to taxable years beginning after December 31,
2017.

SEC. 204. INDIVIDUAL MANDATE.

(a) In General.--Section 5000A(c) of the Internal Revenue
Code of 1986 is amended--
(1) in paragraph (2)(B)(iii), by striking ``2.5 percent''
and inserting ``Zero percent'', and
(2) in paragraph (3)--
(A) by striking ``$695'' in subparagraph (A) and inserting
``$0'', and
(B) by striking subparagraph (D).
(b) Effective Date.--The amendments made by this section
shall apply to months beginning after December 31, 2015.

SEC. 205. EMPLOYER MANDATE.

(a) In General.--
(1) Paragraph (1) of section 4980H(c) of the Internal
Revenue Code of 1986 is amended by inserting ``($0 in the
case of months beginning after December 31, 2015)'' after
``$2,000''.
(2) Paragraph (1) of section 4980H(b) of the Internal
Revenue Code of 1986 is amended by inserting ``($0 in the
case of months beginning after December 31, 2015)'' after
``$3,000''.
(b) Effective Date.--The amendments made by this section
shall apply to months beginning after December 31, 2015.

SEC. 206. REPEAL OF THE TAX ON EMPLOYEE HEALTH INSURANCE
PREMIUMS AND HEALTH PLAN BENEFITS.

Section 4980I of the Internal Revenue Code of 1986 is
amended by adding at the end the following new subsection:
``(h) Shall Not Apply.--No tax shall be imposed under this
section with respect to any taxable period beginning after
December 31, 2019, and before January 1, 2026.''.

SEC. 207. REPEAL OF TAX ON OVER-THE-COUNTER MEDICATIONS.

(a) HSAs.--Subparagraph (A) of section 223(d)(2) of the
Internal Revenue Code of 1986 is amended by striking ``Such
term'' and all that follows through the period.
(b) Archer MSAs.--Subparagraph (A) of section 220(d)(2) of
the Internal Revenue Code of 1986 is amended by striking
``Such term'' and all that follows through the period.
(c) Health Flexible Spending Arrangements and Health
Reimbursement Arrangements.--Section 106 of the Internal
Revenue Code of 1986 is amended by striking subsection (f)
and by redesignating subsection (g) as subsection (f).
(d) Effective Dates.--
(1) Distributions from savings accounts.--The amendments
made by subsections (a) and (b) shall apply to amounts paid
with respect to taxable years beginning after December 31,
2016.
(2) Reimbursements.--The amendment made by subsection (c)
shall apply to expenses incurred with respect to taxable
years beginning after December 31, 2016.

SEC. 208. REPEAL OF INCREASE OF TAX ON HEALTH SAVINGS
ACCOUNTS.

(a) HSAs.--Section 223(f)(4)(A) of the Internal Revenue
Code of 1986 is amended by striking ``20 percent'' and
inserting ``10 percent''.
(b) Archer MSAs.--Section 220(f)(4)(A) of the Internal
Revenue Code of 1986 is amended by striking ``20 percent''
and inserting ``15 percent''.
(c) Effective Date.--The amendments made by this section
shall apply to distributions made after December 31, 2016.

SEC. 209. REPEAL OF LIMITATIONS ON CONTRIBUTIONS TO FLEXIBLE
SPENDING ACCOUNTS.

(a) In General.--Section 125 of the Internal Revenue Code
of 1986 is amended by striking subsection (i).
(b) Effective Date.--The amendment made by this section
shall apply to taxable years beginning after December 31,
2016.

SEC. 210. REPEAL OF MEDICAL DEVICE EXCISE TAX.

Section 4191 of the Internal Revenue Code of 1986 is
amended by adding at the end the following new subsection:
``(d) Applicability.--The tax imposed under subsection (a)
shall not apply to sales after December 31, 2016.''.

SEC. 211. REPEAL OF ELIMINATION OF DEDUCTION FOR EXPENSES
ALLOCABLE TO MEDICARE PART D SUBSIDY.

(a) In General.--Section 139A of the Internal Revenue Code
of 1986 is amended by adding at the end the following new
sentence: ``This section shall not be taken into account for
purposes of determining whether any deduction is allowable
with respect to any cost taken into account in determining
such payment.''.
(b) Effective Date.--The amendment made by this section
shall apply to taxable years beginning after December 31,
2016.

SEC. 212. REDUCTION OF INCOME THRESHOLD FOR DETERMINING
MEDICAL CARE DEDUCTION.

(a) In General.--Subsection (a) of section 213 of the
Internal Revenue Code of 1986 is amended by striking ``10
percent'' and inserting ``5.8 percent''.
(b) Effective Date.--The amendment made by this section
shall apply to taxable years beginning after December 31,
2016.

SEC. 213. REPEAL OF MEDICARE TAX INCREASE.

(a) In General.--Subsection (b) of section 3101 of the
Internal Revenue Code of 1986 is amended to read as follows:
``(b) Hospital Insurance.--In addition to the tax imposed
by the preceding subsection, there is hereby imposed on the
income of every individual a tax equal to 1.45 percent of the
wages (as defined in section 3121(a)) received by such
individual with respect to employment (as defined in section
3121(b)).''.
(b) SECA.--Subsection (b) of section 1401 of the Internal
Revenue Code of 1986 is amended to read as follows:
``(b) Hospital Insurance.--In addition to the tax imposed
by the preceding subsection, there shall be imposed for each
taxable year, on the self-employment income of every
individual, a tax equal to 2.9 percent of the amount of the
self-employment income for such taxable year.''.
(c) Effective Date.--The amendments made by this section
shall apply with respect to remuneration received after, and
taxable years beginning after, December 31, 2022.

SEC. 214. REFUNDABLE TAX CREDIT FOR HEALTH INSURANCE
COVERAGE.

(a) In General.--Section 36B of the Internal Revenue Code
of 1986 is amended to read as follows:

``SEC. 36B. REFUNDABLE CREDIT FOR COVERAGE UNDER A QUALIFIED
HEALTH PLAN.

``(a) Allowance of Premium Tax Credit.--In the case of an
individual, there shall be allowed as a credit against the
tax imposed by this subtitle for the taxable year the sum of
the monthly credit amounts with respect to such taxpayer for
calendar months during such taxable year which are eligible
coverage months appropriately taken into account under
subsection (b)(2) with respect to the taxpayer or any
qualifying family member of the taxpayer.
``(b) Monthly Credit Amounts.--
``(1) In general.--The monthly credit amount with respect
to any taxpayer for any calendar month is the lesser of--
``(A) the sum of the monthly limitation amounts determined
under subsection (c) with respect to the taxpayer and the
taxpayer's qualifying family members for such month, or
``(B) the amount paid for a qualified health plan for the
taxpayer and the taxpayer's qualifying family members for
such month.
``(2) Eligible coverage month requirement.--No amount shall
be taken into account under subparagraph (A) or (B) of
paragraph (1) with respect to any individual for any month
unless such month is an eligible coverage month with respect
to such individual.
``(c) Monthly Limitation Amounts.--
``(1) In general.--The monthly limitation amount with
respect to any individual for any eligible coverage month
during any taxable year is \1/12\ of--
``(A) $2,000 in the case of an individual who has not
attained age 30 as of the beginning of such taxable year,
``(B) $2,500 in the case of an individual who has attained
age 30 but who has not attained age 40 as of such time,
``(C) $3,000 in the case of an individual who has attained
age 40 but who has not attained age 50 as of such time,
``(D) $3,500 in the case of an individual who has attained
age 50 but who has not attained age 60 as of such time, and
``(E) $4,000 in the case of an individual who has attained
age 60 as of such time.
``(2) Limitation based on modified adjusted gross income.--
The credit allowed under subsection (a) with respect to any
taxpayer for any taxable year shall be reduced (but not below
zero) by 10 percent of the excess (if any) of--
``(A) the taxpayer's modified adjusted gross income (as
defined in section 36B(d)(2)(B), as in effect for taxable
years beginning before January 1, 2020) for such taxable
year, over
``(B) $75,000 (twice such amount in the case of a joint
return).
``(3) Other limitations.--
``(A) Aggregate dollar limitation.--The sum of the monthly
limitation amounts taken into account under this section with
respect to any taxpayer for any taxable year shall not exceed
$14,000.
``(B) Maximum number of individuals taken into account.--
With respect to any taxpayer for any month, monthly
limitation amounts shall be taken into account under this
section only with respect to the 5 oldest individuals with
respect to whom monthly limitation amounts could (without
regard to this subparagraph) otherwise be so taken into
account.
``(d) Eligible Coverage Month.--For purposes of this
section, the term `eligible coverage month' means, with
respect to any individual, any month if, as of the first day
of such month, the individual meets the following
requirements:
``(1) The individual is covered by a health insurance
coverage which is certified by the State in which such
insurance is offered as coverage that meets the requirements
for qualified health plans under subsection (f).
``(2) The individual is not eligible for--
``(A) coverage under a group health plan (within the
meaning of section 5000(b)(1)) other than coverage under a
plan substantially all of the coverage of which is of
excepted benefits described in section 9832(c), or
``(B) coverage described in section 5000A(f)(1)(A).
``(3) The individual is either--
``(A) a citizen or national of the United States, or
``(B) a qualified alien (within the meaning of section 431
of the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 (8 U.S.C. 1641)).
``(4) The individual is not incarcerated, other than
incarceration pending the disposition of charges.
``(e) Qualifying Family Member.--For purposes of this
section, the term `qualifying family member' means--
``(1) in the case of a joint return, the taxpayer's spouse,

[[Page H2404]]

``(2) any dependent of the taxpayer, and
``(3) with respect to any eligible coverage month, any
child (as defined in section 152(f)(1)) of the taxpayer who
as of the end of the taxable year has not attained age 27 if
such child is covered for such month under a qualified health
plan which also covers the taxpayer (in the case of a joint
return, either spouse).
``(f) Qualified Health Plan.--For purposes of this section,
the term `qualified health plan' means any health insurance
coverage (as defined in section 9832(b)) if--
``(1) such coverage is offered in the individual health
insurance market within a State (within the meaning of
section 5000A(f)(1)(C)),
``(2) substantially all of such coverage is not of excepted
benefits described in section 9832(c),
``(3) such coverage does not consist of short-term limited
duration insurance (within the meaning of section 2791(b)(5)
of the Public Health Service Act),
``(4) such coverage is not a grandfathered health plan (as
defined in section 1251 of the Patient Protection and
Affordable Care Act) or a grandmothered health plan (as
defined in section 36B(c)(3)(C) as in effect for taxable
years beginning before January 1, 2020), and
``(5) such coverage does not include coverage for abortions
(other than any abortion necessary to save the life of the
mother or any abortion with respect to a pregnancy that is
the result of an act of rape or incest).
``(g) Special Rules.--
``(1) Married couples must file joint return.--
``(A) In general.--Except as provided in subparagraph (B),
if the taxpayer is married (within the meaning of section
7703) at the close of the taxable year, no credit shall be
allowed under this section to such taxpayer unless such
taxpayer and the taxpayer's spouse file a joint return for
such taxable year.
``(B) Exception for certain taxpayers.--Subparagraph (A)
shall not apply to any married taxpayer who--
``(i) is living apart from the taxpayer's spouse at the
time the taxpayer files the tax return,
``(ii) is unable to file a joint return because such
taxpayer is a victim of domestic abuse or spousal
abandonment,
``(iii) certifies on the tax return that such taxpayer
meets the requirements of clauses (i) and (ii), and
``(iv) has not met the requirements of clauses (i), (ii),
and (iii) for each of the 3 preceding taxable years.
``(2) Denial of credit to dependents.--
``(A) In general.--No credit shall be allowed under this
section to any individual who is a dependent with respect to
another taxpayer for a taxable year beginning in the calendar
year in which such individual's taxable year begins.
``(B) Coordination with rule for older children.--In the
case of any individual who is a qualifying family member
described in subsection (e)(3) with respect to another
taxpayer for any month, in determining the amount of any
credit allowable to such individual under this section for
any taxable year of such individual which includes such
month, the monthly limitation amount with respect to such
individual for such month shall be zero and no amount paid
for any qualified health plan with respect to such individual
for such month shall be taken into account.
``(3) Coordination with medical expense deduction.--Amounts
described in subsection (b)(1)(B) with respect to any month
shall not be taken into account in determining the deduction
allowed under section 213 except to the extent that such
amounts exceed the amount described in subsection (b)(1)(A)
with respect to such month.
``(4) Coordination with advance payments of credit.--With
respect to any taxable year--
``(A) the amount which would (but for this subsection) be
allowed as a credit to the taxpayer under subsection (a)
shall be reduced (but not below zero) by the aggregate amount
paid on behalf of such taxpayer under section 1412 of the
Patient Protection and Affordable Care Act for months
beginning in such taxable year, and
``(B) the tax imposed by section 1 for such taxable year
shall be increased by the excess (if any) of--
``(i) the aggregate amount paid on behalf of such taxpayer
under such section 1412 for months beginning in such taxable
year, over
``(ii) the amount which would (but for this subsection) be
allowed as a credit to the taxpayer under subsection (a).
``(5) Special rules for qualified small employer health
reimbursement arrangements.--
``(A) In general.--If the taxpayer or any qualifying family
member of the taxpayer is provided a qualified small employer
health reimbursement arrangement for an eligible coverage
month, the sum determined under subsection (b)(1)(A) with
respect to the taxpayer shall be reduced (but not below zero)
by \1/12\ of the permitted benefit (as defined in section
9831(d)(3)(C)) under such arrangement for each such month
such arrangement is provided to such taxpayer.
``(B) Qualified small employer health reimbursement
arrangement.--For purposes of this paragraph, the term
`qualified small employer health reimbursement arrangement'
has the meaning given such term by section 9831(d)(2).
``(C) Coverage for less than entire year.--In the case of
an employee who is provided a qualified small employer health
reimbursement arrangement for less than an entire year,
subparagraph (A) shall be applied by substituting `the number
of months during the year for which such arrangement was
provided' for `12'.
``(6) Certain rules related to nonqualified health plans.--
The rules of section 36B(c)(3)(D), as in effect for taxable
years beginning before January 1, 2020, shall apply with
respect to subsection (f)(5).
``(7) Inflation adjustment.--
``(A) In general.--In the case of any taxable year
beginning in a calendar year after 2020, each dollar amount
in subsection (c)(1), the $75,000 amount in subsection
(c)(2)(B), and the dollar amount in subsection (c)(3)(A),
shall be increased by an amount equal to--
``(i) such dollar amount, multiplied by
``(ii) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year in which the taxable
year begins, determined--

``(I) by substituting `calendar year 2019' for `calendar
year 1992' in subparagraph (B) thereof, and
``(II) by substituting for the CPI referred to section
1(f)(3)(A) the amount that such CPI would have been if the
annual percentage increase in CPI with respect to each year
after 2019 had been one percentage point greater.

``(B) Terms related to cpi.--
``(i) Annual percentage increase.--For purposes of
subparagraph (A)(ii)(II), the term `annual percentage
increase' means the percentage (if any) by which CPI for any
year exceeds CPI for the prior year.
``(ii) Other terms.--Terms used in this paragraph which are
also used in section 1(f)(3) shall have the same meanings as
when used in such section.
``(C) Rounding.--Any increase determined under subparagraph
(A) shall be rounded to the nearest multiple of $50.
``(8) Rules related to state certification of qualified
health plans.--A certification shall not be taken into
account under subsection (d)(1) unless such certification is
made available to the public and meets such other
requirements as the Secretary may provide.
``(9) Regulations.--The Secretary may prescribe such
regulations and other guidance as may be necessary or
appropriate to carry out this section and section 1412 of the
Patient Protection and Affordable Care Act.''.
(b) Advance Payment of Credit.--Section 1412 of the Patient
Protection and Affordable Care Act is amended by adding at
the end the following new subsection:
``(f) Application to Certain Plans.--The Secretary and the
Secretary of the Treasury shall prescribe such regulations as
each respective Secretary may deem necessary in order to
establish and operate the advance payment program established
under this section for individuals covered under qualified
health plans (whether enrolled in through an Exchange or
otherwise) in such a manner that protects taxpayer
information (including names, taxpayer identification
numbers, and other confidential information), provides robust
verification of all information necessary to establish
eligibility of taxpayer for advance payments under this
section, ensures proper and timely payments to appropriate
health providers, and protects program integrity to the
maximum extent feasible.''.
(c) Increased Penalty on Erroneous Claims of Credit.--
Section 6676(a) of the Internal Revenue Code of 1986 is
amended by inserting ``(25 percent in the case of a claim for
refund or credit relating to the health insurance coverage
credit under section 36B)''.
(d) Reporting by Employers.--Section 6051(a) of such Code
is amended by striking ``and'' at the end of paragraph (14),
by striking the period at the end of paragraph (15) and
inserting ``, and'', and by inserting after paragraph (15)
the following new paragraph:
``(16) each month with respect to which the employee is
eligible for coverage described in section 36B(d)(2) in
connection with employment with the employer.''.
(e) Coordination With Other Tax Benefits.--
(1) Credit for health insurance costs of eligible
individuals.--Section 35(g) of such Code is amended by adding
at the end the following new paragraph:
``(14) Coordination with health insurance coverage
credit.--
``(A) In general.--An eligible coverage month to which the
election under paragraph (11) applies shall not be treated as
an eligible coverage month (as defined in section 36B(d)) for
purposes of section 36B with respect to the taxpayer or any
of the taxpayer's qualifying family members (as defined in
section 36B(e)).
``(B) Coordination with advance payments of health
insurance coverage credit.--In the case of a taxpayer who
makes the election under paragraph (11) with respect to any
eligible coverage month in a taxable year or on behalf of
whom any advance payment is made under section 7527 with
respect to any month in such taxable year--
``(i) the tax imposed by this chapter for the taxable year
shall be increased by the excess, if any, of--

``(I) the sum of any advance payments made on behalf of the
taxpayer under section 7527 and section 1412 of the Patient
Protection and Affordable Care Act, over
``(II) the sum of the credits allowed under this section
(determined without regard to

[[Page H2405]]

paragraph (1)) and section 36B (determined without regard to
subsection (g)(4)(A) thereof) for such taxable year, and

``(ii) section 36B(g)(4)(B) shall not apply with respect to
such taxpayer for such taxable year.''.
(2) Trade or business deduction.--Section 162(l) of such
Code is amended by adding at the end the following new
paragraph:
``(6) Coordination with health insurance coverage credit.--
The deduction otherwise allowable to a taxpayer under
paragraph (1) for any taxable year shall be reduced (but not
below zero) by the amount of the credit allowable to such
taxpayer under section 36B (determined without regard to
subsection (g)(4)(A) thereof) for such taxable year.''.
(f) Effective Date.--The amendments made by this section
shall apply to months beginning after December 31, 2019, in
taxable years ending after such date.

SEC. 215. MAXIMUM CONTRIBUTION LIMIT TO HEALTH SAVINGS
ACCOUNT INCREASED TO AMOUNT OF DEDUCTIBLE AND
OUT-OF-POCKET LIMITATION.

(a) Self-Only Coverage.--Section 223(b)(2)(A) of the
Internal Revenue Code of 1986 is amended by striking
``$2,250'' and inserting ``the amount in effect under
subsection (c)(2)(A)(ii)(I)''.
(b) Family Coverage.--Section 223(b)(2)(B) of such Code is
amended by striking ``$4,500'' and inserting ``the amount in
effect under subsection (c)(2)(A)(ii)(II)''.
(c) Conforming Amendments.--Section 223(g)(1) of such Code
is amended--
(1) by striking ``subsections (b)(2) and'' both places it
appears and inserting ``subsection'', and
(2) in subparagraph (B), by striking ``determined by'' and
all that follows through `` `calendar year 2003'.'' and
inserting ``determined by substituting `calendar year 2003'
for `calendar year 1992' in subparagraph (B) thereof .''.
(d) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2017.

SEC. 216. ALLOW BOTH SPOUSES TO MAKE CATCH-UP CONTRIBUTIONS
TO THE SAME HEALTH SAVINGS ACCOUNT.

(a) In General.--Section 223(b)(5) of the Internal Revenue
Code of 1986 is amended to read as follows:
``(5) Special rule for married individuals with family
coverage.--
``(A) In general.--In the case of individuals who are
married to each other, if both spouses are eligible
individuals and either spouse has family coverage under a
high deductible health plan as of the first day of any
month--
``(i) the limitation under paragraph (1) shall be applied
by not taking into account any other high deductible health
plan coverage of either spouse (and if such spouses both have
family coverage under separate high deductible health plans,
only one such coverage shall be taken into account),
``(ii) such limitation (after application of clause (i))
shall be reduced by the aggregate amount paid to Archer MSAs
of such spouses for the taxable year, and
``(iii) such limitation (after application of clauses (i)
and (ii)) shall be divided equally between such spouses
unless they agree on a different division.
``(B) Treatment of additional contribution amounts.--If
both spouses referred to in subparagraph (A) have attained
age 55 before the close of the taxable year, the limitation
referred to in subparagraph (A)(iii) which is subject to
division between the spouses shall include the additional
contribution amounts determined under paragraph (3) for both
spouses. In any other case, any additional contribution
amount determined under paragraph (3) shall not be taken into
account under subparagraph (A)(iii) and shall not be subject
to division between the spouses.''.
(b) Effective Date.--The amendment made by this section
shall apply to taxable years beginning after December 31,
2017.

SEC. 217. SPECIAL RULE FOR CERTAIN MEDICAL EXPENSES INCURRED
BEFORE ESTABLISHMENT OF HEALTH SAVINGS ACCOUNT.

(a) In General.--Section 223(d)(2) of the Internal Revenue
Code of 1986 is amended by adding at the end the following
new subparagraph:
``(D) Treatment of certain medical expenses incurred before
establishment of account.--If a health savings account is
established during the 60-day period beginning on the date
that coverage of the account beneficiary under a high
deductible health plan begins, then, solely for purposes of
determining whether an amount paid is used for a qualified
medical expense, such account shall be treated as having been
established on the date that such coverage begins.''.
(b) Effective Date.--The amendment made by this section
shall apply with respect to coverage beginning after December
31, 2017.

Subtitle B--Repeal of Certain Consumer Taxes

SEC. 221. REPEAL OF TAX ON PRESCRIPTION MEDICATIONS.

Subsection (j) of section 9008 of the Patient Protection
and Affordable Care Act is amended to read as follows:
``(j) Repeal.--This section shall apply to calendar years
beginning after December 31, 2010, and ending before January
1, 2017.''.

SEC. 222. REPEAL OF HEALTH INSURANCE TAX.

Subsection (j) of section 9010 of the Patient Protection
and Affordable Care Act is amended to read as follows:
``(j) Repeal.--This section shall apply to calendar years
beginning after December 31, 2013, and ending before January
1, 2017.''.

Subtitle C--Repeal of Tanning Tax

SEC. 231. REPEAL OF TANNING TAX.

(a) In General.--The Internal Revenue Code of 1986 is
amended by striking chapter 49.
(b) Effective Date.--The amendment made by this section
shall apply to services performed after June 30, 2017.

Subtitle D--Remuneration From Certain Insurers

SEC. 241. REMUNERATION FROM CERTAIN INSURERS.

Paragraph (6) of section 162(m) of the Internal Revenue
Code of 1986 is amended by adding at the end the following
new subparagraph:
``(I) Termination.--This paragraph shall not apply to
taxable years beginning after December 31, 2016.''.

Subtitle E--Repeal of Net Investment Income Tax

SEC. 251. REPEAL OF NET INVESTMENT INCOME TAX.

(a) In General.--Subtitle A of the Internal Revenue Code of
1986 is amended by striking chapter 2A.
(b) Effective Date.--The amendment made by this section
shall apply to taxable years beginning after December 31,
2016.

The SPEAKER pro tempore. The bill shall be debatable for 4 hours
equally divided and controlled by the chair and ranking minority member
of the Committee on the Budget or their respective designees.
The gentlewoman from Tennessee (Mrs. Black) and the gentleman from
Kentucky (Mr. Yarmuth) each will control 2 hours.
The Chair recognizes the gentlewoman from Tennessee.

General Leave

Mrs. BLACK. Mr. Speaker, I ask unanimous consent that all Members
have 7 legislative days in which to revise and extend their remarks on
H.R. 1628, the American Health Care Act of 2017.
The SPEAKER pro tempore. Is there objection to the request of the
gentlewoman from Tennessee?
There was no objection.
Mrs. BLACK. Mr. Speaker, I yield myself such time as I may consume.
I rise today to speak in favor of the American Health Care Act, a
bill that repeals many of the worst aspects of ObamaCare, and begins to
repair the damage caused by the law by bringing choice, competition,
and patient-centered solutions back into our healthcare system.
Standing here today in the House debating this bill is a proud moment
for me. I was working as a nurse in Nashville in the 1990s when, fresh
off of the failure of HillaryCare, the Clinton administration pushed
out a single-payer pilot program in Tennessee called TennCare.
As the story goes, Vice President Gore and the Democratic Governor
sketched out a program on a napkin while sitting in a local bar. I saw
firsthand the negative impact of government-run health care on patient
care. I saw the costs rise, and the quality of care fall. I saw the
burdens being placed on doctors, patients, hospitals, and care
providers. I saw patients faced with fewer choices and more regulation.
And I saw the devastating impact that TennCare was having on our
State's budget, gobbling up so much State spending that other
priorities like education and infrastructure were getting squeezed.
I couldn't sit idly by while this was happening in my State, so I
decided to get involved in public service, and it is what inspired me
to run for office at the very beginning. And when, in 2009 and 2010, I
saw the same principles being debated and eventually implemented on the
national level, I thought my experience in Tennessee would be valuable
to the national debate. I told the people in my district that, if
elected to Congress, I would fight to repeal and replace ObamaCare.
In 2011, I sponsored the first piece of legislation that repealed a
part of ObamaCare. And today, we take the largest step yet in rescuing
the American people from the damage that has been done by ObamaCare.
We are united in our goal to repeal ObamaCare and replace it with
patient-centered health care. Right now, ObamaCare is imploding. We
were promised premiums that would decrease by $2,500; instead, average
family premiums in the employer market have soared by $4,300.
We were promised healthcare costs would go down; instead, deductibles
have skyrocketed.

[[Page H2406]]

We were promised we could keep our doctor, and keep our health
insurance plans; instead, millions of Americans have lost their
insurance and the doctors that they liked.
In short, the Affordable Care Act was neither affordable, nor did it
provide the quality of care that the American people deserve.
The American Health Care Act is a first step in our efforts to
deliver patient-centered healthcare reform. This bill returns to the
American people freedom and choice in their healthcare decisions. It
gets government out of the relationship between patients and their
doctors--where it has never belonged--and puts people back in charge of
their own health care. It brings the free market principle of
competition to an industry that has long been dominated by government
intervention.
Today we are faced with a stark choice: Do we vote to continue the
damage ObamaCare is doing to our country and our constituents, or do we
vote to go down another path, a better way of doing health care in this
country?
While no legislation is perfect, this bill does accomplish some
important reforms. It zeros out the mandates. It repeals taxes. It
repeals the subsidies. It allows people to choose health insurance
plans that are unique to their families, instead of purchasing a one-
size-fits-all plan that is mandated by some Washington bureaucrat, and
it modernizes Medicaid, a once-in-a-lifetime entitlement reform.
Ending Medicaid's open-ended funding structure will play an important
role in addressing the future budget deficits and our growing national
debt. I applaud my colleagues who have stayed in this fight and
continue to make this bill better.
The members of the Budget Committee, which I chair, outlined four
principles they believed would improve the bill. Those principles led
to significant changes to allow more State flexibility in Medicaid and
ensure that tax credits truly served the people they are meant to
serve.
Others fought to eliminate Federal ObamaCare regulations that drive
up the cost of health care for all Americans and give those powers back
to the States. At the same time, we also ensure that States have the
resources to provide maternity and newborn care and treatment for
mental health and substance abuse.
I agree with these changes, and I applaud my colleagues for the work
to make sure that we truly reverse the damage ObamaCare is doing to our
healthcare system and our economy.
ObamaCare's legacy is clear: more government, less choice, and higher
costs. Our vision for health care in America is the opposite: more
freedom, more choice, and lower costs. Put simply, the American Health
Care Act is a good first step, but it is only a first step.
My good friend and our former colleague, Dr. Tom Price, will use his
position as Secretary of Health and Human Services to address some of
the regulatory burden of ObamaCare through administrative action. We
have voted already and will continue to vote on individual pieces of
legislation to implement even more patient-centered, free market
reforms that we cannot address through reconciliation.

In fact, we just passed two bills already this week. One would allow
small businesses to join together to purchase insurance, and the other
would increase competition by tearing down antitrust regulations. That
bill received 416 votes. This shows that these bills are commonsense
measures that include bipartisan support.
The day is finally here where we have an opportunity to fulfill that
promise that we have made to the American people. I, for one, cannot
sit idly by and let this opportunity go to waste. Campaigning is easy
compared to governing, but our constituents did not elect us to do what
is easy. They elected us to do what is right.
I urge my colleagues to join me in voting ``yes'' on the American
Health Care Act, to rescue the American people from ObamaCare.
Mr. Speaker, I reserve the balance of my time.
Mr. YARMUTH. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, after 7 years of campaigning against the Affordable Care
Act, congressional Republicans have finally produced what they
cynically describe as a replacement plan.
Sadly, however, this bill will unravel all of the progress we made
under the ACA, including expanding access to health insurance to 22
million Americans and improving the quality of coverage and care for
tens of millions more.
It nearly doubles the amount of uninsured people in this country,
guts Medicaid by almost $900 billion, and weakens the Medicare trust
fund.

{time} 1130

That was bad enough. But the last-minute changes to this bill are
astonishing and appalling. This legislation now allows insurers to end
coverage for prescription drugs, mental health, maternity and newborn
care, preventive care, emergency room visits, hospitalizations,
outpatient care, rehab visits, lab services, and pediatric care. That
is not progress. That is not a fix. That is a potential health crisis
for every American.
My Republican colleagues are well aware of this. Why else would they
have drafted this bill and these last-minute changes in secret? Why
else would complicated legislation affecting the lives of millions be
sent to the floor just 2 weeks after it was introduced with no
congressional hearings, not a single one, on a bill that impacts the
health care of nearly every American family? Why else would they rush
the bill to the floor without an updated Congressional Budget Office
estimate of how much coverage and care will be lost by their backroom
deal that ends consumer protections?
I get it. I wouldn't want to, nor would I know how to justify giving
nearly $1 trillion in tax cuts to corporations and the wealthy paid for
by threatening the health and well-being of millions of American
families.
Who is getting these huge windfalls?
Companies like Amgen, with annual profits of more than $3 million;
Medtronic, with annual profits of more than $6 billion; and Gilead
Sciences, with $13 billion in profits in 2016 alone.
When the CBO released its report last week showing that 24 million
hardworking Americans will be left without healthcare coverage by 2026
if we pass this bill, that premiums will rise 15 to 20 percent next
year, that people will pay thousands of dollars more in deductibles and
out-of-pocket costs, and that older Americans will be priced out of the
market by an age tax, I thought for sure it was dead on arrival, that
there was no way my Republican colleagues would walk this plank. But
here they are, and they are trying to take millions of American
families with them.
Fourteen million Americans will lose health coverage next year if
this bill is approved. Twenty-one million Americans will lose coverage
in the next 3 years alone, wiping out all of the coverage gains from
the ACA in just 3 years. For pretty much everyone else in the
individual market, deductibles and other costs will be higher. And for
lower-income individuals, out-of-pocket costs will be much higher.
Insurance companies will again be able to sell plans that offer much
less financial protection, and we will return to the days when millions
of people in this country will live in fear that they are always one
serious illness or accident away from bankruptcy.
This bill will result in the largest transfer of wealth from
struggling families to the well-off in our Nation's history, giving $1
trillion in tax breaks to millionaires, billionaires, and corporations.
It is Robin Hood in reverse, but this is far worse because access to
lifesaving care is being stolen.
I don't say that casually. I have met people, constituents of mine,
whose lives have been saved because of the Affordable Care Act.
This is from one of my constituents:
``My name is Kevin Schweitzer. I am 62 years old and I'm a lifelong
resident of Louisville, Kentucky.
``I worked hard, took risks and built a successful small business
that I sold at age 59. My wife and I were excited about our prospects
as we headed into early retirement. As a retiree too young for
Medicare, I purchased health insurance on the open market. Less than a
year later, I was diagnosed with lymphoma. I have undergone multiple
scans and 2 cycles of chemo. I am winning the battle so far, but since
this disease is in my blood I will be fighting it for the rest of my
life.

[[Page H2407]]

``A cancer diagnosis is a life-changing event that not only attacks
the body, but the mental stress is just as tough to deal with. Thanks
to ObamaCare, I've been able to rest easier knowing that my illness
wouldn't bankrupt my family and that I'll be able to provide for my
wife even after I'm gone.''
I also heard from a young woman named Sarah Adkins. She suffers from
chronic kidney disease. Sarah was able to get health insurance because
of the ACA. On January 9, 2011, it saved her life. One of her kidneys
shut down and almost went septic. If she didn't have coverage, she
would have waited or not gone to the hospital at all. The doctor told
her that if she had arrived at the ER an hour later, she would have
died.
Mr. Speaker, the health of my constituents Kevin Schweitzer and Sarah
Adkins is at stake in this debate. They, and the hundreds of other
constituents I have heard from who have serious and chronic health
conditions, will need high-quality, affordable health coverage for the
rest of their lives. Under this bill, they will get less coverage, it
will cost more, and eventually they will be priced out of the market,
leaving them nowhere to turn for the care they need.
And that is not all. Because of the last-minute changes to this bill,
insurers will be able to sell stripped-down coverage to weed out people
with preexisting conditions. They will be able to refuse, for example,
to offer coverage for chemotherapy drugs and cancer treatments, insulin
pumps, hospital stays, and prescription drugs that treat chronic
conditions across the board. Basically, if you have a serious health
problem, the care you need may not be available to you at all.
When the American people were promised by President Trump and
Republican congressional leadership that their existing coverage would
be preserved and that everybody would have insurance and it would be
less expensive and much better, they, understandably, believed they
would be treated much better than this. None of those promises are in
this bill. In fact, the opposite of every one of those promises is what
is in this bill. Those were promises made to every family in our
congressional districts, and this bill fails them at every turn.
Mr. Speaker, I urge my colleagues to oppose this legislation, and I
reserve the balance of my time.
Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from
California (Mr. McClintock).
Mr. McCLINTOCK. Mr. Speaker, I remind the gentleman from Kentucky
that every promise made to the American people in support of ObamaCare
was rapidly broken. We are now, at this moment in time, watching the
death throes of ObamaCare.
More people are paying the State tax penalty or claiming hardship
exemptions than are buying ObamaCare policies. In a third of our
counties, there is no choice left at all. You get one provider. Soon,
we are warned, some regions will have no providers at all. Premiums
soared an average of 25 percent last year, and this year we are warned
it could be 40 percent or more.
Critics cite the CBO estimate that 24 million Americans will lose
their coverage. It is important to understand their reasoning there.
The CBO believes that people won't buy health insurance unless we force
them to buy health insurance. In fact, people won't buy health
insurance that is not a good value for them, and, clearly, ObamaCare
isn't.
We replace it with a vigorous buyer's market where plans across the
country will compete to offer consumers better services at lower prices
tailored to their own needs and wants. And we assure these plans are
within their financial reach with $90 billion of additional support
that the CBO simply ignores.
The AHCA's biggest achievement is to replace coercion with choice for
every American. It ends the individual mandate that forces Americans to
buy products they don't want. It ends the employer mandate that has
trapped many low-income workers in part-time jobs. It begins to restore
consumers' freedom of choice, the best guarantee of quality and value
in any market. It allows Americans to meet more of their healthcare
needs with pretax dollars. It relieves the premium base of the enormous
cost of preexisting conditions by moving them to a block-granted
assigned risk pool.
Mr. Speaker, ObamaCare is collapsing, premiums are skyrocketing, and
providers are fleeing. This may well be our last off-ramp on this road
to ruin.
Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for
this bill will result in 38,200 people from his congressional district
in California losing health care and coverage.
Mr. Speaker, I yield 1\1/2\ minutes to the gentlewoman from
California (Ms. Lee), a distinguished member of the Budget Committee.
Ms. LEE. Mr. Speaker, I rise in strong opposition to H.R. 1628, which
is a bill to take away health care from 24 million Americans.
Whether you believe it or not, health care is a basic right. This
shameful bill steals from those who can least afford it, including
seniors, veterans, people living with HIV, children, and the disabled.
It would, yes, rip away health care from 24 million people. It would
reduce benefits, make families pay more for less, and transfer $600
billion in tax cuts to the very wealthy. This is outrageous.
Access to women's health is denied by defunding Planned Parenthood.
Medicaid, as we know it, will end. Healthcare costs for working
families and seniors will skyrocket. And now it eliminates essential
health benefits like maternity, mental health, and emergency care.
This is not a health bill. It is a tax giveaway to the wealthy.
Let me tell you, as a woman of faith, I am appalled and I am saddened
by the hypocrisy displayed in this bill by people who say they are
religious. I want to remind you--in the Scriptures, the Book of Mark,
chapter 12:31, we are reminded to love your neighbor as yourself.
This bill shows disdain for the most vulnerable and would lead to
death and destruction and disease for millions of Americans.
I hope Republicans remember to love their neighbor as themselves
today and vote ``no'' on this mean-spirited bill. Let's defeat this
harmful and morally bankrupt bill. This is a matter of life and death,
and the American people deserve better.
Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from Ohio
(Mr. Johnson), a member of the Budget Committee.
Mr. JOHNSON of Ohio. Mr. Speaker, the American people spoke loudly
and clearly last November. In fact, they have been speaking loudly and
clearly ever since this fatally flawed bill called ObamaCare was signed
into law. And now we are hours away from the vote that the American
people have been waiting years for.
This vote can be distilled down to simply this, and each Member of
this body must ask themselves this simple question: Are they willing to
allow ObamaCare to remain the law of the land? Or are we going to begin
to restore healthcare decisions to the American people and their
doctors?
Those who choose to vote against the American Health Care Act,
regardless of how they attempt to justify it, will be voting to keep
ObamaCare in place. This is an inescapable fact that will remain long
after the smoke and spin and handwringing from political pundits
following this vote has gone and disappeared, regardless of how the
votes go.
There is no such thing as perfect legislation in a body of 435 men
and women representing 435 different parts of the Nation.
There is consensus among the American people that this law should be
repealed and replaced, and today the people's House will either
acknowledge the will of the people or we will defy it.
Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for
this bill will result in 40,500 people from his congressional district
in Ohio losing health coverage and care.
Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from
Massachusetts (Mr. Moulton), a distinguished member of the Budget
Committee.
Mr. MOULTON. Mr. Speaker, I would also like to remind the gentleman
from Ohio that the latest poll put the will of the American people at
17 percent in favor of this bill.
I would like to read a message from my Republican constituent:
``The American Health Care Act would strain the fiscal resources
necessary to support the Commonwealth's

[[Page H2408]]

continued commitment to universal health coverage.''
This constituent is the Republican Governor of Massachusetts, who
knows that TrumpCare destroys our ability to ensure access to quality,
affordable healthcare coverage.
Another Republican in my State, Governor Mitt Romney, worked with the
Democratic legislature to create the Nation's first system to provide
affordable, comprehensive health care. RomneyCare wasn't perfect, but
Republicans and Democrats worked together to improve it, and they
created a system with higher approval ratings than TrumpCare or even
ObamaCare.
We can do this. Health care should not be partisan. It should be
about investing in our people, in our families, and in our future so
that Americans can live healthy, productive lives. But that is not what
this Republican TrumpCare bill does.
Michael is a constituent from Gloucester, the old fishing city. He
was prescribed OxyContin by his doctors, and then became addicted. But
he was able to enter a treatment program through Medicaid, the kind of
program that will be cut by TrumpCare. He is now back at work as an
electrician, and he says that the Affordable Care Act saved his life.
I am a veteran, and I get my health care at the VA. Sometimes it
takes me weeks to get an appointment. If this Republican bill passes,
it will throw 8 million veterans off private health care, forcing them
into the VA, and creating even longer wait times. That is no way to
treat those who have put their lives on the line for our country.
Perhaps it's no surprise that this bill is being jammed down the
throats of Congress and the American people like a dead fish.
Nobody wants it and it will make a lot of people sick.
What we should be doing here in Washington is coming together as
Republicans and Democrats to have an open, honest debate, and improve
the health care system.
Everyone says Congress doesn't work--don't prove them right.
I urge my colleagues to vote no on this terrible bill and to instead
come to the table like we did in Massachusetts.
Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from
Minnesota (Mr. Lewis), who is a distinguished member of the Budget
Committee.

{time} 1145

Mr. LEWIS of Minnesota. Mr. Speaker, I rise today in support of the
American Health Care Act, and I ask the other side: Just what is it you
are trying to preserve by voting ``no?''
Premiums rising double digits for years for the last 7 years? In my
home State of Minnesota, back-to-back premium increases of 50 to 67
percent?
Young, healthy people being priced out of the insurance market, 8
million in 2014, choosing to pay the penalty instead of buying
insurance?
That is the genesis of the death spiral in the insurance markets.
That is what this bill is trying to correct.
Deductibles, copays--I had a deductible on my own individual policy,
a skyrocketing deductible. There are deductibles of $13,000. That is
not health care. That is not even access.
Drug formularies being tightened to save money, so people are denied
prescription drugs, a prescription drug tax; thousands of Minnesotans
losing their plans, 100,000 when a big insurer dropped out; 1,000
counties with one insurer--that is what you are trying to preserve on
the other side, people voting ``no'' on this bill?
Emergency State legislation trying to prop up MNsure in my home State
because it is failing, and $1 trillion in taxes and spending that is
bankrupting the country--that is what the other side is trying to
preserve.
Those voting ``no'' on this bill, we have a choice today. You can
embrace the status quo and see the markets spiral out of control
completely, or you can vote for change and do the right thing.
Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for
this bill will result in 50,200 people from his congressional district
in Minnesota losing health coverage and care.
I yield 1\1/2\ minutes to the gentleman from New York (Mr. Jeffries),
a distinguished member of the Budget Committee.
Mr. JEFFRIES. Mr. Speaker, the Trump Presidency has been
characterized by chaos, crisis, and confusion, and this Republican
healthcare debacle has been no different.
The American people clearly understand that TrumpCare will be an
unmitigated disaster. Under TrumpCare, working families will pay more
and get less. Under TrumpCare, premiums will increase. Under TrumpCare,
copays will increase. Under TrumpCare, deductibles will increase. Under
TrumpCare, out-of-pocket expenses will increase.
Under TrumpCare, 24 million hardworking Americans will lose their
health coverage. Under TrumpCare, individuals between the age of 50 and
64 will pay a regressive age tax.
Health care is a matter of life and death; that is why we take it so
seriously. TrumpCare will lead to increased death, disease, and
destitution, and that is why we oppose this horrible piece of
legislation.
Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from
Texas (Mr. Arrington) who is a member of the Budget Committee.
Mr. ARRINGTON. Mr. Speaker, ObamaCare's disastrous effects over the
last several years have wreaked havoc on our small businesses, broken
the backs of middle and working class families, and have had a
disproportionately negative impact on rural America. Those are the
folks who I represent in west Texas.
While the current bill before us is far from perfect--and let's be
honest, there is no such thing as perfect legislation--it reverses
course and takes us in the right direction. It repeals the mandates and
restores freedom to individuals and markets.
It repeals about $1 trillion of taxes. It reduces deficit spending by
over $100 billion, making it the largest entitlement reform since the
1960s. It rolls back regulations, gives maximum flexibility to States,
and begins to defederalize health care.
For 7 years now, Republicans have promised the American people that
if we were given control of the Presidency and the House and the
Senate, then we would repeal and replace ObamaCare. And now that we are
given the opportunity to govern and to keep our promises and to deliver
results for the American people, we can't let perfect be the enemy of
good.
The debate is now closing. We have two choices. We either pass a good
but imperfect bill, or we leave ObamaCare in place. That is an
unacceptable alternative.
As leaders, we have a moral obligation to do something, to not stand
idly by while the people suffer under a system that is failing them.
If we are going to restore the greatness of America and transfer
power back to the people, we need more than policy solutions, even
perfect policy solutions. We need the political will and the courage to
lead.
This is a rescue mission, Mr. Speaker, and it isn't without risk; but
I have faith in the President and his team. I have faith in our States
and the free markets, and, above all, Mr. Speaker, I have faith in the
American people.
Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for
this bill will result in 60,400 people from his congressional district
in Texas losing health coverage and care.
I yield 2 minutes to the gentleman from New York (Mr. Higgins), a
distinguished member of the Budget Committee and the Ways and Means
Committee.
Mr. HIGGINS of New York. Mr. Speaker, this never needed to be an
ideological fist fight. Democrats were always willing to take into
account serious and constructive alternatives to the law that we have
today that make it better, to make it affordable, more affordable for
the American people.
But this bill is a blatant takeaway from the American people of money
and protection. If you are 50 to 64 years old, you get clobbered. If
you are 64 years old, you make $26,000 a year, according to the
Republican-led Congressional Budget Office, your premiums go from
$1,700 a year to $14,000 a year.
Fact: UnitedHealthcare is one of the largest private health insurers
in America.
Fact: UnitedHealthcare will have $200 billion in revenues this year,
and they paid their chief executive officer $66 million in compensation
in 2014.

Fact: UnitedHealthcare is under investigation today by the Department
of Justice for stealing billions of dollars from the Medicare program.

[[Page H2409]]

Fact: The Republican health bill, on page 67, in 7 words, gives
UnitedHealthcare, their high-paid executives, and all of their cronies,
a massive tax cut to continue to screw the American people.
Mr. Speaker, we can do much better. We are prepared to do much
better. But this is a financial assault on good, hardworking Americans
who want to do one thing at the end of the day, after paying too much
money for health care throughout the year, and that is, when they need
their health care, it is available to them and their family.
Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from New
York (Mr. Faso), a distinguished member of the Budget Committee.
Mr. FASO. Mr. Speaker, I wanted to point out to my colleagues that a
fundamental change is being made with the new health law we have before
us, and that is, we are, for the first time, equalizing the treatment
of people who do not have employer-provided health care.
Those of us who have employer-provided health care, 170 million
Americans, that is not a taxable event for them. It is not a taxable
event where they have to pay tax at the end of the year on the value of
that employer-provided health care.
And yet, if you are the person who does not have employer-provided
health care, if you are the husband and wife with two kids making 45 or
$50,000, and your employer does not provide health care, you receive
absolutely no tax subsidy through the Tax Code.
This bill, through the advance refundable tax credits, will, for the
first time, give someone the choice to buy health care and give them
the opportunity and the means to buy health care that they previously
have not had. It is not a markedly important distinction, frankly, from
the Affordable Care Act, where you only could buy the health care
through an exchange-approved policy.
This policy, under this legislation today, will allow someone the
flexibility and the freedom to buy a policy of their choosing, not one
dictated by Washington. So that is a fundamental important distinction
between the status quo and what this legislation would offer.
Mr. Speaker, and my colleagues, I urge support for the bill. It is
not perfect, as we all know, but it is something that is long overdue.
I would also point out that the numbers that my colleague from
Kentucky uses are really based upon fantasy. Those numbers are simply
incorrect, and the people of our State and our country will have health
care under the provisions of this bill, and we will work hard to ensure
that they do.
Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for
this bill will result in 65,800 people from his congressional district
in New York losing health coverage and care.
I yield 2 minutes to the gentlewoman from Washington (Ms. DelBene), a
distinguished member of the Budget Committee and the Ways and Means
Committee.
Ms. DelBENE. Mr. Speaker, if Republicans crafted legislation that
lived up to the promise of insurance for everybody, they would have
broad bipartisan support. But that is not what they did.
This bill threatens massive disruption and chaos, not only to our
healthcare system, but to middle class families, families who sit at
their kitchen table trying to figure out how to pay their mortgage, buy
groceries, and also get health coverage for their kids. This Republican
bill does nothing to help them.
In their rush to check a political box, Republicans have crafted
legislation that does nothing but hurt working Americans, and, in the
last 24 hours, it has gone from bad to worse.
Make no mistake, the changes made in the 11th hour to appease the
most extreme Members of Congress have put lifesaving care even further
out of reach.
Some may use alternative facts, but this is reality, and the reality
is that their bill robs $75 billion from Medicare, forces older
Americans to pay five times more than others, and shifts $312 billion
in out-of-pocket costs onto middle class families.
But this is about more than numbers. It is about people like Rachel,
from Kirkland, Washington, who suffered a heart attack and blood clot
at the age of 35. She now depends on frequent tests, medications and
doctors' visits to stay healthy. Thankfully, it is all covered by her
insurance.
Rachel told me: ``I'm horrified by the talking point that equates
repealing the Affordable Care Act with getting freedom back. For me,
the loss of the ACA gives me nothing but the freedom to die sooner and
worry more.''
I am not voting against this bill because it is a Republican bill. I
am voting ``no'' for families like Rachel's.
Health care doesn't need to be a partisan issue, and I stand ready
and willing to work on commonsense solutions that expand coverage and
reduce costs. But I was sent here to make my constituents' lives
better. This bill does not do that. I encourage my colleagues to vote
``no.''
Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from
Florida (Mr. Gaetz) who is a distinguished member of our Budget
Committee.
Mr. GAETZ. Mr. Speaker, I rise to repeal the disaster that is
ObamaCare. ObamaCare functions as a wet blanket over the American
economy, stopping businesses from growing, and impairing the rights of
individuals to make their own decisions about health care.
Mr. Speaker, I specifically implore my conservative colleagues to
vote for this bill and give us a chance to get out from under this
disastrous law. This legislation represents $1 trillion in tax cuts,
$1.15 trillion in spending cuts, $150 billion in deficit reduction;
defunding Planned Parenthood.
How long have we been fighting to defund Planned Parenthood?
Close the illegal alien loophole that allows people to enroll in
ObamaCare, only to check their status in this country subsequently.
We install work requirements. I don't think people that are able to
work but choose not to should expect us to go borrow money from China
to pay for their health care. Installing those work requirements is
fundamental to bold conservative reform.
Block grants for States so that finally they can be liberated from
the oppressive hand of the Federal Government, and also blocking States
from additional Medicaid expansion.
We have been engaging in these conservative fights for years, and
finally, today, we have got the chance to put a win on the board; and
so I am joining our President, our Speaker, and many conservatives in
this Congress in voting for the American Health Care Act.
When we win, when we do this, not only do we enhance our economy, not
only do we free up opportunities for broader prosperity in America, but
we allow people to be in charge of health care, and we move from a
government-centered system to a patient-centered system. That was the
promise we made in the elections, and that is the promise I intend to
keep by voting for this bill.
Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for
this bill will result in 56,000 people from his congressional district
in Florida losing health coverage and care.
I yield 1\3/4\ minutes to the gentlewoman from Florida (Ms. Wasserman
Schultz), a distinguished member of the Budget Committee.

{time} 1200

Ms. WASSERMAN SCHULTZ. Mr. Speaker, I stand in opposition to the
Republican pay more for less care act, under which Americans will
suffer from higher healthcare costs, less coverage, a crushing age tax,
and a ransacking of the Medicare trust fund, which our seniors depend
on for long-term care.
Under the age tax, Americans aged 50 to 64 will be forced to pay five
times higher premiums than others, no matter how healthy they are.
Under TrumpCare, a 64-year-old with an income of $26,500 in the
individual market will pay $12,900 more in their premiums every year
under this bill.
In addition, TrumpCare will take away health care from 24 million
hardworking Americans and will force families to pay higher premiums
and deductibles. In fact, for families enrolled in the ACA marketplace,
premiums are expected to increase by 15 to 20 percent.
It will also punish millions of people who experience a lapse in
coverage by forcing them to pay a 30 percent higher premium each month
in order to receive care.

[[Page H2410]]

Tell that to Suzanne Boyd from Sunrise, Florida, who, with two
daughters heading to college, lost her husband to lung cancer and then
lost the insurance coverage she had through her employer. Thankfully,
she was able to obtain coverage under the ACA for $192 a month with
subsidies rather than a 30 percent Republican sick tax for getting a
life-threatening illness.
Yet this bill apparently isn't harmful enough for the far-right
extremists in the Republican Party, whom Republican leadership has
tried to appease by cutting the ACA essential health benefits like
mental health, maternity, and emergency services.
Mr. Speaker, this bill is like taking a sledgehammer to a clock that
is moving a little slow rather than working on precision fine tuning
instead. It is an immoral piece of legislation. As a breast cancer
survivor, I urge every Member to stand with my sister survivors all
across the country, who number in the millions, to make sure that you
don't devastate our health and make sure that we don't have our lives
threatened.
Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from
Indiana (Mr. Rokita), who is the vice chair of the Budget Committee.
Mr. ROKITA. Mr. Speaker, I thank the chairwoman.
I am really proud, Mr. Speaker, of the Budget Committee. We did great
work last week, and everyone was heard: six motions on the Republican
side, six motions on the Democratic side, and the debate was civil.
Tones weren't raised; theatrics, by and large, weren't employed; and we
made the bill better. That was the process the week before that when
the committees of jurisdiction had this legislation.
It is my hope that, as we pass this bill off the floor of the House--
and it is a bill being passed off the floor of the House and not into
law right now--and as it goes to the Senate, that the bill will
continue to be improved. That is the legislative process.
I am very proud of the members of the staff of the Budget Committee
for being a major part of that process and starting that process. We
did good work. You don't have to pass this bill to find out what is in
it as we had to with ObamaCare. This process will continue.
I am very pleased, also, that we have Medicaid block grants, or lump
sum payments to the States, that are available now to cover at least
our able-bodied children and adults. It is a huge step forward in
letting States have the flexibility they need to decide who really
needs this assistance, how they should get it, and what they should get
in terms of health care.
This is good legislation. This is what we were sent to do, and we are
keeping our promises to the American people by passing this
legislation.
Mr. Speaker, I urge all my colleagues to vote ``yes.''
Mr. YARMUTH. Mr. Speaker, I remind my friend from Indiana that his
vote for this bill will result in 37,900 people from his congressional
district losing health coverage and care.
Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from
Pennsylvania (Mr. Brendan F. Boyle), who is a distinguished member of
the Budget Committee.
Mr. BRENDAN F. BOYLE of Pennsylvania. Mr. Speaker, I rise today in
opposition to TrumpCare, the Republican plan to cut Medicare and
Medicaid, increase healthcare costs, and take health care away from
tens of millions of Americans, all while providing the largest transfer
of wealth from working families to our Nation's richest, and all of
this in the name of choice and freedom. But we all know that, under
this bill, that is just code for survival of the fittest, economic
Darwinism.
Mr. Speaker, let me bring this a little closer to home for me. Thanks
to TrumpCare, 36,700 of my constituents covered by the ACA's Medicaid
expansion now stand to lose this lifesaving coverage. Here is one of
them, constituent Maura McGrath, a 17-year-old with Down syndrome.
Maura's parents, Joe and Rita, know firsthand why Medicaid is so
important. Medicaid has been critical to keeping their daughter alive
and saving their family from bankruptcy. Even though Joe and Rita both
work, the cost of Maura's care is too expensive to afford on their own,
not to mention that Rita is a breast cancer survivor and Joe suffers
from Parkinson's disease. Medicaid provides the McGraths peace of mind
knowing Maura will receive the care that she needs and they aren't
alone to fend for themselves, given the tough hand they have been
dealt.
Mr. Speaker, for Maura and everyone in my district, say ``no'' to
TrumpCare.
Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from
Louisiana (Mr. Higgins).
Mr. HIGGINS of Louisiana. Mr. Speaker, I rise unscripted and in
passionate support of freedom. I have heard many statements with words
like ``fact'' and details of the minutia of these plans. I will share
with you a fact.
Two hundred years ago, my ancestral forefather was born. He was a
young, poor Irishman born into indentured servitude. He heard a whisper
of a land born across the sea, a land where a man could own his own
property, a land where a man could keep the toil of his labor. So he
garnered his courage, he saved his money, and he booked passage on a
cargo vessel converted to carry human beings. According to the letter
unearthed by my sainted mother, his sleeping berth measured 2 by 2 by
5.

What could have driven my ancestral forefather--and yours, Mr.
Speaker--indeed, all of America? What drove our ancestral forefathers
to come to this land? Freedom. Freedom drove us, and it is freedom for
which I stand.
The Affordable Care Act, known as ObamaCare, is 8,000 pages--8,000
pages--of regulation and taxation. There is not a man or a woman
amongst us, from sea to shining sea, who believes this body can produce
8,000 pages of freedom. The American Health Care Act is 124 pages of
reasonable legislation based upon the best input of free market
principles.
A vote against the American Health Care Act is a vote against
freedom. It is a vote against 124 pages of reasonable legislation, and
it is a vote for 8,000 pages of ObamaCare.
Mr. Speaker, I urge my colleagues to vote ``yes'' for the American
Health Care Act.
Mr. YARMUTH. Mr. Speaker, I remind my colleague that the gentleman's
vote for this bill will result in 50,100 people from his congressional
district in Louisiana losing health coverage and care.
Mr. Speaker, I yield 1\1/2\ minutes to the gentlewoman from
Washington (Ms. Jayapal), who is the distinguished vice ranking member
of the Budget Committee.
Ms. JAYAPAL. Mr. Speaker, I thank the distinguished gentleman for
yielding and for his tremendous leadership.
Mr. Speaker, this reckless Republican plan is a betrayal of the
American people. How is it a betrayal?
Callously stripping 24 million people of health care is a betrayal.
Putting an age tax on people aged 50 to 64 who will pay up to $14,000
more in annual premiums is a betrayal.
Gutting essential benefits like maternity care, prescription drug
coverage, emergency services, and fundamentally destroying protections
for Americans with preexisting conditions is a betrayal.
Slashing Medicaid by $880 billion and stripping the safety net for
our seniors, our kids, and people with disabilities is a betrayal.
The burden of all of this, Mr. Speaker, will fall on the States, who
will have to come up with billions of dollars.
Mr. Speaker, this bill is not about freedom or choice. This bill is a
travesty, and the American people will pay the price.
This is not a healthcare bill. The only people who benefit are
millionaires, billionaires, and insurance companies, who will get $1
trillion in tax benefits while working Americans pay more and get
nothing.
Mr. Speaker, this bill is pure greed, and real people will suffer and
die from it. Vote ``no,'' and protect our care.
Mrs. BLACK. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, I want to recognize that our Members on the other side
of the aisle are sharing some data on the coverage of per congressional
district based on a study that was conducted by the Center for American
Progress, which is a left-leaning organization to begin with. The
Center for American Progress employs a flawed methodology for
estimating this coverage. In

[[Page H2411]]

fact, their foundational numbers are actually based on CBO's coverage
estimates, estimates that the CBO itself has established are not
infallible.
These coverage numbers only take into account plans that they
consider comprehensive major medical policies. This is a term that is
used in the very law that we are trying to dismantle today. These
coverage estimates do not account for things that we have in our bill,
such as HSA plans that allow purchase with tax credits, and many
medical plans.
So the AHCA increases freedom for Americans to purchase the kind of
coverage that works for them, not the narrowly defined coverage that we
see that the Federal Government likes.
Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from California
(Mr. McClintock), who is a member of our committee.
Mr. McCLINTOCK. Mr. Speaker, I simply want to underscore what the
chairwoman has already laid out.
When my friend from Kentucky says that his constituents will lose
coverage, he is basing it on two premises. He is ignoring the $90
billion of additional funds that we freed up in the Budget Committee to
assure that nobody will face sticker shock as we make this transition.
Second, he assumes that the only reason that people buy insurance is
if we force them to buy it. The reality is many are refusing to buy
ObamaCare policies even when they are faced with these crushing tax
policies. The AHCA replaces this heavyhanded and failing bureaucratic
nightmare.
Ultimately, we are going to be judged not on polls or fairy tales,
but on whether the vast majority of Americans have a better experience
with this new consumer-driven market than they had with the
bureaucratized, one-size-fits-all ObamaCare system. That system has
already been weighed in the balance and found wanting by the American
people, and I am here to stake my reputation on the prediction that
they will find better policies with better services at lower costs when
they are restored the freedom to be consumers in a marketplace with a
supportive tax structure that assures that these policies are within
the financial reach of every American family.
Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for
this bill will result in 38,200 people from his congressional district
in California losing health coverage and care.
Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from California
(Mr. Carbajal), who is a distinguished member of the Budget Committee.
Mr. CARBAJAL. Mr. Speaker, before I came to Congress, I worked in
local government as a county supervisor. One of my proudest
achievements during that time was working in a bipartisan way to create
a program that reduced the rate of uninsured children in our county by
over 90 percent--all before the Affordable Care Act was signed into
law. Since the Affordable Care Act, I saw firsthand the direct and
positive impact of this legislation over the past 7 years to
communities and families across the central coast.
The Affordable Care Act meant Sarah, from Lompoc, could open her
small business and afford insurance coverage for her two children.
It meant that Kathleen, in San Luis Obispo, who was diagnosed with
ovarian and breast cancer, that her $500,000 medical bill was covered
by her healthcare plan.
It meant that Adrienne, from Buellton, now could afford to pay for
her husband's nursing facility, as his debilitating disease prevents
her from being able to physically care for him.
Repealing legislation that has improved the quality of life not only
for Sarah, Kathleen, and Adrienne, but for the over 20 million
Americans who have gained health insurance under the Affordable Care
Act, would be callous, cruel, and irresponsible.
Instead of taking away health care from 24 million Americans, let's
work together to create a more equitable, affordable, and accessible
healthcare system for all.

{time} 1215

Mrs. BLACK. Mr. Speaker, I yield 1 minute to the gentleman from South
Carolina (Mr. Sanford).
Mr. SANFORD. Mr. Speaker, I want to make clear that I agree with what
every Republican speaker has said thus far on the need to repeal and
replace the Affordable Care Act. I want to say how much I admire the
Speaker and the leadership team, President Trump and his team,
Chairwoman Black, and others on the Budget Committee for what they have
brought to bear.
My simple question is one of timing. What I tell my boys consistently
is: If you don't know, you don't go.
One of the things that I think we have to really look at in this bill
is one of process. It does do a lot of good things, as has been pointed
out by the Republican speakers, but it still leaves in place community
rating. It leaves in place the architecture, I think, of a flawed bill
that came with the Affordable Care Act.
The question is: Can we build on top of that to do the very good
things that are talked about in this bill, or do we take just a little
bit more time to make certain that we have it right?
I think that when you look at this notion of lowering premiums, look
at it like rent control in New York. Rent control in New York has done
a lot of good for some folks, but it has hurt a lot of others in the
process.
The question we fundamentally have to ask ourselves is: At this
juncture, can we make the changes necessary?
Mr. YARMUTH. Mr. Speaker, I mention to my colleague that his vote
against this bill will result in 56,600 people from his congressional
district in South Carolina losing health coverage and care.
Mr. Speaker, I yield 1\3/4\ minutes to the gentlewoman from Texas
(Ms. Jackson Lee).
Ms. JACKSON LEE. Mr. Speaker, I thank the distinguished gentleman of
the Budget Committee for his leadership.
Our mothers and our doctors have warned us about poison pills. Well,
let me say that, this morning, the Republicans are giving to the
American people a poison meal that would affect my friend, the senior
citizen, with $175 billion being taken away from Medicare; a poison
meal that will affect a young child who is being seen by a doctor.
The Children's Hospital Association, including the Texas Children's
Hospital, has said to vote ``no'' on this bill because 30 million
children will have no health insurance.
This will impact working families making $31,000 a year. They will
have to pay $4,000 more out of pocket. In 2026, under pay more for
less, $52 million Americans will be uninsured.
This poison meal is getting worse and worse.
Then, in the dark of night, what did they do?
They took away hospitalization. They took away pregnancy, maternity,
and newborn care. They took away mental health and substance abuse
care.
Those States that are experiencing the opioid abuse and epidemic,
what are they going to do?
They have threatened community health centers. They are closing rural
hospitals.
What is this disaster of TrumpCare?
It is injuring my good friend who is sitting there in the hospital
room. It is injuring Anna Nunez. It is injuring small businesses who
say that they can live better under the Affordable Care Act, and the
youngster that is a junior in college who said she would not be alive
had it not been for the Affordable Care Act.
More than half of the American people--and it is growing--are against
this bill done in the dark of night. It is the poison meal that is
keeping those who need health insurance away from health insurance.
I ask my colleagues to vote ``no.'' Don't feed the American people a
poison meal.
Mr. Speaker, as a member of the Budget Committee and the
representative of a congressional district that has benefited
enormously from the Affordable Care Act, I rise in strong and
unyielding opposition to H.R. 1628, the so-called ``American Health
Care Act,'' which more accurately should be called ``Trumpcare, the Pay
More For Less Act.''
Seven years ago yesterday, March 23, 2010, President Barack Obama
signed into law the landmark Affordable Care Act passed by the
Democratic controlled 111th Congress.
Seven years later, the verdict is in on the Affordable Care Act; the
American people have judged it a success and are adamantly opposed to
any effort to repeal a law that has brought to more than 20 million
Americans the peace of mind and security that comes with

[[Page H2412]]

knowing they have access to affordable, high quality health care.
Before the passage of the Affordable Care Act, 17.1 of Americans
lacked health insurance; today nearly nine of ten (89.1%) are insured,
which is the highest rate since Gallup began tracking insurance
coverage in 2008.
Because of the Affordable Healthcare Act:
1. insurance companies are banned from discriminating against anyone,
including 17 million children, with a preexisting condition, or
charging higher rates based on gender or health status;
2. 6.6 million young-adults up to age 26 can stay on their parents'
health insurance plans;
3. 100 million Americans no longer have annual or life-time limits on
healthcare coverage;
4. 6.3 million seniors in the ``donut hole'' have saved $6.1 billion
on their prescription drugs;
5. 3.2 million seniors now get free annual wellness visits under
Medicare, and
6. 360,000 Small Businesses are using the Health Care Tax Credit to
help them provide health insurance to their workers;
7. Pregnancy is no longer a pre-existing condition and women can no
longer be charged a higher rate just because they are women.
We are becoming a nation of equals when it comes to access to
affordable healthcare insurance.
The President and congressional Republicans call this enviable record
of success a ``disaster.''
The American people do not agree and that is why they reject
overwhelmingly (56%-17%) this Republican attempt to repeal the
Affordable Care Act according to the latest Quinnipiac poll.
Americans know a disaster when they see one and they see one in the
making: it is called ``Trumpcare,'' masquerading as the ``American
Health Care Act,'' which will force Americans to ``pay more for less.''
And they are right to be alarmed at what they see.
This ``Pay-More-For-Less'' bill is a massive $900 billion tax cut for
the wealthy, paid for on the backs of America's seniors, the
vulnerable, the poor, and working class households.
This ``Robin Hood in reverse'' bill is unprecedented and breathtaking
in its audacity--no bill ever tried to give so much to the rich while
taking so much from the poor and working class.
Trumpcare represents the largest transfer of wealth from the bottom
99% to the top 1% in American history.
This callous Republican scheme gives gigantic tax cuts to the rich,
and pays for it by taking insurance away from 24 million people,
leaving 52 million uninsured, and raising costs for the poor and middle
class.
In addition, Republicans are giving the pharmaceutical industry a big
tax repeal, worth nearly $25 billion over a decade without demanding in
return any reduction in the cost of prescription and brand-name drugs.
To paraphrase Winston Churchill, of this bill, it can truly be said
that ``never has so much been taken from so many to benefit so few.''
The Pay-More-For-Less plan destroys the Medicaid program under the
cover of repealing the Affordable Care Act Medicaid expansion.
CBO estimates 14 million Americans will lose Medicaid coverage by
2026 under the Republican plan.
In addition to terminating the ACA Medicaid expansion, the bill
converts Medicaid to a per-capita cap that is not guaranteed to keep
pace with health costs starting in 2020.
The combined effect of these policies is to slash $880 billion in
federal Medicaid funding over the next decade.
The cuts get deeper with each passing year, reaching 25% of Medicaid
spending in 2026.
These steep cuts will force states to drop people from Medicaid
entirely or ration care for those who most need access to comprehensive
coverage.
The Pay-More-For-Less plan undermines the health care safety net for
vulnerable populations.
Currently, Medicaid provides coverage to more than 70 million
Americans, including children, pregnant women, seniors in Medicare,
people who are too disabled to work, and parents struggling to get by
on poverty-level wages.
In addition to doctor and hospital visits, Medicaid covers long-term
services like nursing homes and home and community-based services that
allow people with chronic health conditions and disabilities to live
independently.
To date, 31 states and D.C. have expanded Medicaid eligibility to
low-income adults, which, when combined with the ACA's other coverage
provisions, has helped to reduce the nation's uninsured rate to the
lowest in history.
Trumpcare throws 24 million Americans off their health insurance by
2026 according to the Congressional Budget Office.
Low-income people will be hit especially hard because 14 million
people will lose access to Medicaid by 2026 according to CBO.
Trumpcare massively shifts who gets insured in the nongroup market.
According to CBO, ``fewer lower-income people would obtain coverage
through the nongroup market under the legislation than current law,''
and, ``a larger share of enrollees in the nongroup market would be
younger people and a smaller share would be older people.''
The projected 10% reduction in premiums is not the result of better
care or efficiency--it is in large part the result of higher-cost and
older people being pushed out of a market that is also selling plans
that provide less financial protection.
People with low incomes suffer the greatest losses in coverage.
CBO projects the uninsured rate for people in their 30s and 40s with
incomes below 200% of poverty will reach 38% in 2026 under this bill,
nearly twice the rate projected under current law.
Among people aged 50-64, CBO projects 30% of those with incomes below
200% of poverty will be uninsured in 2026.
Under current law, CBO projects the uninsured rate would only be 12
percent.
Being uninsured is not about ``freedom.''
Speaker Ryan has argued that people will happily forgo insurance
coverage because this bill gives them that ``freedom.''
The argument makes as much sense as the foolish claim that slaves
came to America as ``immigrants'' seeking a better life.
The freedom to be uninsured is no freedom at all to people in their
50s and 60s with modest incomes who simply cannot afford to pay
thousands of dollars toward premiums.
They do not really have a choice.
The claim of our Republican friends that Trumpcare provides more
freedom to all Americans calls to mind the words of Anatole France:
``The law, in its majestic equality, forbids the rich as well as the
poor to sleep under bridges, to beg in the streets, and to steal bread
from the market.''
Trumpcare raises costs for Americans nearing retirement, essentially
imposing an ``Age Tax.''
The bill allows insurance companies to charge older enrollees higher
premiums than allowed under current law, while reducing the size of
premium tax credits provided.
Again, these changes hit low-income older persons the hardest.
A 64-year-old with an income of $26,500 buying coverage in the
individual market will pay $12,900 more toward their premiums in 2026,
on average.
Trumpcare raises costs for individuals and families with modest
incomes, particularly older Americans.
A recent analysis found that in 2020, individuals with incomes of
about $31,000 would pay on average $4,000 more out of pocket for health
care--which is like getting a 13% pay cut.
And the older you are, the worse it gets.
An analysis by the Urban Institute estimates that for Americans in
their 50s and 60s, the tax credits alone would only be sufficient to
buy plans with major holes in them, such as a $30,000 deductible for
family coverage and no coverage at all of brand-name drugs or many
therapy services.
Another reason I oppose the Trumpcare bill before us is because its
draconian cuts in Medicaid funding and phase-out of Medicaid expansion
put community health centers at risk.
Community health centers are consumer-driven and patient-centered
organizations that serve as a comprehensive and cost effective primary
health care option for America's most underserved communities.
Community health centers serve as the health care home for more than
25 million patients in nearly 10,000 communities across the country.
Across the country, 550 new clinics have opened to receive 5 million
new patients since 2009.
Community health centers serve everyone regardless of ability to pay
or insurance status:
1. 71% of health center patients have incomes at or below 100% of
poverty and 92% have incomes less than 200% of poverty;
2. 49% of health center patients are on Medicaid; and
3. 24% are uninsured;
4. Community health centers annually serve on average 1.2 million
homeless patients and more than 300,000 veterans.
Community health centers reduce health care costs and produce
savings--on average, health centers save 24% per Medicaid patient when
compared to other providers.
Community health centers integrate critical medical and social
services such as oral health, mental health, substance abuse, case
management, and translation, under one roof.

[[Page H2413]]

Community health centers employ nearly 190,000 people and generate
over $45 billion in total economic activity in some of the nation's
most distressed communities.
Community health centers serve on the front lines of public health
crises such as the Zika virus and the opioid epidemic.
Mr. Speaker, community health centers are on the front lines of every
major health crisis our country faces, from providing access to care
(and employment) to veterans to addressing the opioid epidemic to
responding to public health threats like the Zika virus.
We should be providing more support and funding to community health
centers, not making it more difficult for them to serve the communities
that desperately need them by slashing Medicaid funding.
Trumpcare Republican plan leaves rural Americans worse off.
Mr. Speaker, health insurance has historically been more expensive in
rural areas because services cost more and it is hard to have a stable
individual market with a small population.
Under the Affordable Care Act, premium subsidies are tied to local
costs, which helps keeps premium costs down.
But they are not under the Republican plan.
So, under the Republican plan residents in rural areas, who tend to
be older and poorer, will pay much more and get much less health
insurance.
At the end of the day, Mr. Speaker, the powerful and compelling
reasons to reject Trumpcare lies in the real world experiences of the
American people.
Let me briefly share with you the positive, life affirming difference
made by the Affordable Care Act in the lives of just three of the
millions of Americans it has helped.
Joan Fanwick: ``If Obamacare is repealed, I don't know if I'll live
to see the next President''
``After nearly a decade of mysterious health scares, I was diagnosed
with an autoimmune disorder called Sjogren's Syndrome last year, when I
was a junior at Temple University.
``It's a chronic illness with no known cause or cure, and without
close medical surveillance and care, it can lead to life-threatening
complications (like the blood infections I frequently experience).
``For me, having this disorder means waking up every morning and
taking 10 different medications.
``It also means a nurse visiting my apartment every Saturday to
insert a needle into the port in my chest, so I can give myself IV
fluids throughout the week.
``Without insurance, my medical expenses would cost me about $1,000
per week--more than $50,000 per year. And that doesn't even include
hospitalizations.
``My medical bills aren't cheap under Obamacare, but I can afford
them.
``Under Obamacare, insurance companies aren't allowed to cut you off
when your costs climb so right now, the most I personally have to pay
out of pocket is $1,000 per year.''
Brian Norgaard: ``I am a small business owner and leadership trainer
who Obamacare has helped tremendously.''
Brian Norgaard, a Dallas, Texas resident, called my office to express
his opposition to Trumpcare and to offer share how the Affordable Care
Act has helped small business owners like himself:
``I am a small business owner and leadership trainer who Obamacare
has helped tremendously.
``My wife and I both own small businesses in the Dallas, Texas area
and as a result of the huge savings we received after paying lower
[healthcare] premiums under Obamacare, we were able to reinvest those
saving into both of our businesses and the community.
``And the healthcare we received was quality, at that.''
Ashley Walton: ``For cancer survivors, we literally live and die by
insurance''
Ashley Walton was 25 when a mole on her back turned out to be
melanoma.
She had it removed, but three years later she discovered a lump in
her abdomen.
She was then unemployed and uninsured, and so she put off going to a
doctor.
She tried to buy health insurance. Every company rejected her.
Ashley eventually became eligible for California's Medicaid program,
which had been expanded under the Affordable Care Act.
The 32-year-old Oakland resident credits her survival to the ACA.
Without it, ``I would likely be dead, and my family would likely be
bankrupt from trying to save me.''
Before any of our Republican colleagues supporting this bill cast
their vote, I urge them to reflect on the testimony of Joan, Brian, and
Ashley, and to on this question posed by a constituent to Sen. Cotton
of Arkansas at a recent town hall:
``I've got a husband dying and we can't afford--let me tell you
something.
``If you can get us better coverage than this [Obamacare], go for it.
``Let me tell you what we have, plus a lot of benefits that we need.
``We have $29 per month for my husband. Can you beat that? Can you?
With all the congestive heart failures, and open heart surgeries,
we're trying. $29 per month. And he's a hard worker.
$39 for me.''
I urge all Members to reject Trumpcare, one of the most monstrously
cruel and morally bankrupt legislative proposals ever to be considered
in this chamber.
To paraphrase a famous former reality television personality,
``believe me, Trumpcare is a disaster.''
We should reject it and keep instead ``something terrific'' and that
is the Affordable Care Act, regarded lovingly by millions of Americans
as ``Obamacare.''

March 24, 2017.
Re Changes to the Affordable Healthcare Act.

The President of the United States of America,
The White House,
Washington, DC.
Greetings Mr. President: Today is a very crucial and
important day for the residents of the City of Houston's
District D, where I serve as the elected City Council Member,
which also falls under Congressional Districts 18 and 7. As a
local elected official whose mother is on a fixed income,
this will not only impact her but many other senior citizens
who I represent.
In the news, we see how the Affordable Healthcare Act is
proposed to be changed. Under the new revisions to the
healthcare bill, which is called The American Health Care
Act, about $337 Billion will be cut from the current plan
over a 10 year period causing 24 million Americans, including
Democrats, Republicans, Independents, poor and the middle
class, to lose their healthcare. This proposed health care
bill is receiving criticism from the health care providers,
some conservatives and a united Democratic Party. The
Congressional Budget Office even showed how this current
proposed plan will negatively impact everyone. What is most
concerning to me in regards to this program is the impact
that it will have on our senior citizens.
52% of my District is made up of Senior Citizens who are on
fixed incomes. These senior's will have to pay more for their
health care under this proposed American Health Care Act. In
no way is this acceptable. I am an advocate for my seniors
and I refuse to quietly sit back while this is being
considered.
I have encouraged everyone to reach out to their Members of
Congress to let them know that this isn't something that we
stand for and to work on their behalf to vote this item down
today.
Sincerely,

Dwight Boykins,

Houston City Counsel,
District D.

Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from
Wisconsin (Mr. Grothman), who is also a member of the Budget Committee.
Mr. GROTHMAN. Mr. Speaker, I would encourage my colleagues to vote
for the bill. The reason I ask you to vote for the bill is kind of like
the reverse: What is going to happen if this bill fails?
If this bill fails, you won't be able to have the huge increase in
funding in HSAs, a free-market, patient-centered tax provision which is
going to help many people and particularly allow flexibility for older
married couples.
If this bill doesn't pass, we are going to continue to levy fines on
young people who don't want health insurance, as so many people have
not had when they are young. We will continue to levy fines on small
business that can't afford health insurance.
If this bill fails to pass, we are not going to allow States to put
work requirements on Medicaid. Quite frankly, Medicaid, in many ways,
is a more generous policy than the one that people who do work are able
to afford through their insurers.

[[Page H2414]]

If this bill doesn't pass, we won't be able to stop the bleeding on
Medicaid funding. We are approaching a $20 trillion debt. Of course,
the bulk of that spiraling debt is caused by mandatory spending, of
which Medicaid is one of the worst parts.
Finally, for the first time in years, we are passing a law that will
make a significant dent in that mandatory spending.
If this bill isn't passed, we prevent putting a provision in here
requiring documentation of citizenship for Medicaid. Right now, we are
becoming the healthcare provider for the world. We cannot afford to
become the healthcare provider of the world.
Under this bill, we are providing funds, seed money for high-risk
pools for States, which will hold down insurance costs, which is the
underlying problem we have here.
If this bill doesn't pass, we continue to fund abortion providers. I
think this is the best bill in decades for those of us who wish we
would stop funding these organizations.
We are providing assistance for people who can't get insurance
through their employer. It is high time the Tax Code provided equality
for people who get insurance from their employer and those who don't.
Finally, if we don't pass this bill, we don't end ObamaCare.
The SPEAKER pro tempore. The time of the gentleman has expired.
Mrs. BLACK. Mr. Speaker, I yield an additional 30 seconds to the
gentleman.
Mr. GROTHMAN. Already a third of the counties only have one provider.
If we don't pass this bill now, we are going to go into the next year
and we are going find a lot of people who think they have ObamaCare but
have nothing because there will be no providers left.
We have got to step in to save those people and provide insurance in
those counties in which ObamaCare will leave no insurance companies
remaining.
Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for
this bill will result in 44,600 people from his congressional district
in Wisconsin losing health coverage and care.
Mr. Speaker, I yield 2 minutes to the gentlewoman from Illinois (Ms.
Schakowsky), a distinguished member of the Budget Committee and the
Energy and Commerce Committee.
Ms. SCHAKOWSKY. Mr. Speaker, I sincerely ask my Republican
colleagues: Did you really come here to take health care away from 24
million people?
Over 40,000 people in my district will lose their coverage.
Did you come to Congress to make insurance more expensive for my
constituent, Mary, who has a preexisting condition and now pays half of
what she used to pay for insurance because of the tax credits she got
from ObamaCare?
Did you come to Congress to impose a crippling age tax on Americans
50 to 60 years old?
Your bill would increase their premiums an average of $8,000 a year.
According to the Congressional Budget Office, within 10 years, nearly
30 percent of those 50-to 64-year-olds would be without any insurance.
Did you really come to Congress to take nursing home and home care
away from the elderly and the disabled?
Did you get elected in order to take health care from mothers?
Your bill would kick them off of Medicaid if they don't find a job 60
days after they give birth.
We have heard over and over that patients need choices and should be
empowered to choose the care that they want. But, apparently, that
doesn't apply to women. The bill would block millions of women from
choosing Planned Parenthood, a trusted healthcare provider to 2.5
million patients every year.
The American people are not clamoring for you to repeal ObamaCare.
Only 17 percent of Americans say that you should vote to repeal
ObamaCare. The average American overwhelmingly wants you to vote
``no.''
Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from
Kansas (Mr. Marshall), who is a physician.
Mr. MARSHALL. Mr. Speaker, Kansas voters sent me to fix health care.
Doing nothing is not an option. I cannot sit here idly while the ACA
destroys and bankrupts America's healthcare system.
This bill eliminates nearly a trillion dollars of taxes. This bill
eliminates funding for Planned Parenthood. This bill will save many
hospitals in Kansas from closing by increasing funding for Medicare
patients. This bill allots $100 billion for high-risk pools. This bill
specifies another $15 billion specifically for maternity coverage,
which is near and dear to my heart; newborn care; mental health care;
and substance abuse disorders.
Mr. Speaker, this is the best bill that we can get through this
process. I am excited to be part of it. This is the first chapter of a
new book, with many more chapters to come. We will fix health care.
Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for
this bill will result in 50,000 people from his congressional district
in Kansas losing health coverage and care.
Mr. Speaker, I yield myself 2 minutes.
Mr. Speaker, in concluding the presentation from the Budget
Committee, I just have to say that the bill we are considering today is
a mess. It is not a healthcare bill at all.
This bill is driven by a desire to cut taxes for the wealthiest
Americans and many wealthy corporations by nearly $1 trillion in all.
It is paid for by making health care unaffordable for millions of
people.
This is irresponsible. It is not what the American people want, it is
not what they deserve, and it is certainly not what they can afford.
We are not the only ones opposing this legislation. It is opposed by
an amazing array of American organizations and individuals, including
the American Medical Association, the American Hospital Association,
the American Nurses Association, the National Rural Health Association,
AARP, the National Disability Rights Network, the American Diabetes
Association, American Cancer Society, and Easterseals, virtually every
healthcare and consumer advocacy group, Governors from both sides of
the aisle, and a growing list of our Republican colleagues.
Mr. Speaker, I thank the Budget Committee staff for the incredible
job they have done throughout this process.
Mr. Speaker, I reserve the balance of my time, and I ask unanimous
consent that the gentleman from New Jersey (Mr. Pallone), chairman of
the Energy and Commerce Committee, control the balance of my time.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from Kentucky?
There was no objection.
Mrs. BLACK. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, I want to remind my fellow colleagues that, currently,
when we look at the access to care for people, one-third of our
counties only have one provider; two-thirds of our counties only have
two providers. In my State of Tennessee, there are 14 counties where
they will have no insurance provider on the marketplace. So when we
talk about people losing their insurance, they are losing their
insurance by not having access to even purchase the insurance.
One of my former colleagues, the gentleman from Minnesota, asked:
What are my colleagues on the other side of the aisle trying to
preserve?
I want to point to this chart here to ask that question, because
these are the broken promises of ObamaCare.
Why are you trying to preserve something where they say premiums will
decrease by $2,500, and we see the average family premiums have soared
by $4,300, making insurance unaffordable for many families?
Another broken promise: the cost of health care will go down.
We see some deductibles that have gone up as much as 60 percent. In
my own State, they have gone up by 63 percent, making coverage
unaffordable.
You can keep your doctor--70 percent of the plans consist of narrow
networks, which means they cannot keep their doctor. I cannot tell you
the number of people who have called me because their doctor was not on
their inept plan.
Finally, ``middle class Americans won't see a tax increase.'' This
was a promise by former President Obama. ObamaCare penalties were put
in place, so people are receiving a tax penalty.
These are the broken promises that the other side of the aisle wants
to continue to protect. As opposed to that, we

[[Page H2415]]

want a system that is going to be open with patient care and give
affordability so people can get the services that they want with a cost
that they can afford.
I also thank the Budget Committee for the work that they have done,
and all the staff that have worked endless hours to make it possible
for this to be here on the floor today.
Mr. Speaker, I yield 30 minutes to the gentleman from Oregon (Mr.
Walden), and I ask unanimous consent that he may control that time.
The SPEAKER pro tempore. Is there objection to the request of the
gentlewoman from Tennessee?
There was no objection.
Mr. WALDEN. Mr. Speaker, I yield myself such time as I may consume.
After 7 years, we have heard the stories of our constituents,
patients, friends, and family who have suffered under ObamaCare. We
have heard from those who have benefited in some respects.
I think of the struggles of constituents like Indra from Bend,
Oregon. She lost her private insurance and her preferred doctor. When
she went to look for a new plan under ObamaCare, she found the plans
were too expensive, and she went without insurance for almost 2 years.
See, her story should not be lost in this debate either.

{time} 1230

Then there is April. Last fall, she found out her insurer would not
be offering her plan this year. The most comparable plan available
would raise her monthly premium by $564 per month, bringing her total
monthly premium to $1,503.
You see, there is a whole other group of Americans out there who are
suffering these effects of ObamaCare. The American Health Care Act
represents a better way for patients like Indra and April all across
our country. Our plan will rescue and revitalize the market and lower
costs and increase flexibility for patients to choose. They will have
more choices for health care and keep a health insurance plan that
works for them and for their family.
This legislation creates the Patient and State Stability Fund. Now,
this is an innovative approach to give States the financing and
flexibility to repair the damage done to the insurance markets by
ObamaCare and meet the unique needs of their citizens. More
importantly, we provide an additional $15 billion, Mr. Speaker, to
States devoted for maternity coverage. We heard from people who said we
need to do more in this area: newborn care, mental health, and
substance disorders.
We are also taking action to strengthen Medicaid. We want to put
Medicaid on a sustainable path so it can better care for those it was
intended to serve, a path through this per capita program for States
that, frankly, was at one time embraced by Democrats, including
President Clinton.
The most vulnerable in our communities need this help. It represents
the most substantive reform to the Medicaid program since its creation
and will restore power to our States and local communities and
governments where they can make better decisions than a one-size-fits-
all here in Washington. We want to give our States more control in how
they manage these people that they are closest to.
In closing, I want to thank our colleagues and the President of the
United States and the Vice President and Secretary Price. They have
worked day in and day out, tirelessly, without hesitation, to help get
to the best policy possible here and to work and listen to our
colleagues, as we have all done, to craft the best bill we can, given
the constraints under which we must operate.
The end result highlights the diverse ideas of our Conference that
come from the American people and the determination that we share to
save this market and make it work again.
Remember, we are talking about a narrow slice of the insurance
market, that driven by ObamaCare, that, last year, there were 225
counties in America where, if you were looking for insurance on that
exchange, you had one option. This year, it is 1,022 counties. That is
one out of every three in America. And that was before Humana pulled
out and other companies said this market is about gone.
We need to fix this market. That is what this legislation seeks to
do.
Mr. Speaker, I want to thank our terrific staff that has worked day
and night to get us to this point. We know there is a lot more work to
do. This should not be taken in isolation as the only healthcare reform
on our list. We are going to go after the cost drivers. We are going to
go after prescription costs. We are going to go after hospital costs.
Wherever it is in the health system, if you have nothing to hide, you
won't have to fear our investigations. But we are going to get costs
down. We are going to get costs down.
The American Health Care Act is just the first step in our mission to
rescue the American people from the failures of the underlying law. We
know they are there. We are going to fix this. We are committed to it.
Mr. Speaker, I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, I remind my colleague, my chairman, Greg Walden, that
his vote for this bill will result in 64,300 people from his
congressional district in Oregon losing health coverage and care.
Mr. Speaker, President Trump and congressional Republicans are not
leveling with the American people when they say no one will be worse
off under this repeal bill. TrumpCare dismantles the health and
economic security that millions of hardworking Americans have gained
over the last 7 years, and it should be defeated.
There is a reason this bill was hatched up in the back rooms only to
be finalized last night, and that is because congressional Republicans
did not want the American people to see what was in it.
TrumpCare provides less coverage, fewer protections, and higher
costs.
TrumpCare is Robin Hood in reverse, taking benefits and financial
assistance from hardworking, middle class Americans and our most
vulnerable in order to give tax breaks to the wealthiest and the
corporations.
TrumpCare cuts a combined $1 trillion from Medicare and Medicaid.
These cuts are devastating, Mr. Speaker.
TrumpCare will ration care for the 76 million Americans who rely on
Medicaid, including seniors with long-term care needs, Americans with
disabilities, pregnant women, and vulnerable children.
I fear for seniors, Mr. Speaker, those in nursing homes. When States
get less money, what will they do? They will give less money to nursing
homes. We will go back to the days that I remember in New Jersey when
nursing homes were terrible places, where there weren't enough nurses,
where there were fires because of lack of maintenance of the nursing
home.
Working families are going to pay more for less. They will see their
premiums and deductibles skyrocket. My GOP colleagues talk about high
deductibles and copays. Well, you ain't seen nothing yet.
You are going to see that this repeal repeals the limits on
deductibles and copays that exist under the current law. Out-of-pocket
costs are going to go through the roof. The deductibles will go even
higher. The copays will go even higher. The out-of-pocket costs will go
even higher.

And the bottom line is Americans between the ages of 50 and 64 will
pay an age tax and be forced to pay premiums five times higher than
what younger people pay for their coverage.
I have heard my colleagues on the other side say, well, that is only
fair. Well, I don't think it is fair that seniors should have to pay a
lot more, that those between 50 and 64 should have to pay a lot more.
Also, TrumpCare leaves the sickest and vulnerable Americans at the
mercy of insurance companies, allowing them to charge a 30 percent
penalty or sick tax to those who are unable to maintain continuous
coverage. So if you fail to pay your insurance for a month and then you
want to get it again, even if you have a preexisting condition, which
is often the case, you are going to pay a 30 percent penalty, or sick
tax. I don't think that is very fair.
Last night, in order to garner votes from the extreme right in their
party, House Republicans added a provision that eliminates protections
for essential health benefits. Now, maybe people don't understand that,
but let me explain it.

[[Page H2416]]

The ACA ensured that, when a consumer purchased health insurance on
the individual market or gained coverage through Medicaid expansion,
their plan would cover 10 critical, essential benefits.
TrumpCare eliminates this guarantee, meaning that unscrupulous
insurance companies can sell skeletal plans, junk insurance, without
benefits for hospitalization, maternity care, mental health, drug
treatment services, and Americans won't even know what they are
getting. They won't realize that they have worthless insurance until
they get sick and it is too late.
The bottom line is this bill should be defeated for so many reasons
because so many more people will not have health insurance, because
their costs are going to go up, and because they won't even know what
insurance they are buying. We are going go to back to the old days of
the Wild West when insurance companies could sell whatever junk
insurance they want and the public won't even know what they are
getting. It is a disaster for the American people.
I urge my colleagues to vote ``no,'' and I reserve the balance of my
time.
Mr. WALDEN. Mr. Speaker, I yield myself 20 seconds.
The irony of that argument is it was just a year or so ago that every
Member of this House who was here at the time and the Senate, by a
unanimous vote, agreed to waive the essential benefits he just listed
off for the employment market between 51 and 100--and, by the way,
those essential benefits don't apply to the large group market--so this
has already been done.
I yield 1\1/2\ minutes to the gentleman from Texas (Mr. Barton), the
vice chairman of the full committee.
Mr. BARTON. Mr. Speaker, I supported this bill when it came out of
the Energy and Commerce Committee 2 or 3 weeks ago, and I want to thank
Chairman Walden for his excellent leadership.
As he knows, I had some concerns about the bill at the time. I didn't
think it addressed all the problems that we needed to address.
At the start of this week, I was a ``no'' vote--a friendly ``no''
vote, but I was a ``no'' vote. Our Republican leadership in the House
and the President and his senior advisers continued to involve
themselves in constructive discussions with people like myself.
Yesterday they agreed to put back in the repeal of the essential health
benefits provision, and that is a big win for conservative values, so I
am now a ``yes'' vote.
My friends on the left seem to think the only way to get a benefit is
to have the Federal Government mandate it and then have the Federal
Government pay for it. I am here to tell you, Mr. Speaker, that markets
work. If we create a healthcare market where people can choose their
insurance that fits their needs, there will be plans that provide for
every so-called essential health benefit. But there will also be plans
that provide for specific markets of young people without children or
elderly couples or whatever it is.
Mr. Speaker, markets work, and you don't have to mandate benefits for
those markets to work.
The SPEAKER pro tempore. The time of the gentleman has expired.
Mr. WALDEN. Mr. Speaker, I yield an additional 15 seconds to the
gentleman from Texas.
Mr. BARTON. Mr. Speaker, we always want to score a touchdown.
Sometimes we take a field goal. What we don't want to do today is take
a safety.
Vote for this bill. Let's send it to the other body and continue to
work to improve it. It is a good bill. Please vote ``yes.''
Mr. PALLONE. Mr. Speaker, I remind my colleague that, in Mr. Barton's
case, his vote for this bill will result in 64,900 people from his
congressional district in Texas losing health coverage and care.
I yield 2 minutes to the gentlewoman from California (Ms. Eshoo).
Ms. ESHOO. Mr. Speaker, I thank the gentleman for yielding me time.
Mr. Speaker, the American people are very smart. They listen up. They
kind of knit their eyebrows together. They listen to the debate. They
want the facts, and then they make up their mind. What our colleagues
on the other side of the aisle have brought forward today is a disaster
for the American people, and the American people know it.
You have 17 percent of the American people that are for your plan,
and the reason why? They know there are going to be higher costs.
Families are going to have to pay more and get less--pay more for their
premiums, more for their deductibles, and more in their out-of-pocket
costs.
You are taking health care away from 24 million Americans. That is
more than the entire population of Australia. Who comes to Congress to
hurt people?
The promise of the Affordable Care Act was no one--no one ever
again--will be able to take away your insurance the way the insurance
companies did 7-plus years ago. Now it is only the Republican Party
that can take away Americans' insurance.
There isn't one developed country in the world that has your plan. It
is a combination of all kinds of things to get votes.
What free markets? What are you talking about? There is hypocrisy
here because you all have the Affordable Care Act insurance. Every
single Member of Congress does. So I guess it is good enough for you
but it is not good enough for your constituents.
This is a matter of life and death. You are playing with people's
lives. It is a profound issue. This doesn't deserve one vote in the
House of Representatives. Vote it down.
The SPEAKER pro tempore. The Chair would remind all Members to direct
their remarks to the Chair.
Mr. WALDEN. Mr. Speaker, I yield myself 10 seconds before I yield to
the gentleman from Michigan.
I would just suggest that the American people are very smart.
Unfortunately, under ObamaCare, 19.2 million Americans said: I am not
going to buy ObamaCare. I am going to pay a penalty to the IRS instead.
You see, we are trying to fix it so they will want to buy it.
I yield 2 minutes to the gentleman from Michigan (Mr. Upton).
Mr. UPTON. Mr. Speaker, you know, there is an old Upton family quote
that my grandfather would always say: Was you always perfect? No, none
of us are.
And you know what? This is not a perfect bill. That is for sure. But
ObamaCare is broken. One out of three counties has only one provider,
and it looks like it is going to get worse as other major insurance
companies are on the verge of pulling the plug.
Nearly two dozen of the nonprofit CO-OPS have already gone belly up.
In my home State, folks saw their premiums increase by nearly 17
percent. Some States have had premium increases of more than 100
percent. Most had double-digit increases, many over 20 percent, and
some forecast 40 to 50 percent increases come fall if nothing happens.
The calls on both sides of the aisle have often used the R word--on
this side, ``replace''; on your side, the Democratic side, ``repair.''
Let's both agree. The status quo is not acceptable. But this, this
bill, is the only train leaving the station. Is it going to improve if
it gets to the Senate? Of course it will. We should all work for that
goal.
For me, I worked with Medicaid expansion States like Michigan
providing a reasonable transition until 2020 and then grandfathering
all those folks until they are off. Some of my colleagues called to end
Medicaid expansion even this year. They want total repeal.

{time} 1245

What would total repeal mean? Total repeal would mean taking away the
ability of HHS to provide flexibility to the States to administer this
critical program. It would mean taking away insurance for young kids on
their parents' policies. It would reinstall a cap on insurance. And,
yes, it would allow insurance companies to discriminate against those
with preexisting illnesses.
This bill still allows all of those important protections to stay in
place. A number of us will continue to work with HHS to provide even
more flexibility to States like Michigan. This has to be a key
component of moving forward.
At the end of the day, I would like to think that we could work
together on a bipartisan basis. High premiums and a lack of access
impact us all. Let's work together. You can't get to second base unless
you get to first.

[[Page H2417]]

Mr. PALLONE. Mr. Speaker, I remind my colleague from Michigan that
his vote for this bill will result in 43,500 people from his
congressional district in Michigan losing health coverage and care.
Mr. Speaker, I yield 1 minute to the gentleman from New York (Mr.
Engel).
Mr. ENGEL. Mr. Speaker, when people look at these bills, they want to
know what they are going to pay. What this bill does is simple--you pay
more and you get less. That is the bottom line--pay more and get less.
The President promised better health care for more people at a lesser
cost. But my Republican colleagues can no longer claim with any
credibility that their plan achieves these goals.
Twenty-four million people will lose coverage. People 50 to 64 will
be hit with an age tax and pay premiums five times higher than
everybody else. Deductibles will go up. And protections that make sure
insurance companies offer minimum value will be thrown out.
Again, the Republican bill, TrumpCare--pay more, get less--but it
gives billionaires a tax break. That is really important; isn't it?
With the Affordable Care Act, we set out to give Americans more
affordable, higher quality health care.
Is the law perfect? No. We should be working together to tweak the
law. We should be working together to improve the law, not putting in a
clunker like this bill, which will roll back the time on people's
coverage. Roll back the time, give people less coverage, and let them
pay more. That is not what the American people want. I urge my
colleagues to vote ``no.''
Mr. WALDEN. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from
Mississippi (Mr. Harper), the chairman of the House Administration
Committee, and a valuable member of the Energy and Commerce Committee.
Mr. HARPER. Mr. Speaker, ObamaCare has failed. Contrary to what was
promised, premiums have gone up and there are fewer health insurance
options. This bill addresses a crisis that before now had no end in
sight.
Not only does this bill work to solve the problems we see in the
private insurance market, it addresses one of our Nation's most vital
programs--Medicaid. This program is a critical lifeline for hundreds of
thousands of Mississippians.
Medicaid is a safety net program that was designed for children, the
elderly, pregnant mothers, and the disabled. This bill will refocus
attention back on the program's initial goals, but will modernize it to
better serve these patients.
We should move decisionmaking authority down to those who are best
positioned to address these problems. A program run primarily by the
States with assistance from the Federal Government will best be able to
help those who need it most.
By giving States more tools to address costs, this bill will allow
States to explore ways to make accepting Medicaid more attractive to
providers, leading to better health outcomes. Without addressing the
current problems facing the Medicaid program, it will not survive. This
bill puts Medicaid on a path to sustainability. An insolvent safety net
will harm those it intends to help.
This is our moment. We have a historic opportunity to enact the
biggest entitlement reform in our lifetime. We have a chance to save
Medicaid.
I urge my colleagues to vote for this bill.
Mr. PALLONE. Mr. Speaker, I remind my colleague from Mississippi that
his vote for this bill will result in 69,600 people from his
congressional district losing health coverage and care.
Mr. Speaker, I yield 2 minutes to the gentleman from Texas (Mr. Gene
Green), the ranking member of the Health Subcommittee.
Mr. GENE GREEN of Texas. Mr. Speaker, this is outrageous. TrumpCare
will rip health insurance from 24 million Americans, almost as many
people who live in the State of Texas.
TrumpCare is a direct assault on the President's promise to the
American people. It will saddle families across the country with
massive health costs. It will lead to higher premiums, less benefits,
and more people uninsured.
Under this bill, premiums increase 15 to 20 percent in each of the
next 2 years. It will particularly be terrible for the near-elderly
Americans because TrumpCare allows insurance companies to charge them
five times higher than what others would pay for coverage. It destroys
protections for Americans with preexisting conditions. It guts the
essential benefits so consumers won't know what coverage they have.
Plans would not have to cover things like emergency care,
hospitalization, or even prescription drugs.
What do you do when you leave people with that? Junk plans that are
insurance in name only. What is the point of having insurance if it
doesn't cover anything?
For those who aren't one of the 24 million who lose insurance, many
will be left with plans that are more expensive but don't have to cover
things like prescription drugs or mental health and substance abuse.
This bill will make it harder for people to get treatment. It will
destroy the Medicaid program, the bedrock of our social safety net that
insures 74 million Americans, including children, pregnant women, and
one in seven seniors on Medicare.

TrumpCare harms Medicare. It will make the program insolvent 3 years
earlier, directly causes part B premiums to go up $8.7 billion, and
takes away funds that seniors depend on for long-term care. It is
impossible to overstate how terrible TrumpCare will be for the American
people.
This is a dangerous bill. It is opposed by physician groups and
hospital associations.
I urge my colleagues to vote ``no.''
Mr. WALDEN. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from
Kentucky (Mr. Guthrie), the former head of the Medicaid task force.
Mr. GUTHRIE. Mr. Speaker, about 7 years ago, I was on the floor
talking on the Affordable Care Act. And I remember talking about, I had
just left the State Senate, and bringing up that my colleagues are in
Frankfort and they are doing work on the budget; and, in the future, it
is going to make it more difficult for them to pass budgets because of
the expansion in Medicaid, and that is coming to pass. It will be in
the next budget session they have to deal with moving forward, if we
don't address this situation.
So people keep talking about a rush process. Over a year ago, we put
together a Medicaid task force, met with groups of people, met with
Governors, we took a lot of information, and put together a plan that
addresses the needs of Medicaid. Medicaid is growing. It will be over a
$1 trillion program within 10 years if we don't deal with it. It is
going to implode. So we actually worked to put it on a sustainable
budget. It is growing. People talk about cuts to Medicaid. Only in
Washington, D.C., is slowing the growth of a program looked at as a
cut. So we have worked hard to move that forward.
The other thing I want to talk about is, last year, small businesses
were going to be hit by the minimum essential benefits. Small
businesses were saying: We like our plans, and we want to keep it. We
are going to have our prices go up, and we are not going to be able to
afford to provide coverage.
So we all came together, bipartisan, to address that to exempt the
small-business plans for those programs. It passed by voice vote in the
House, unanimous consent in the Senate, and signed by then-President
Obama.
So the question is, if small businesses can design and keep their own
plans, I think individuals can, too.
I agree with my friend from California that the American people are
smart. I disagree with my other colleague who says: They will buy
things, and they won't even know what is in it.
They are smart, and I urge support for this bill.
Mr. PALLONE. Mr. Speaker, I remind my friend from Kentucky that his
vote for this bill will result in 44,000 people from his congressional
district losing health coverage and care.
Mr. Speaker, I yield 2 minutes to the gentlewoman from Colorado (Ms.
DeGette).
Ms. DeGETTE. Mr. Speaker, President Trump promised his healthcare
plan would be ``much better health care at a much lower cost.''
Secretary of Health and Human Services Tom Price even promised ``nobody
will be

[[Page H2418]]

worse off financially.'' In reality, of course, the TrumpCare bill will
leave just about everybody worse off, with less care at a higher cost.
This bad bill would rip health insurance money away from millions of
people--24 million over 10 years, and 14 million next year alone.
Americans who are lucky enough to hold on to coverage if this bill
becomes law will pay more for it in premiums, deductibles, and other
out-of-pocket costs, especially people age 50 and up.
Mr. Speaker, the deals that were cut last night to win more
Republican votes for TrumpCare would be even more devastating. Trips to
the emergency room, mental health and substance abuse treatment,
maternity care both before and after birth, prescription drugs, lab
tests, and more essential services could be cut.
Apparently, some people don't think these services deserve guaranteed
health insurance. They would let insurers sell skimpy plans that don't
even cover patients' basic needs.
Democrats believe we can, and should, work together to improve the
ACA, not to work on a misguided bill that would gut it.
We owe this to folks like Amanda Miller of Denver. Amanda changed
jobs last year. During her period of unemployment, she and her husband
decided the smart thing to do was to get coverage to fill the gap.
Thank God they did.
Shortly after that, she and her husband got into a serious car
accident. Amanda walked away unscathed, but her husband was badly
injured. She could see more of his skull than she could see of his
scalp. Luckily, there were some nurses in a car behind them, and they
stabilized him and took him to the emergency room.
Their hospital bill of $16,000 was paid in full, thanks to Amanda's
coverage through the ACA. What do we say to Amanda? Can we guarantee
her better insurance and a better financial situation? I don't think
so.
Let's defeat this bill, and let's start working towards a good one
that will cover everybody.
Mr. WALDEN. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from
Indiana (Mr. Bucshon).
Mr. BUCSHON. Mr. Speaker, when ObamaCare was debated 7 years ago, I
wrote my Member of Congress to urge him to vote against what I saw as a
government takeover of our healthcare system.
At that time, I was a practicing physician, and I could foresee the
disastrous consequences of this law and what it would do to patients
across this country, including my own. And I wasn't alone.
Citizens from every corner of America stood up and demanded that
Congress reject the ObamaCare bill, but we were ignored. Since then,
out-of-pocket costs for families have skyrocketed, patient-choice has
evaporated, and ObamaCare has inched closer to the brink of collapse.
In that time, those same Americans who fought against passage of
ObamaCare have delivered Republicans majorities in the House, in the
Senate, and put a Republican in the White House. They did so, in part,
based on our promises to repeal and replace ObamaCare.

And here we stand, 7 years after ObamaCare passed, with the
opportunity to finally deliver on that promise, and to bring relief to
patients across this country who haven't been able to find the care
they were promised at a cost they can afford.
It is an opportunity for us to fulfill our promise to our
constituents. Let's be clear: a vote against this bill today is a vote
for preservation of the ObamaCare disaster, a vote to keep critical
healthcare decisions in the hands of bureaucrats in Washington, D.C.,
and a vote against the largest entitlement reform in a generation.
I urge all of my colleagues to do the right thing and vote for this
bill.
Mr. PALLONE. Mr. Speaker, I remind my colleague from Indiana that his
vote for this bill will result in 37,800 people from his congressional
district losing health coverage and care.
Mr. Speaker, I yield 1 minute to the gentleman from Pennsylvania (Mr.
Michael F. Doyle).
Mr. MICHAEL F. DOYLE of Pennsylvania. Mr. Speaker, for the last 7\1/
2\ years, Republicans have promised Americans something better than the
ACA. Instead, today, they are giving us something much worse.
Twenty-four million people lose their insurance? Stripping away
guaranteed benefits? Putting maternity, mental health, and pediatric
care at risk? Shame on you.
Pitting the elderly against children, the disabled, and the mentally
ill in the Medicaid program? Placing a tax penalty on veterans?
Charging a crushing age tax on 50- to 64-year-olds, forcing them to pay
five times more than what others pay? Shame on you.
This isn't a healthcare bill. This is a tax cut bill masquerading as
a healthcare bill. This bill does nothing to lower premiums, copays, or
deductibles.
You cut taxes by almost $1 trillion for corporations and the rich,
while ransacking Medicaid and the Medicare trust fund. That is
shameful.
Americans will not forget who did this to them today.
Mr. WALDEN. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from
Texas (Mr. Flores), a real leader on the Energy and Commerce Committee.

{time} 1300

Mr. FLORES. Mr. Speaker, we have heard numerous comments from the
left extolling the virtues of ObamaCare, and I think it is instructive
to hear the words of a former Democratic President that is beloved by
the left. Here is what he said less than 6 months ago: ``So you've got
this crazy system where all of a sudden 25 million more people have
health care and then the people who are out there busting it, sometimes
60 hours a week, wind up with their premiums doubled and their coverage
cut in half. It's the craziest thing in the world.''
Mr. Speaker, hardworking American families in my district, they don't
want crazy. They want the American Health Care Act, a sane plan that
gives them their freedom back.
In a few minutes, Mr. Speaker, you are going to hear somebody from
the other side say that a bunch of my constituents are going to lose
coverage. That is absolutely false. Those constituents are getting
their freedom back to choose whether or not they want healthcare
coverage and what kind of healthcare coverage they want. I say vote
``yes.''
Mr. PALLONE. Mr. Speaker, I remind my colleague from Texas that his
vote for this bill will result in 61,900 people from his congressional
district losing health coverage and care.
Mr. Speaker, I yield 1 minute to the gentleman from North Carolina
(Mr. Butterfield).
Mr. BUTTERFIELD. Mr. Speaker, over the last few days, 110
organizations have written to me in opposition to TrumpCare. You know
who they are: AARP, American Hospital Association, American Heart
Association, American Medical Association, American Academy of
Physicians, American Academy of Pediatrics, American Psychiatric
Association, National Association of School Nurses, Alliance for
Retired Americans, American Federation of Teachers, National
Association of School Psychologists, National School Boards
Association, National Education Association, the Children's Defense
Fund, March of Dimes, the National Committee to Preserve Social
Security and Medicare, the American College of Physicians North
Carolina Chapter, North Carolina Society of Addiction Medicine,
Consumers Union, United Steelworkers, AFL-CIO, Families USA, Center for
American Progress, National Association of Pediatric Nurse
Practitioners, and the list goes on and on.
Mr. Speaker, I include in the Record a list of entities opposing
TrumpCare.

1. AARP
2. American Hospital Association
3. American Heart Association
4. American Medical Association
5. American Academy of Physicians
6. American Academy of Pediatrics
7. American Psychiatric Association
8. National Association of School Nurses
9. Alliance for Retired Americans
10. American Federation of Teachers
11. National Association of School Psychologists
12. National School Boards Association
13. National Education Association
14. Children's Defense Fund
15. March of Dimes
16. National Committee to Preserve Social Security and
Medicare
17. American College of Physicians North Carolina Chapter
18. North Carolina Society of Addiction Medicine

[[Page H2419]]

19. North Carolina AIDS Action Network
20. Consumers Union
21. SEIU
22. United Steelworkers
23. AFL-CIO
24. Families USA
25. Center for American Progress
26. Southern HIV/AIDS Strategy Initiative
27. National Association of Pediatric Nurse Practitioners
28. Children's Hospital Association
29. National Rural Health Association
30. American Lung Association
31. ACLU
32. National Urban League
33. Black Women's Health Imperative
34. Communications Workers of America
35. International Brotherhood of Teamsters
36. National Rural Education Association
37. National Association of Social Workers
38. National Association of Pediatric Nurse Practitioners
39. Lutheran Services in America
40. NETWORK Lobby for Catholic Social Justice
41. Children's Dental Health Project
42. Family Voices
43. First Focus Campign for Children
44. American Psychological Association
45. National Council for Behavioral Health
46. National Hemophilia Foundation
47. American Congress of Obstetriticians and Gynecologists
48. American Sexual Health Association
49. Big Cities Health Coalition
50. National Women's Law Center
51. Human Rights Campaign
52. Partnership for America's Children
53. Friends Committee on National Legislation
54. National Partnership for Women & Families
55. Planned Parenthood Action Fund
56. National Center for Learning Disabilities
57. Save Medicaid in Schools Coalition
58. HIV Medicine Association
59. Drug Policy Alliance
60. League of Conservation Voters
61. Natural Resources Defense Council
62. Green Latinos
63. Green For All
64. Safe Climate Campaign
65. Climate Reality Project
66. Center for Reproductive Rights
67. Interfaith Disability Advocacy Collaborative
68. International Federation of Professional and Technical
Engineers
69. Trust for America's Health
70. AIDS United
71. AFSCME
72. Cystic Fibrosis Foundation
73. AASA, The School Superintendents Association
74. Accelify
75. American Foundation for the Blind
76. Association of Assistive Technology Act
77. Programs Association of Educational Service Agencies
78. Association of School Business Officials International
79. Association of University Centers on Disabilities
80. Autistic Self Advocacy Network
81. Center for American Progress Center for Public
Representation
82. Clearinghouse on Women's Issues
83. Colorado School Medicaid Consortium
84. Conference of Educational Administrators of Schools and
Programs for the Deaf
85. Council for Exceptional Children
86. Council of Administrators of Special Education
87. Disability Rights Education & Defense Fund
88. Division for Early Childhood of the Council for
Exceptional Children (DEC)
89. Health and Education Alliance of Louisiana
90. Healthy Schools Campaign
91. Higher Education Consortium for Special Education
92. Judge David L. Bazelon Center for Mental Health Law
93. LEAnet, a national coalition of local education
agencies
94. Learning Disabilities Association of America
95. Lutheran Services in America Disability Network
96. Michigan Association of Intermediate School
Administrators
97. Michigan Association of School Administrators
98. National Association of Pediatric Nurse Practitioners
99. National Association of State Directors of Special
Education (NASDSE)
100. National Association of State Head Injury
Administrators
101. National Black Justice Coalition
102. National Center for Learning Disabilities
103. National Disability Rights Network
104. National Down Syndrome Congress
105. National Health Law Program
106. National Respite Coalition
107. Paradigm Healthcare Services
108. School Social Work Association of America
109. School-Based Health Alliance
110. Society for Public Health Education
111. Teacher Education Division of the Council for
Exceptional Children

Mr. BUTTERFIELD. What is it about this, Mr. Speaker, that you don't
understand?
You are wrong on this. Don't let your base push you over the cliff on
this bill.
Mr. WALDEN. Mr. Speaker, I yield 1\1/2\ minutes to the gentlewoman
from Indiana (Mrs. Brooks).
Mrs. BROOKS of Indiana. Mr. Speaker, I appreciate the passion I have
heard from colleagues on both sides of the aisle and from Hoosiers on
all sides of this issue. The issue of health care is personal for
people, and it should be. But today, health care isn't personal. Under
ObamaCare, healthcare coverage has been a one-size-fits-all approach.
I have heard from so many of my constituents in my more than 4 years
in Congress about how ObamaCare has cost them and their families--lost
doctors, higher premiums and deductibles, and a lack of options for
coverage.
As an example of just one of those Hoosiers, Lon told me his premiums
and deductibles doubled last year when he lost his healthcare plan. He
has had to change his insurance 3 times in 3 years. That is not how
healthcare coverage should work.
The American Health Care Act makes healthcare coverage more personal
for every American. This bill empowers you, and every American, to
choose the best health care for you and your family. It empowers our
Governors and our State legislatures to meet the individual healthcare
needs of their citizens, including the people struggling to make ends
meet and the most vulnerable: the elderly, pregnant moms, kids, and
people with disabilities.
I applaud our Hoosier Governor Holcomb, who wrote a letter to
Congress with other Governors from around the country who support this
bill, he, too, believes it is in the best interest of Hoosiers. I agree
and I urge my colleagues to join me in support of the American Health
Care Act.
Mr. PALLONE. Mr. Speaker, I remind my colleague from Indiana that her
vote for this bill will result in 37,700 people from her congressional
district losing health coverage and care.
Mr. Speaker, I yield 2 minutes to the gentlewoman from Florida (Ms.
Castor), the vice ranking member of our committee.
Ms. CASTOR of Florida. Mr. Speaker, my neighbors back home in Florida
work very hard for their health coverage. When they pay their hard-
earned copayments and premiums, they expect something meaningful in
return: real health care. That is what the Affordable Care Act
provided; not just a piece of paper, but real health services, an end
to discrimination against preexisting conditions, and all sorts of
other consumer protections.
But in the middle of the night last night, the Republicans turned
back the clock. They have eliminated from the basic health insurance
policy coverage for emergency room visits, hospitalization,
prescription drugs, and more.
They have really embraced the moniker of pay more for less. And on
top of it, remember, this bill rips health insurance away from millions
of our neighbors back home. It raises costs on hardworking Americans,
especially our older neighbors. It is practically an age tax, if you
are over 50 years old. It breaks that fundamental guarantee that has
existed for 50 years, that if your family is struck with an Alzheimer's
diagnosis, a child with a complex condition, a handicap, that you are
not going to live your remaining years in poverty, all the while,
taking your tax dollars and shifting it to millionaires and
billionaires and corporations.
TrumpCare is a recipe for disaster. It is a fundamental violation of
the values we share as Americans, and it should meet its demise today.
Mr. WALDEN. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from
New York (Mr. Collins), a real leader on our committee.
Mr. COLLINS of New York. Mr. Speaker, today is a historic day, make
no mistake about it. The American Health Care Act changes the
trajectory of health policy in this country. Here are just a few of the
highlights:
This bill eliminates the individual mandate penalty; eliminates the
employer mandate penalty; eliminates the ObamaCare subsidies in 2020;
eliminates ObamaCare tax increases; eliminates insurance mandates so we
can lower premiums; provides refundable tax credits for individuals and
families who do not get their health insurance through their employer
or the government, and allows them to choose the health care that works
for them; almost doubles the contribution limits

[[Page H2420]]

for health savings accounts; provides $115 billion for the Patient and
State Stability Fund to lower patient cost and stabilize the insurance
market; and enacts the most significant reforms to Medicaid in history,
ensuring that Medicaid is sustainable and available for the most
vulnerable among us for generations to come.
The American Health Care Act is a monumental step toward freedom,
choice, and individual responsibility in health care.
Mr. Speaker, I will proudly vote for this bill today, and I urge all
of my colleagues to do the same.
Mr. PALLONE. Mr. Speaker, I remind my colleague from New York that
his vote for this bill will result in 58,000 people from his
congressional district losing healthcare coverage and care.
Mr. Speaker, I yield 1 minute to the gentleman from Maryland (Mr.
Sarbanes).
Mr. SARBANES. Mr. Speaker, this is a terrible bill. It is a terrible
bill. It is wrong for the country.
Why would the President, why would the leadership on the Republican
side here in Congress, why would they choose as the first order of
business taking healthcare coverage away from 24 million Americans?
It is wrongheaded. It is immoral. It is inhumane. It makes no sense.
It is wrong for America.
In the people's House, we need to vote it down.
Mr. WALDEN. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from
Michigan (Mr. Walberg).
Mr. WALBERG. Mr. Speaker, for 7 years, I have heard story after story
from people in my district about how the Affordable Care Act is
anything but affordable.
Families and small businesses are paying more for less, and insurers
are dropping out of the marketplaces, leaving behind fewer options.
Government-run health care isn't working, and we are repealing and
replacing ObamaCare like we promised our constituents we would do.
The American Health Care Act is the first step of a three-step
process to repair our broken healthcare system. This bill moves power
away from Washington and puts doctors and patients at the center of
their healthcare decisions. It reforms and strengthens Medicaid and
gives States the flexibility to innovate and best meet the needs of
their citizens.
This patient-centered approach will bring costs down, increase choice
and competition, and provide important protections for patients with
preexisting conditions.
Mr. Speaker, these are the types of things we promised, and doing
nothing is not an option. May I remind my colleague from the other side
of the aisle: I have seen those numbers. My constituents will not
simply walk away and do nothing just because the other side says that
they will be uncovered. Now they will have a choice. Those thousands of
people will not walk away. They will choose something better for them.
There will be thousands of people that have insurance that covers their
needs, and not what, Mr. Speaker, my colleague says they will do. They
are not that stupid. They won't walk away.
Mr. PALLONE. Mr. Speaker, I remind my colleague from Michigan that
his vote for this bill will result in 39,500 people from his
congressional district losing health coverage and care.
Mr. Speaker, I yield 1 minute to the gentleman from California (Mr.
McNerney).
Mr. McNERNEY. Mr. Speaker, since the implementation of the ACA, over
3.9 million women age 18 to 64 have gained health coverage through
Medicaid. The ACA ended gender rating, meaning that the insurance
companies cannot charge women more than they charge men for the same
coverage. TrumpCare also eliminates Medicaid funding for Planned
Parenthood, reducing access to health care for women. Millions of women
rely on Planned Parenthood for both routine and lifesaving care, such
as preventative services, family planning, and preventing unwanted
pregnancies. When the GPO strips Planned Parenthood funding, health
care of women will suffer.
TrumpCare and its Medicare cuts also hurts seniors. Older Americans
account for over 60 percent of Medicare spending. Insurance companies
will now be able to charge more based on their age, which will increase
premiums by thousands.
Mr. Speaker, watching Republicans sell this bill is like buying a
used car from a guy with a crooked smile, even they don't believe in
it. I ask my Republican colleagues to withdraw this horrible bill and
work with Democrats to improve the ACA instead of trying to sell this
atrocity.
Mr. WALDEN. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from
Georgia (Mr. Carter), our resident pharmacist on the committee.
Mr. CARTER of Georgia. Mr. Speaker, I am joyous to be here today on
such a historical day. You see, for the past 7 years, I have practiced
in ObamaCare, I have practiced under ObamaCare, and I have practiced in
that setting; and I can tell you that what it promised, it has not
delivered on.
There has not been increased accessibility, no. Instead of that, we
have got five States in our country that only have one plan to offer.
We have a third of the counties in our country that only have one plan
to offer. We have 16 counties in Tennessee that don't even have a plan,
and now we are going to have the opportunity to have access. Now we are
going to have choice.
We have also been told about affordability. Well, let's talk about
affordability. We see what ObamaCare did. It increased premiums 25
percent this year alone; 50 percent in seven States. That is
unsustainable.
What is our plan going to do?
It is going to give affordability. It is going to give competition.
We are going to have choices.
And what else?
It is going to remove red tape. It is going to remove the barriers
between healthcare professionals and patients. It is going to empower
patients. That is what health care in America is about: people making
healthcare decisions with their healthcare practitioners. That is what
we are going to do. That is what this does.
The two worst things that ObamaCare did to the healthcare system in
America, first of all, is it took the free market out of America. It
took the free market out of health care in America. It also expanded
Medicaid, a safety net program that was intended for the aged, the
blind, the disabled, children, and mothers, and extended it to able-
bodied adults--something that it was never intended to do.
Mr. Speaker, I look forward to hearing how many people in my district
are going to be empowered now from the gentleman from New Jersey.
Mr. PALLONE. Mr. Speaker, I remind my colleague from Georgia that his
vote for this bill will result in 62,800 people from his congressional
district losing health coverage and care.
Mr. Speaker, I yield 1 minute to the gentleman from Vermont (Mr.
Welch).
Mr. WELCH. Mr. Speaker, those of us who support the Affordable Care
Act know that the work of improving health care and making it more
affordable and accessible is never done. It matters. It really matters
to the mothers and fathers we represent and to the children that they
love. But this bill, stripping 24 million Americans of health care, a
$1 trillion tax cut to the wealthiest among us, making people 50 to 64
pay five times as much as other Americans, obviously, is a giant step
backwards.
One of those Americans is Linda from Burlington. She left an abusive
marriage, but had to leave her health care behind. The Affordable Care
Act rescued her, and she has gone on to revive her life and her future.

{time} 1315

Our community hospitals that do so much good in our communities have
gone from red ink to black ink by the help that the Medicare expansion
provided.
It is a sad day for this institution. We did all of this without
hearing from a single patient, a single doctor, a single person. We had
no hearings.
Mr. Speaker, can we do better than that?
Mr. WALDEN. Mr. Speaker, I yield 2 minutes to the gentlewoman from
North Carolina (Ms. Foxx), the chairwoman of the Education and the
Workforce Committee.
Ms. FOXX. Mr. Speaker, skyrocketing cost, diminished choices for
patients, small businesses destroyed, fewer jobs, and lower wages, that
is

[[Page H2421]]

ObamaCare's legacy. That is what Democrats imposed on our country.
We believe the American people deserve a better way, and that is what
this legislation will deliver. The American Health Care Act puts the
American people back in control of their health care. It restores
choices, protects the most vulnerable, encourages lower healthcare
costs, empowers States, and frees families and small businesses from
costly taxes and mandates.
Let's keep our promise to provide a better way on health care by
voting ``yes'' on the American Health Care Act.
Mr. Speaker, I ask the gentleman from Oregon (Mr. Walden) to engage
in a brief colloquy.
Health sharing ministries play an increasingly important role in the
lives of many Americans, particularly in the devastating wake of
ObamaCare. In recent days, constituents have expressed concerns about
the future of these healthcare plans, particularly as it relates to
whether they would be considered credible coverage under the bill's
continuous coverage provisions.
Will Chairman Walden work with me, as the bill moves forward, to
ensure we address the concerns of those who benefit from health sharing
ministries?
Mr. WALDEN. Will the gentlewoman yield?
Ms. FOXX. I yield to the gentleman from Oregon.
Mr. WALDEN. Mr. Speaker, I would be delighted to work with the
gentlewoman from North Carolina.
Health care sharing ministries are a vital part of our healthcare
system. They are a shining example of how communities can come together
without government mandates or dictates to provide innovative
healthcare solutions.
I look forward to working with Chairwoman Foxx on these concerns that
have been raised and will work with the Senate to get repeal and
replacement of ObamaCare to the President's desk.
Mr. PALLONE. Mr. Speaker, I remind my colleague from North Carolina
that her vote for this bill will result in 80,600 people from her
congressional district losing health coverage and care.
I yield 1 minute to the gentleman from New Mexico (Mr. Ben Ray
Lujan).
Mr. BEN RAY LUJAN of New Mexico. Mr. Speaker, my Republican
colleagues have called TrumpCare everything from an act of mercy to a
rescue mission. Now, I might live at the end of a long dirt road, but I
didn't fall off the turnip truck yesterday and neither did the American
people.
Congressional Republicans are jamming their catastrophic bill that
will take health insurance away from 24 million Americans, raise your
premiums, raise your deductibles, raise your out-of-pocket costs, and
will slap a crushing age tax on those over the age of 50.
Republicans in Congress promised they would lower costs, but this
mess raises costs on families. Not only does the CBO tell us premiums
will increase 15 to 20 percent, but TrumpCare will allow insurance
companies to increase deductibles and out-of-pocket costs.
Under the guise of State flexibility, Republicans say they are
shifting responsibilities to States. Here is what that means: TrumpCare
will force States to raise taxes and ration care. It will repeal the
requirement for insurance plans to cover doctor visits, emergency room
care, prescription drug coverage, and even mental health services.
Everyone is entitled to their own opinions but not their own facts.
The fact is TrumpCare will raise your premiums, raise your deductibles,
and hurt millions of hardworking families.
I urge my colleagues to vote ``no.''
Mr. WALDEN. Mr. Speaker, I yield 2 minutes to the gentleman from
Pennsylvania (Mr. Murphy), our resident psychologist who does a
remarkable job on mental health care issues and all of these healthcare
issues.
Mr. MURPHY of Pennsylvania. Mr. Speaker, in my district over the time
span since the Affordable Care Act, ObamaCare, was passed, I fielded
many, many a call from persons who said they could not afford health
care. In some of those instances, even though a person was able to
afford the premium, they could not afford the deductible.
A gentleman aged 55 and his wife said they would have to pay $27,000
out of pocket between premium deductibles and copays before they could
use their first benefits. He was one of the 19.2 million Americans who
chose to pay the fine rather than get on the Affordable Care Act,
ObamaCare. We suspect that many more will continue on with saying they
would rather pay a fine or find a way out rather than continue to pay
for it if this continues on as is.
In the past, we have been battling many things under this with regard
to mental health care. The past administration attempted to strip the
protected drug class status for lifesaving psychiatric medications. We
fought back on that. We also worked together, however, in a bipartisan
way to make sure we had assured things for mental health care.
This bill has several provisions which are extremely important. It
has $100 billion which States may use to help in their stabilization
fund to fund mental health care. There is another $15 billion focused
on mental health care. There is $500 billion for substance abuse.
Funding will be in there.
My hope is that States make a decision. It is in their hands with the
passage of this bill so they can make the right choice to continue
mental health care, and I trust they will do that.

Mr. PALLONE. Mr. Speaker, I remind my colleague from Pennsylvania
that his vote for this bill will result in 37,100 people from his
congressional district losing health coverage and care.
I yield 1 minute to the gentleman from New York (Mr. Tonko).
Mr. TONKO. Mr. Speaker, a resounding ``no'' to TrumpCare, President
Trump's broken promise to our great America. There is no disputing the
devastation this bill will cause for America's working families.
TrumpCare will rip health insurance away from 24 million people.
It will raise costs for consumers and lower standards of care, with
premiums rising and deductibles increasing by an average of $1,500.
TrumpCare will eliminate required mental health and addiction
benefits, jeopardizing recovery for millions of Americans in the midst
of this opioid epidemic.
It imposes a crushing new age tax on seniors and those approaching
retirement, amounting to tens of thousands of dollars.
TrumpCare steals from Medicare, and it cuts Medicaid by $839 billion,
mercilessly putting children, the elderly, the disabled, and our most
vulnerable at risk.
It does all this to give a $1 trillion tax cut to millionaires,
billionaires, and corporations.
The American people overwhelmingly reject this bill.
Defeat TrumpCare. Vote ``no.''
Mr. WALDEN. Mr. Speaker, I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentlewoman from
New York (Ms. Clarke).
Ms. CLARKE of New York. Mr. Speaker, I rise today in strong
opposition to this sham American Health Care Act.
I am from Brooklyn, and in Brooklyn we know: Men lie; women lie; the
numbers don't. Here are the numbers:
This reckless and destructive bill leaves 24 million Americans
without coverage. It will cause the uninsured rate for my district to
skyrocket over 12 percent and leave over 400,000 Brooklynites without
coverage.
Because of age discrimination in this bill, the age tax, it will put
our seniors in the terrible position of having to choose between
eating, visiting their doctors, or purchasing medication.
Which one do you, Mr. Speaker, suggest they choose?
I also vehemently oppose the Empire State kickback language put in
this bill as an attempt to get Republican votes. This language is a
dressed up earmark that specifically targets New York City. It targets
my home.
This would further reduce Medicaid funds for New York by an
additional $2 billion. The trade-off, raising city taxes to cover the
gap.
For most Americans, Medicaid benefits are not the end goal but rather
[provides] temporary support, but for our seniors Medicaid can mean the
difference between nursing home care, family home care and dying alone.
I urge my colleagues to consider the harmful real life impact of this
legislation and to oppose it. Brooklyn Resists . . . America must
resist.

[[Page H2422]]

Thank you and I yield the balance of my time.
Mr. WALDEN. Mr. Speaker, I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, may I inquire how much time remains on both
sides?
The SPEAKER pro tempore (Mr. Collins of Georgia). The gentleman from
New Jersey has 68 minutes remaining, and the gentleman from Oregon has
65\1/2\ minutes remaining.
Mr. PALLONE. Mr. Speaker, what did the Chair say?
The SPEAKER pro tempore. One hour and eight minutes remaining.
Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentleman from Iowa
(Mr. Loebsack).
Mr. LOEBSACK. Mr. Speaker, I am disheartened by what Congress is
doing here today.
My number one goal has always been to ensure Iowans have access to
quality, affordable care. This legislation does not do that. It
implements an age tax, raising costs on older Americans. It cuts nearly
$900 billion from the elderly, nursing homes, and disabled children.
This is unacceptable. Exactly those who need health coverage the
most--middle class families, people with disabilities, and those who
are less fortunate--are the ones who lose out in this Republican bill.
I remain committed to working to improve healthcare coverage so it
works better for Iowans and all Americans. We cannot go back to a time
when Iowa families had to choose between putting food on the table and
getting medical care for their children. Unfortunately, that is just
what this bill does.
I urge my colleagues to vote this bill down.
Mr. WALDEN. Mr. Speaker, if I could get an indication in terms of the
amount we are down on each side here? I think we were allocated a half
an hour.
The SPEAKER pro tempore. Is the gentleman referring to the time in
which he is acting as the designee of the gentlewoman from Tennessee on
behalf of the Committee on Energy and Commerce?
Mr. WALDEN. Yes.
The SPEAKER pro tempore. The gentleman from Oregon has 9\1/2\ minutes
remaining in the Energy and Commerce portion of this debate.
Mr. WALDEN. Mr. Speaker, and the minority side? Or is that what is
remaining split equal?
The SPEAKER pro tempore. The gentleman will suspend.
The gentleman from Kentucky has not assigned designees on the basis
of committee affiliation. The rule provides for four total hours of
debate.
Mr. PALLONE. Mr. Speaker, could we just ask the total because then
maybe we can figure it out on the minority side?
The SPEAKER pro tempore. The Chair has provided the total time
remaining for the minority. So that is the total time we are working
back off of. The Chair will consult with the gentleman on the committee
time.
The gentleman from Oregon has 9\1/2\ minutes remaining in the Energy
and Commerce time.
Mr. PALLONE. What is the total time remaining currently?
The SPEAKER pro tempore. There are 67 minutes remaining for the
gentleman from New Jersey as the designee of the gentleman from
Kentucky. That is 1 hour and 7 minutes.
Mr. WALDEN. Mr. Speaker, I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentleman from
Oregon (Mr. Schrader).
Mr. SCHRADER. Mr. Speaker, after all these late nights and backroom
deals, here we are. This version of the bill was just dropped on our
lap this morning, so we ought to take a careful look at what is in
front of us.
First of all, the bill defunds access to preventative health care and
wellness. All the programs that we made progress on will be gone.
It shortchanges the Medicare trust fund. Seniors might be paying
thousands more than they are now to get the care they need.
It returns us to a system with skimpy benefits without serious
coverage for maternity care and mental health.
Most dramatically, the bill dismantles the Medicaid system as we know
it, which has been a success across much of the country.
In Oregon, children and families finally have access to care that
fits their needs. People living with disabilities are leading
productive lives now. Hospitalizations and emergency room visits have
been cut in half, and costs are down.
We are all going to do this--take health care away from 24 million
Americans, 14 million just this next year--and not going to save any
more money than under the original ACA?
Look, I know there are parts of the ACA that need fixing. While
millions of people got coverage for the first time, premiums are still
too high in the individual market. That is only 5 percent.
Vote ``no'' on this bill, and let's make the system better.

{time} 1330

Mr. WALDEN. Mr. Speaker, I don't believe I have any other speakers,
so I will continue to reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentleman from
Massachusetts (Mr. Kennedy).
Mr. KENNEDY. Mr. Speaker, 5 years ago, I got the phone call everyone
dreads. My wife had collapsed at work and was being rushed to an
emergency room. It is a moment that is painfully familiar to far too
many. Time stops. You fight to push your breath down your throat. Your
brain gets stuck in that highlight reel of worst-case scenarios. You
are terrified.
Fortunately, we were among the lucky ones. Lauren was okay. Most
critically, our health coverage gave us the support that we needed to
be able to focus on the one thing that mattered most, her recovery.
For families in America, that is the simple expectation of our
country's healthcare system, a commitment that our society makes to
care for one another in our time of deepest need because our health is
our great equalizer.
No matter your power or privilege, no one among us escapes our time
here on Earth without watching someone we love fight for their life. So
we fortify this social contract, not just out of sympathy for the
suffering, but so that it is there for us, too, when we need its sturdy
brace.
``Blessed are the merciful, for they shall be shown mercy.''
Mr. WALDEN. Mr. Speaker, I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, I yield to the gentlewoman from California
(Ms. Lofgren) for a unanimous consent request.
(Ms. LOFGREN asked and was given permission to revise and extend her
remarks.)
Ms. LOFGREN. Mr. Speaker, I rise in opposition to this terrible bill
that will hurt my constituents in California.
Mr. Speaker, each one of us was elected by our constituents to stand
up for them here in Washington. Today, I will stand up for people who
live in the 19th Congressional District by voting no on this terrible
bill.
It's small wonder that polling shows only 19 percent of Americans are
in favor of this bill. With the bill, 24 million fewer Americans will
have health care insurance. Families will pay increased out of pocket
costs with higher deductibles.
Incredibly, it allows insurance companies to penalize people older
than 50 by allowing them to charge 5 times more for insurance than
younger Americans.
It hurts Seniors in other ways too. . . . by shortening the life of
the medicare trust funds, by increasing costs for medicine for medicare
recipients and by smashing the safety net for nursing home care which
the Medicaid program provides.
Incredibly, it also has a special penalty for veterans, by barring
veterans from receiving tax credits if they are nominally eligible for
VA care, even if there is no room for them at the VA.
Let's stand together for our hardworking Americans all over our
country and in our own districts by voting no on this poorly crafted
bill that cuts taxes for the richest Americans and leaves regular
Americans on the short end of the stick when it comes to health care.
Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentleman from
California (Mr. Cardenas).
Mr. CARDENAS. Mr. Speaker, I rise today to urge my colleagues to own
up to their bad bill. It is clear this is not what the American people
deserve or what the American people are asking for.
This legislation guts Medicaid. It steals from Medicare. It crushes
our seniors and our working families. And

[[Page H2423]]

just when you thought it couldn't get worse, they went after veterans
and their children.
What's more, this bill means insurance companies won't cover new
mothers, newborn babies, and prescription drugs. The Republicans are
making health care for Americans worse and worse and worse.
The Republicans have secretly wheeled and dealed in back rooms at the
expense of millions of Americans in our great country, while giving tax
breaks to millionaires and billionaires.
Mr. Speaker, I urge my colleagues to own up to this bill and oppose
it for the sake of the American people.
God bless us.
Mr. WALDEN. Mr. Speaker, I yield myself such time as I may consume.
One of the great tragedies of this debate is some of the scare
tactics we have heard. And to listen to the gentleman from California
talk about how removing essential benefits from the Federal mandate
from the law is going to cause all that to happen is tragic because he,
on March 25 of 2015, cosponsored legislation that did precisely that,
removed the same Federal mandates for workers in the 51-100 pool of
employees for employers. He said it was too much of a mandate then on
those businesses, when they provide insurance.
So every Member of the House who was here then, and every Senator,
including the Democrat leader of the Senate at the time, voted for
that, passed unanimously.
By the way, the Congressional Budget Office said that those
regulations that we are pulling back here would have made nongroup
premiums 27 percent to 30 percent higher in 2016, than they otherwise
would have been. So we are basically taking what CBO said is a good
policy and implementing it here once again.
Last time, in 2015, that was bipartisan. It was a voice vote. Today,
you would think the world was falling around us, the sky was falling.
Yet, everybody who was here in 2015 said, that is okay, it is the right
thing to do because it will lower premiums, like CBO said, by 27 to 30
percent.
So we thought what was good for those in the work world, for
everybody who is insured through a large group plan, which is about 155
million Americans--they don't live under this mandate, yet they have
all those services and benefits--that that would make sense to lower
premiums for individuals on the ObamaCare exchange, because what I hear
is, premiums are too high, deductibles go up.
Nobody sees this thing coming down. We are making changes here
because those exchanges are collapsing. We want to bring the premiums
down. We want to make the changes that will bring them down. CBO says
doing this on essential benefits would have resulted in nongroup
premiums 27 to 30 percent lower than they would have otherwise been.
They basically say they would be higher in 2016 than they would have
otherwise been. So we are taking that, using that and saying: let's
drive them down; let's get premiums down.
It is unfortunate that you were willing to do that 2 years ago. It
was bipartisan. Today, it is some extraordinary thing we are doing that
is bad. It is not. We want to get lower premiums.
Mr. Speaker, I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, Chairman Walden is completely
mischaracterizing the bill that was led by Mr. Cardenas.
I yield 1 minute to the gentleman from California (Mr. Ruiz).
Mr. RUIZ. Mr. Speaker, the majority of my patients in the emergency
department are age 50 and older. This bill's age tax will devastate
Americans ages 50 to 64 who have worked their whole lives, planned for
retirement, and now are wondering how they will make ends meet.
The age tax will force older Americans to pay premiums up to five
times higher than others, no matter how healthy they are, no matter how
responsibly they have lived, making coverage too expensive, and forcing
them to be uninsured.
For example, Rex, from my district, wrote me that he was worried
about choosing between affordable insurance or saving for his
retirement. Insurance for older Americans like Rex will be too
expensive, leaving them uninsured when they need coverage the most.
Under this bill, a 64-year-old like Rex, with an income of $26,500,
in the individual market, will pay up to $14,000 for health insurance.
That is more than half of their income on premiums alone, leaving
little for food, for medicine, rent, and other basic necessities.
I stand with our older Americans, and I urge everyone, Democrats and
Republicans, to stand with older Americans. Put ideology, partisanship,
and politics aside and do the right thing.
Mr. WALDEN. Mr. Speaker, I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentleman from
California (Mr. Peters).
Mr. PETERS. Mr. Speaker, I came to Congress ready to help improve our
healthcare system. And as our colleagues on Chairman Walden's side have
pointed out, there are some insurance markets that aren't providing the
choice and the low cost that consumers want, so let's fix them.
But that is not what this bill does. This bill takes away health
insurance from 24 million Americans, including 37,000 people in my
district in San Diego. And the last-minute changes made will cost the
Federal Government even more money, without increasing coverage or
reducing premiums. Is that really the best we can do?
The only reason we are in this mess is because the Speaker of the
House only ever sought 218 Republican votes. That is why we are left
with a bill that is opposed by doctors, nurses, hospitals, and just
about everyone because it makes the problems in our healthcare systems
worse, not better. That is what happens when you never even reach out
to the other side.

Whether this bill dies today, or in the Senate, I hope we can get to
work together, Republicans and Democrats, to do better for the American
people.
Mr. WALDEN. Mr. Speaker, I yield myself 30 seconds.
Actually, we did reach out to Democrats. We have always reached out
to Democrats. The vice chair of the Committee held lunches with
Democrats to say: How can we work together on this? And we were told:
No, we can't work with you on this particular measure. I hope we can. I
agree, there is a lot we need to do together. It is what the American
people expect.
We have had these individual conversations out of the bright lights
of the cameras. Let's get together. Let's get this done. A lot hangs in
the balance.
Mr. Speaker, I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentlewoman from
Michigan (Mrs. Dingell).
Mrs. DINGELL. Mr. Speaker, today, the House will vote on a bill that
will take us back in our Nation's history. My family has worked for
decades for affordable quality health care for every American. It took
a long time to achieve the progress we have made today.
We began with Social Security, then we created Medicare, developed
the National Institutes of Health, the children's healthcare program,
and many other efforts that have helped every single one of our
communities across this country.
Hearing after hearing, amendment after amendment, the Affordable Care
Act was eventually developed. Coverage was expanded. Costs were
lowered. Certainty was brought to uncertainty.
Let me remind you that before the Affordable Care Act, many had to
decide between bankruptcy and death. Children hit lifetime caps. Cancer
and being a woman were preexisting conditions where it costs too much
money for premiums, or you couldn't get them at all.
Millions now have coverage who didn't, lifesaving screenings,
preventative care, and, today, we are talking about taking it back by
eliminating essential services. Please vote ``no'' for America's heart
and soul.
Mr. WALDEN. Mr. Speaker, I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, I yield myself 1 minute.
Mr. Speaker, I think it is very telling that the gentleman from
Oregon has no more speakers on his side for what they claim to be a
very significant bill, and it certainly is significant; but the reason
for that, in my opinion, is because this Republican bill is hurting
real people.

[[Page H2424]]

Don't tell the real people, don't tell the Americans in my district
or the rest of the country who are coming to your doors and going to
your legislative offices and calling you by the thousands to tell you
not to pass this bill, don't tell them your answer that I hear over and
over again: Well, trust us. Trust us.
The problem is we have to look at the bill that is before us today.
This is a terrible bill. Millions of people, 24 million people, are
going to lose their insurance. Many more are going to pay a lot more
out of pocket with higher deductibles and higher copays.
And the worst part of all is you are allowing the insurance companies
to sell junk insurance that doesn't even cover their care; it doesn't
even necessarily provide any coverage.
So I ask my colleagues on the other side, think of the people. Think
about your heart. Think about what this really means. And if you look
at it, you will know that this is a bad bill and should be defeated.
Vote ``no.'' I urge my colleagues to vote ``no.''
Mr. Speaker, I reserve the balance of my time.

=========================== NOTE ===========================

March 24, 2017, on page H2424, the following appeared: Mr.
Speaker, I yield back the balance

The online version has been corrected to read: Mr. Speaker, I
reserve the balance

========================= END NOTE =========================

Mr. WALDEN. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, here is what I would say: What you have heard from the
other side is everything is working perfectly; leave it alone.
Democrats created ObamaCare. Democrats created the exchange. They
said: We are going to tell you the kind of insurance you have to buy;
we are going to force you to buy it, or you will answer to the IRS and
pay a penalty. They mandated that.
Then they came back and said: Well, that didn't work so well, so we
had better get rid of the essential benefits for the workers and
employers, 51-100 employees in a company; we are going to take that off
because that will drive up premiums. And they voted unanimously to do
that. Today, they come back and say: Oh, that would be horrible. But
they did it before, so they were for it before they were against it.
But let me talk about what really matters here. First of all, there
is lot of scare tactics out there by a lot of high-paid organizations.
The first is, we preserve your right as a citizen to acquire health
insurance regardless of your health condition.

{time} 1345

So here is the deal: preexisting conditions, we protect that;
lifetime caps, we protect that so that insurance companies can't go
over the top of you; keep your kids on until they are 26, we protect
that. Those were good things. We agree in a bipartisan way those should
be protected. We do that.
But we also recognize that 19.2 million Americans looked at the
Democrats' healthcare exchanges and plans, went the other direction,
and said no. They have walked with their wallets and their feet and
said: I don't like what you are selling and I can't afford what you are
selling. I will even pay the IRS $600 or $700 not to take ObamaCare.
Meanwhile, Mr. Speaker, the insurers have said that the way the
Democrats created the insurance markets all over the country, we can
stay in them. We are losing too much money, and we are out.
That is why in one out of three counties today in America you only
have one choice, and that is called a monopoly. We are trying to fix
this market so people will have choices that are affordable. We are
trying to make sure people have access to coverage they want and can
afford. This is the first step, not the last step, toward fixing this
market.
I look at it like we have poured the foundation. Construction
projects are a little messy when you are just pouring the foundation.
Now we are going to put up the walls, we are going to put the roof on,
and we are going to build this out in multiple steps throughout this
year and next.
Meanwhile, we provide complete coverage. We do all the protections
ObamaCare continues in its support for people while we fix the market
and allow it to come back. We have timed this out. I know there are
some on my side of the aisle who wanted to get rid of those
protections, and we brought them around or they are going to vote
``no.'' But we said: No; we have to have those protections in place--
existing conditions, no more lifetime caps, keeping your kids on until
they are 26.
We have a product here that needs to go to the next step. We will all
work on it and continue to make it better as we go forward. But if we
do nothing and let it fail today, these markets are going to get worse
and worse under the Democrats' ObamaCare plans, and people won't have a
choice in States and counties all over America.
I wish we could join together today and put forward a bipartisan vote
to save these markets and help our constituents going forward. Mr.
Speaker, we owe it to them. They have asked for it for 7 years. Let's
get it done.
Mr. Speaker, I urge support for this legislation, and I reserve the
balance of my time.
Mr. PALLONE. Mr. Speaker, I yield the balance of my time to the
gentleman from Massachusetts (Mr. Neal), and I ask unanimous consent
that he be allowed to control that time.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from New Jersey?
There was no objection.
Mrs. BLACK. Mr. Speaker, I yield 30 minutes to the gentleman from
Texas (Mr. Brady), and I ask unanimous consent that he may control that
time.
The SPEAKER pro tempore. Is there objection to the request of the
gentlewoman from Tennessee?
There was no objection.
Mr. BRADY of Texas. Mr. Speaker, I yield myself such time as I may
consume.
Mr. Speaker, last month, President Trump stood right here in this
room and said to Congress: ObamaCare is collapsing. He called on us to
take decisive action to protect all Americans.
Today we have a choice to make: will we answer the President's call
to action and pass this legislation to repeal and replace ObamaCare? Or
will we allow ObamaCare to remain fully in place and deny our
constituents the relief they urgently need?
I, for one, refuse to allow my constituents in Texas to suffer
ObamaCare's impacts any longer. For the past 7 years, we have watched
ObamaCare fail Americans on every single promise, and throughout this
time, as the Obama administration turned a deaf ear to the American
people, House Republicans were listening. We were listening to all
those facing severe premium increases, people like Lauren in my
district, in my hometown of The Woodlands. Lauren recently emailed me
to say that her premiums this year have gone up by nearly 70 percent.
Now they are $900 a month.
We were listening to all those who can no longer see the doctor of
their choice or access the care they need at an affordable price,
people like Elizabeth from Conroe, Texas, another constituent of my
mine. Her family pays about $800 a month in healthcare premiums, yet
they can no longer see any of the doctors they know and trust. This
includes the primary care doctor that Elizabeth and her husband have
been seeing for over a decade. It includes her children's longtime
pediatrician. All of these doctors are now out of reach, thanks to
ObamaCare.
That is the thing with this law. It has helped some, no doubt, but
far more people have been hurt, people like Lauren and Elizabeth, who
are paying significantly more for significantly less access to health
care.
It doesn't have to be this way. After 7 years of listening carefully
to the American people, we have now arrived at this moment of decisive
action. With the American Health Care Act, we have the best opportunity
since ObamaCare's enactment to repeal this harmful law, clear the deck,
and begin over with a step-by-step process to deliver a healthcare
system based on what patients and families truly want and need, not
what Washington thinks is best.
This bill gets us off to an excellent start. First, it delivers swift
relief to the American people by immediately repealing ObamaCare's most
harmful provisions. The individual mandate--the tax penalty--is gone.
The employer mandate tax penalty is gone. Nearly $900 billion in
ObamaCare tax hikes that have driven up costs and reduced access to
care for families, patients, and jobs, those tax hikes are gone.

From here, the American Health Care Act takes significant action to
replace ObamaCare with patient-focused solutions that expand choice,
lower

[[Page H2425]]

costs, and enhance competition. This is where we reclaim control of
health care from Washington and put it back where it belongs--with
patients, families, and States.
We expand health savings accounts, making them more flexible and more
user-friendly. We protect health coverage for the more than 150 million
Americans who receive it through their job. We deliver the largest
entitlement reform in decades, giving power to States to improve and
streamline Medicaid so they can better serve the needs of local
patients and families.
For low- and middle-income Americans who don't receive coverage
through work or a Federal program, we offer an advanceable, refundable
tax credit that people can use immediately to help purchase coverage
that is tailored to their needs. These tax credits provide a
conservative, free-market alternative to inefficient ObamaCare
subsidies that exist today. They deliver support to low- and middle-
income Americans. At the same time, they will encourage real
competition and choice in the health insurance market.
Finally, as a committed pro-life conservative, I am pleased to say
this bill defunds Planned Parenthood while funding the community health
centers for women's truly needed health care, and takes vital action to
protect the right to life. No Federal funding can be used for elective
abortions. The language is crystal clear.
The American Health Care Act represents a critical first step in our
multiphase effort to tear down ObamaCare and reinstate patient-focused
solutions that help all Americans. But we know there is more work to
do. ObamaCare was a massive government takeover of health care. To
fully uproot the law, it is going to take a sustained, coordinated, and
relentless effort from both Congress and the administration.
Fortunately, we have incredible partners in President Trump and
Secretary Price at the Department of Health and Human Services. They
are already beginning work on the next phases of the process, stripping
away ObamaCare's regulations so we can enact additional free-market
solutions. These include consensus conservative proposals, such as
allowing insurance to be sold across State lines.
But to see success in the next phases, we have to take the first step
today. We have to pass the American Health Care Act, deliver immediate
relief to the American people, and provide a conservative path forward.
In closing, I thank all the leaders in the House who worked hard to
craft the bill before us today: Chairman Greg Walden, Chairman Diane
Black, and so many others.
I also want to offer my gratitude to everyone from the Congressional
Budget Office, the Joint Committee on Taxation, and the House Office of
Legislative Counsel who provided analysis and support as we developed
this legislation.
I would like to give a special thanks to Emily Murry, Stephanie
Parks, and all of our hardworking staff on the Ways and Means
Committee.
At the end of the day, on this day, we will have our first true vote
to repeal ObamaCare. History will record where we stand. This is a
clear choice. We can stand with President Trump and more freedom for
Americans to buy health care they choose, or stand with ObamaCare and
more government that gets in the way. I proudly stand with President
Trump and more freedom for the American people.
Mr. Speaker, I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, I yield myself such time as I may consume.
Recently, President Trump said: Who knew that health care could be so
complicated?
Well, 70 years ago, Harry Truman knew how complicated it could be
when he first proposed national health insurance. Lyndon Johnson knew
more than 50 years ago when he proposed, successfully, Medicare and
Medicaid. Richard Nixon knew when he proposed the individual mandate.
Bob Dole knew when he proposed the individual mandate. In
Massachusetts, Mitt Romney knew when he proposed the individual
mandate.
Mr. Speaker, recently, within the last week, the great on-the-street
writer, Jimmy Breslin, died. Amongst the great columns and the great
books he wrote, one of them that he wrote that will be with us in a
timeless manner was ``The Gang That Couldn't Shoot Straight.''
That is what this institution has been like for the last 10 days.
There were caucuses and there were conferences. People were running
back and forth with new CBO scores and coming back to the floor with
new proposals. Members are put in the position of being offered special
arrangements so that they might be brought over the goal line--that,
after 61 times they have voted in this House to try to repeal the
Affordable Care Act.
Well, here is what we have in front of us this afternoon: a CBO score
says that 24 million Americans will see either an increase in premiums
or they will lose their insurance, there will be an imposition of an
age tax on older Americans, and a tax cut of $1 trillion. This bill has
gone from bad to worse.
If that wasn't enough, to get the votes to pass the bill, they want
to cut prescription drug benefits, mental health benefits, hospital
benefits, and maternity care; and, yes, every one of us in this
institution knows a family who is struggling with a loved one's
addiction, and they want to roll back that benefit.
Recently, the conservative columnist Bill Kristol tweeted:

The healthcare bill doesn't, A, lower costs that they have;
B, it doesn't improve insurance; C, it doesn't increase
liberty; D, it doesn't make health care better. So what is
the point?

Here is the point: it is a $1 trillion tax cut so that they can
change the baseline for their tax cuts that are coming down the road.
That is what this is about.
Now, the President said he wanted an insurance plan that covered all
members of the American family. What they are offering up today is a
plan that cuts health insurance for 24 million American family members.
It does not increase coverage, it does not lower costs, and it does not
strengthen consumer protections.

So what does it do?
Sadly enough, back to the old argument that we have had in this
institution for years: a $1 trillion tax cut for the people at the top
and special interests.
The former speaker here a minute ago, the chairman of the Energy and
Commerce Committee, spoke about perfection. I was here when this
legislation was authored, and I helped to write it. I can tell you this
right now: we knew it was not about perfection, but we subscribed to
the idea, as was the case with Social Security, Medicare, and Medicaid,
that we would improve it as time went on. We would fix it so that all
members of the American family might benefit from the basic notion of
access and affordability as it relates to health care.
So what do we have here?
$839 billion of cuts to Medicaid, which is now long-term care for
members of the American family.
Do you know why?
Sixty percent of Medicaid dollars go to nursing home care, and they
want to cut $839 billion to provide a $1 trillion tax cut. Let me tell
you, members of the American family can understand that.
In Massachusetts, where proudly I can say 100 percent of the children
in our State are covered, 97 percent of the adults in Massachusetts are
covered. And guess what? It polls regularly in the high seventies as to
consumer satisfaction. A Republican Governor of Massachusetts has
advised them to go slowly and to go carefully, that this is not the
path that they want to travel down, as well as other Governors across
the country who happen to be a Republican.

{time} 1400

The hard truth here today is they are asking the American family to
pay more to get less. Dozens of Republicans have said so today.
Secretary Mnuchin recently said that ``there will be no absolute tax
cut for the upper class.'' I hope that the Republican Conference
confers with Secretary Mnuchin so that they might get their facts
straight on this issue.
Mr. Speaker, I reserve the balance of my time.
Mr. BRADY of Texas. Mr. Speaker, I yield 3 minutes to the gentleman
from Ohio (Mr. Tiberi), the chairman of the Health Subcommittee, who
played an invaluable role in solutions to lower healthcare costs for
Americans.

[[Page H2426]]

Mr. TIBERI. Mr. Speaker, I thank the gentleman for his leadership in
this important matter, and I echo his words with respect to the staff,
Emily Murry and her team, as well as Whitney Daffner and Abby Finn in
my office.
Mr. Speaker, like the chairman, I had a front row seat in 2009 and
2010 to the passage of the Affordable Care Act and a front row seat to
all the promises made about this wonderful bill called the Affordable
Care Act.
Then, over the last 6 years, like the chairman, I heard from my
constituents and fellow Ohioans. I heard about their sad ObamaCare
stories of a road of broken ObamaCare promises.
There was a lady east of Columbus who had cancer. She was a survivor.
Fast-forward to a few years ago. She gets cancer again and finds out
that the oncologist that she had, she could no longer have. He was not
in the network. She could not go to the hospital in her community. She
had to go 60 miles away.
Or there is the small-business owner and his wife and family on the
individual market and now on the exchange not getting employer-provided
health care and, therefore, not getting the benefit. They saw their
plan price quadruple in the last several years. Mr. Speaker, we are
going to take care of that person and give them a tax credit so they
have the ability, just like employer-provided employee's health care.
In Ohio, last year, our CO-OP collapsed. We had 20,000 people without
health care. Many saw bills not being paid. Twenty counties in my State
had one provider and fewer choices.
Broken promises. Constituents can't keep their doctor, can't keep
their hospital. Constituents saw emergency room visits go up. It was
supposed to go down under the Affordable Care Act. Premiums and
deductibles are going up, not down, in my district.
One promise wasn't broken, and that is a government-mandated, one-
size-fits-all Washington plan that many of my constituents didn't want
and others couldn't afford. That was their ObamaCare.
We can do better, and in this bill we do. In one step, in the first
step, more steps to come, we begin creating a patient-centered
healthcare system that will not only put more power in the hands of our
constituents, but it will also drive down healthcare costs.
Remember what they said in Ohio newspapers in my State about
ObamaCare: a tough pill to swallow, a nightmare, very taxing, just more
red tape. These aren't my words, Mr. Speaker; these are hardworking
Ohioans' words. They deserve better. They deserve more choices. They
deserve better access, the access and the choices they want for them
and their families.
We begin, Mr. Speaker, with this bill. We don't end here. There is
much more to do. We are putting the people's power back in their hands,
not in Washington's hands. Today, it is time for us to deliver.
Mr. NEAL. Mr. Speaker, I would remind my friend--and he is my
friend--from Ohio that his vote will result in 39,500 people losing
their healthcare coverage if this legislation prevails.
Mr. Speaker, I yield 2 minutes to the gentleman from Michigan (Mr.
Levin), who was a substantive and major player in the development of
the ACA when it was passed.
(Mr. LEVIN asked and was given permission to revise and extend his
remarks.)
Mr. LEVIN. Mr. Speaker, I thank Mr. Neal for his work and that of all
of us on the committee on the Democratic side.
As CBO has said, under this bill, 24 million Americans would lose
their health insurance next year, and 24 million over the next decade.
Today, most are invisible, but they would become seen and heard at
emergency rooms, with no other place to go with more serious illnesses
because of no preventive care.
They are people 50 to 64 with far higher premiums; mothers without
access to affordable maternity care; elderly evicted from nursing
homes, losing coverage from Medicaid, the largest source of long-term
care in our Nation; and lives lost that could have been saved. I
repeat: lives lost that could have been saved.
I remember some time ago I met a woman who had health insurance
through her job. She contracted breast cancer and received treatment
but then lost her job and insurance. Then the ACA covered her. She
looked straight at us and said that, without further treatments, she
would not be alive today.
Under this bill, a trillion dollars is lost for health care, and
there will be a trillion dollars in tax cuts, mostly for the very
wealthy and corporations.
This is not America. I repeat: This is not America.
Mr. BRADY of Texas. Mr. Speaker, I yield 2 minutes to the gentleman
from Nebraska (Mr. Smith), the chairman of the Human Resources
Subcommittee.
Mr. SMITH of Nebraska. Mr. Speaker, I rise today in support of H.R.
1628, the American Health Care Act of 2017. This legislation is the
first step in a process to unravel ObamaCare's taxes and mandates and
provide relief to the American people.
To understand the extent of ObamaCare's failures and their impact on
hardworking Americans and their families, just look at the rapid
collapse of ObamaCare's Consumer-Operated and Oriented Plans, or CO-
OPs.
The story of these failed ObamaCare CO-OPs began in my home State of
Nebraska, with the abrupt collapse of CoOportunity Health, which left
120,000 Nebraskans and Iowans without health insurance. I repeat: It
left 120,000 Nebraskans and Iowans without health insurance.
CoOportunity Health was the first ObamaCare CO-OP to collapse, but it
wasn't long before 18 more followed suit, closing their doors and
leaving hundreds of thousands more without health insurance. Only 4 of
the 23 CO-OPs created under ObamaCare actually remain, and these
remaining 4 will likely face the same fate as they continue to struggle
with dire financial challenges.
Americans were falsely promised, if they liked their insurance, they
could keep it. After complying with ObamaCare's mandates, many
Nebraskans could not even keep the insurance this law created.
One of my constituents in western Nebraska, Pam, who is self-
employed, lost her insurance four times under ObamaCare. Prior to
ObamaCare's implementation, she had a plan she liked and that actually
covered her preexisting condition. She was forced off of that original
plan when ObamaCare began and then lost her coverage three more times
through no fault of her own.
For Pam and millions of others across the country, ObamaCare has
severely limited options for affordable care. This is simply
unsustainable. Constituents in rural districts like mine are being hit
the hardest by ObamaCare's dwindling insurance markets. Because of
ObamaCare, Nebraskans are down to only two insurers from which to
choose, and other rural areas are down to only one or even zero
providers on their exchanges.
Adding insult to injury, according to the Obama administration's own
report on the individual market, 2017 premiums in Nebraska increased by
51 percent.
The SPEAKER pro tempore. The time of the gentleman has expired.
Mr. BRADY of Texas. Mr. Speaker, I yield the gentleman an additional
30 seconds.
Mr. SMITH of Nebraska. Mr. Speaker, places like Oklahoma are
experiencing premium increases of 69 percent, and it is only projected
to get worse if we do not act.
Doing nothing is certainly not an option. We must come together to
rescue this rapidly collapsing healthcare system. Let's come together
to do right by the American people.
I urge passage of this bill.
Mr. NEAL. Mr. Speaker, I would remind my colleague that his vote for
this bill will result in 50,000 people in his congressional district in
Nebraska losing their health coverage and care.
Mr. Speaker, I yield 2 minutes to the gentleman from Georgia (Mr.
Lewis), a giant in terms of the morality of our time and a good friend
and individual who helped write the Affordable Care Act, as well.
Mr. LEWIS of Georgia. Mr. Speaker, I want to thank my friend for
yielding.
Mr. Speaker, I rise to oppose this bill.
As elected Representatives, we have a mission, an obligation, and a
mandate to fight for each and every American.

[[Page H2427]]

I ask you, Mr. Speaker: Who will stand for the American people? Who
will speak up for those who have been left out and left behind?
Mr. Speaker, I have said it time and time again: Health care is a
right. It is not a privilege reserved for a wealthy few, for what does
it profit this body to pass this bill and lose our soul?
This bill is a shame. It is a disgrace.
Mr. Speaker, today my heart breaks for the disabled, for women, for
seniors, and for working families. My heart aches for those who are
living paycheck to paycheck. My heart mourns for innocent little
children whose very lives depend on if their families can pay the
bills.
This is the right and wrong of it. This is the heart and soul of the
matter.
We cannot abandon our principles, Mr. Speaker. We cannot forget our
values. I have fought too hard and too long to back down now.
I will fight any bill that turns the clock back to a darker time. I
will fight every single attempt to turn a deaf ear, a blind eye, and a
cold shoulder to the sick, to our seniors, and to working families.
Mr. Speaker, I will fight every day, every hour, every minute, and
every second. I oppose this bill with every breath and every bone in my
body. We must not give up. We cannot--I will not--give in, not today,
not tomorrow, not never, ever.
On this bill, there is only one option, and that option is to vote
``no.'' We can do better. Mr. Speaker, we must do better. Vote ``no''
on this bill.
Mr. BRADY of Texas. Mr. Speaker, I first would remind my friend from
Georgia that nearly 700,000 Georgians have chosen to either pay a fine
or exempt themselves from ObamaCare because it has failed them so
badly.
And to my friend from Michigan, 420,000 Michiganders, more than half,
chose to exempt themselves from ObamaCare rather than accept that
failed health care.
Mr. Speaker, I yield 2 minutes to the gentleman from Minnesota, (Mr.
Paulsen), a key member of the Ways and Means Committee.
Mr. PAULSEN. Mr. Speaker, today we are taking a very important step
to lift the burden of the Affordable Care Act off of the backs of the
American people. A key component of this is repealing the burdensome
mandates and tax increases that were imposed to help fund this failed
law. This includes the medical device tax, a senseless policy that
placed an excise tax on lifesaving medical technology.

What did this achieve? A loss of 30,000 high-paying American jobs,
less research and development, canceled projects, and postponed
expansions. Most importantly, it hurt patients.
There is good news. Just a few years ago, in 2015, we came together
on a bipartisan basis and suspended the tax for 2 years. We are seeing
positive results. Companies are now hiring again, we have increased
research and development, and we have new investments in facilities
coming online.
We need to permanently repeal this onerous tax or it is going to
start up again. Voting ``yes'' today means permanent repeal of the
medical device tax.
Mr. Speaker, I am also encouraged to see several provisions I have
authored to enhance and expand the use of health savings accounts and
flexible spending accounts that are included in this legislation today.
HSAs and FSAs are now more popular than ever and used by 20 million
Americans. It is time to remove the restrictions on HSAs that were
imposed in ObamaCare so that we can make them more accessible and
easier to use and empower Americans to take more control of their
healthcare decisions.
Expanding HSAs will help us also begin to address the rising costs of
health care. One recent study showed that, when a large employer
switched their employees over to an HSA plan, it lowered their
healthcare spending by an average of $900 per employee over a 5-year
period. That is real savings, Mr. Speaker.
Let's support a better way forward to lower healthcare costs for
patients and put them back in control of their healthcare decisions.

{time} 1415

Mr. NEAL. Mr. Speaker, I remind my colleague that his vote for this
bill will result in 49,200 people in his congressional district in
Minnesota losing their healthcare coverage and care.
Mr. Speaker, I include in the Record a letter from Governor Charlie
Baker of Massachusetts that relates to the debate we are having today.

Office of the Governor, Commonwealth of Massachusetts,
State House,
Boston, MA, March 21, 2017.
Dear Delegation Member: Health care is once again at the
forefront of national and state policy discussions; I know we
all share the goal of ensuring access to quality, affordable
health care coverage for the people of Massachusetts. With
Congress set to take up the American Health Care Act (AHCA)
imminently, I wanted to share with you my administration's
analysis of the potential effects this bill would have on our
state.
The Congressional Budget Office (CBO) released its score of
the AHCA on March 13. This analysis is broadly consistent
with concerns we have raised, with you and others, regarding
the bill's impact on the state and its residents' access to
affordable healthcare. Applying CBO's assumptions to
Massachusetts results in at least $1 billion of reduced
federal revenue beginning in 2020, and we estimate reduced
revenue of $1.3 billion in 2021, and $1.5 billion in 2022,
with likely a greater annual impact in the years that follow.
Specifically, our estimate extrapolated from the CBO
analysis of a $1.5 billion impact for FY 2022 includes $1.3
billion of annual MassHealth federal revenue losses and $200
million in annual reduced federal subsidies for private
insurance through the Connector.
Several key areas of concern for Massachusetts were not
included in the CBO analysis and could further impact the
Commonwealth's budget. For example, the CBO estimate does not
address 1115 waiver payments that we believe this bill would
put at risk. By FY22, the Commonwealth estimates an
additional $425-475 million per year of reduced federal
revenue in potential elimination of 1115 payments not
captured under the per capita targets, including federal
matching funds for a state-run ConnectorCare Wrap subsidy.
The actual experience for these and other factors is
significantly dependent on how the U.S. Department of Health
and Human Services implements the legislation and
unpredictable factors in the future (e.g., pharmaceutical
growth).
In addition to reduced federal revenue for Medicaid, the
CBO also projects a reduction in employer-sponsored health
insurance of 7 million people nationwide as a result of the
repeal of the federal Employer Mandate. This would exacerbate
a trend that Massachusetts has seen over the last several
years. Massachusetts repealed the Chapter 58 Fair Share
Contribution in 2013 in order to comport with the ACA. My
administration has proposed reinstating an employers' shared
responsibility for the costs of health care. This would be
increasingly important if the federal Employer Mandate were
repealed, as the AHCA proposes.
The Commonwealth does have certain protections in place
that could mitigate the impact of some of these changes.
Massachusetts retains its individual health insurance
mandate, reducing the likelihood that many people would drop
out of the insurance market due to the repeal of the federal
mandate. Massachusetts also has protective insurance coverage
laws that would not be superseded by the federal legislation.
The AHCA includes a provision that would prevent Medicaid
from reimbursing Planned Parenthood for providing important
health services such as cancer screenings. My administration
opposes this provision, and has already committed to funding
these services with state dollars if it should pass.
During conversations with governors across the country, the
Trump Administration has expressed a general openness to
providing greater state flexibility with respect to health
care, including through a letter issued by HHS Secretary
Price on March 14 to states. Our administration will pursue
additional flexibilities to stabilize our markets and ensure
continued coverage for residents and we urge you to support
these efforts by leading discussions in Congress to ensure
the people of Massachusetts continue to have access to a
quality health care system.
Overall, our analysis indicates that the AHCA would
increasingly strain the fiscal resources necessary to support
the Commonwealth's continued commitment to universal health
care coverage. I hope this information is helpful to you as
Congress takes up the American Health Care Act.
My administration and I will continue to stay in touch with
you as we work together to ensure access to quality,
affordable health coverage for all Massachusetts residents.
Sincerely,
Charles D. Baker,
Governor.

Mr. NEAL. Mr. Speaker, I yield 2 minutes to the gentleman from Texas
(Mr. Doggett), who played a major role in the substantive contribution
he made to writing the ACA.
Mr. DOGGETT. Mr. Speaker, TrumpCare is big on Trump, but it is weak
on care. After falsely promising that there would be coverage for
everyone for less and better, TrumpCare only cares about huge tax
breaks for the superrich and special interests, like

[[Page H2428]]

the totally unjustified $28 billion windfall for the pharmaceutical
industry that they grab right out of the Medicare trust fund so that
premiums will go up. Those earning $1 million within a single year get
79 percent of a $230 billion tax break, but there is no genuine relief
for middle class taxpayers.
Removing the essential health benefits provisions will only enable
insurers to exclude the very healthcare protections that folks thought
they were getting when they paid their premiums. Insurance plans will
not just be skinny, they will be a sham; a provision that at the very
time you need the care, it won't be there. Many certificates of
insurance will become as worthless almost as a diploma from Trump
University.
This Republican bill targets our veterans by denying them tax
credits. For millions of people who are just a few years too young to
qualify for Medicare, their premiums will go through the roof. It will
cost thousands of dollars more in order to get insurance. Yes, the
Republicans have been divided and factionalized. They are divided
between those who want nothing care and those who want little care.
But, mostly, they don't seem to care how many millions of people lose
their health insurance.
Mr. President, this is not the art of the deal. It is the art of the
steal, of taking away insurance coverage from families that really need
it to provide tax breaks for those at the very top. Those who
understand health care, the professionals, say reject this bill, and it
should be rejected.
Mr. BRADY of Texas. Mr. Speaker, I remind my friend from Texas that 2
million Texans eligible, forced into ObamaCare and getting deep
subsidies, have said: No thanks. ObamaCare has failed me.
Two out of three Texans eligible.
Mr. Speaker, I yield 2 minutes to the gentleman from New York (Mr.
Reed), a key member of our Committee on Ways and Means.
Mr. REED. Mr. Speaker, I rise today in support of this legislation. I
ask my colleagues on the other side of the aisle--as I stood in front
of town halls and I listened to thousands of folks across my district
say what we should be working on is fixing the Affordable Care Act to a
T, I have heard my colleagues on the other side of the aisle say: It is
not perfect; we need to repair it.
Yet, today we take the first step in this endeavor by the legislation
that is before us, and all we hear is how bad this legislation is. All
we hear today, Mr. Speaker, is how bad this first step in this journey
for the American people we need to go on when it comes to American
health care is.
I don't hear rhetoric saying let us talk about phase 2, let us talk
about phase 3, where we can come together as Democrats and Republicans
for the people we represent.
The American people are lost in this bickering that we have here in
this Chamber today, but I don't forget their voice. I am not going to
forget the voice of the constituents that came to me as small-business
owners saying: You are putting me out of business with these insurance
premiums. They are going through the roof.
I won't forget the faces of the people who are saying: My copays are
going through the roof. My deductibles are higher. I don't have
coverage that I had 7 years, 8 years ago before ObamaCare.
Mr. Speaker, I implore all of us in this Chamber to work together for
the American people as a whole. The American people want freedom. They
don't want mandates. They want to choose the insurance that works best
for them. They want to access their doctors that they select. They want
to have the promise that was made to them, that they could have their
insurance and keep it going forward honored and respected by this
institution. That is what our legislation starts today.
Not a soul on our side of the aisle says the issue of health care
will go away because of the first step we take today, because we have
to do better for the American people when it comes not only to health
insurance, but for health care in America. I know we can, and I want to
be a voice to say let us join together to get this done for the
American people.

Mr. NEAL. Mr. Speaker, I remind my colleague that his vote for this
bill today will result in 68,300 people from his congressional district
losing their health coverage and care.
Mr. Speaker, I yield 1 minute to the gentleman from California (Mr.
Thompson), a very thoughtful member of the Committee on Ways and Means
who also helped to write the ACA.
Mr. THOMPSON of California. Mr. Speaker, I rise in opposition to this
bad bill. It is not a step toward fixing the ACA, this is a step toward
destroying health care. It was bad when it ripped health care away from
24 million Americans. It was bad when it created an age tax, forcing
seniors to pay five times that of what other people pay. It was bad
when it forced hardworking Americans to pay higher premiums and
deductibles while billionaires get a trillion dollars' worth of tax
cuts. And it was bad when it shortened the life of Medicare.
But today it got worse. Today Republicans gutted coverage for
emergency services, prescription drugs, hospitalization, mental health
coverage, and preventative coverage. This bill also prevents millions
of veterans from getting health care. This is a truly bad bill. It will
cost millions of Americans their health care. It will force them to pay
more for fewer benefits, and it gives the richest Americans a huge tax
cut. This is a tax-cut bill, not a healthcare bill. The American people
deserve much better. I urge everyone to vote ``no'' on this bad bill.
Mr. BRADY of Texas. Mr. Speaker, I remind my friend from California,
1.5 million Californians forced into ObamaCare and given generous
subsidies found a way to exempt themselves because ObamaCare failed.
Mr. Speaker, I am proud to yield 3 minutes to the gentleman from
Pennsylvania (Mr. Kelly), a small-businessman and a key member of our
committee.
Mr. KELLY of Pennsylvania. Mr. Speaker, I am proud to stand today in
support of this bill. I have been told that this is a rookie mistake. I
understand that. We have been working 7 years to undo that rookie's
mistake. That is why we are here today. A rookie who didn't know what
he was doing, but lectured to us, told us: This is what you have to do;
and if you do this, you can keep your doctor, you can keep your health
plan, you can just stay on board, and we are going to insure millions
of you.
Nothing could be further from the truth. The big thing was you are
going to save $2,300 on your premiums. He forgot to tell everybody but
the people who were actually in that business. Incredible. Incredible.
Now, this isn't about me, and it is not about you. This is about
people. We are in the people's House. Let me just read to you a couple
letters from the people who I represent back home. By the way, out of
the seven counties I represent, five have one insurer, and the rest of
them got out because they couldn't stand to try and work under this
onerous law.
Let me tell you what Amanda says: I am very happy to hear that you
are working to repeal the Affordable Care Act. I just got an up-close-
and-personal look at how dysfunctional it is while trying to shop for
my own plan. It is hard enough to start a business in this country due
to so many rules, regulations, and confounding taxes. This law makes it
even harder. And I don't think the government should make me buy
coverages I simply don't need. I know my situation, and I should be
able to buy whatever I want without incurring four-figure tax
penalties.
Jason says to me: Dear Mike, I am a self-employed father of four
feeling the hurtful effects of ObamaCare. For years there has been so
much talk from Republicans about repealing ObamaCare. I am paying yet
more money for less coverage. We are really feeling the effects of this
in my family in our budget. My kids are going to bed hungry after
dinner. We desperately need relief and now, not next year. I
enthusiastically pulled the lever for Donald Trump and for you, and we
are counting on you to make some real change in D.C. Please keep up the
fight, and do it quickly.
So this is not about Mike, it is not about John, it is not about any
of us. What it is about is taking care of the people that we were sent
here to represent. They are Republicans and they are Democrats, who
some people could care less about any of us, but they expected us to do
something for them. We are sitting here today because this law

[[Page H2429]]

is so bad. If it was so good, we wouldn't have to worry, but it is bad,
with a capital B.
Now, I have got to tell you, growing up, as a young kid, as it got
toward Christmas--and I say this to my friends, by the way, on our
side--I used to make a list right before Christmas. I put on that list
everything I wanted. You know what, Mr. Speaker? Come Christmas
morning, I never got everything I wanted, but I was so thankful for
everything I got.
We have to deliver today. We have to keep a promise today to the
American people. We have to backtrack on a rookie mistake 7 years ago
and make it better for the American people, not just for Republicans,
not just for Democrats, not just for those who vote blue or red, but
for those who expect us to do what we are supposed to do in the
people's House. This is not the Republican House or the Democrat House,
this is the people's House.
Isn't it time for all of us to come together to get this done?
We have a marvelous opportunity, but we could lose it. I ask you all
and I urge you all to please vote for this act.
Mr. NEAL. Mr. Speaker, I remind my colleague and my friend that with
his vote for this bill, 41,400 people from his congressional district
in Pennsylvania will lose their healthcare coverage.
Mr. Speaker, I yield 2 minutes to the gentleman from Connecticut (Mr.
Larson), who is from an adjacent district and a close friend and a
long-time member of the Committee on Ways and Means and an individual
who also contributed mightily to the development and writing of the
Affordable Care Act.
Mr. LARSON of Connecticut. Mr. Speaker, I associate myself with Mr.
Neal's remarks, and especially him framing this issue from the outside
about the arc of history.
As we have witnessed in this Chamber time and again, dating back to
Franklin Delano Roosevelt, when you look at the impact of 24 million
people, you have to look at your colleagues on the other side of the
aisle and say: Are you frozen in the ice of your indifference to what
impacts the daily lives of people who have showed up at our forums and
the forums that you have conducted?
The sheer humanity of what is taking place across this country cries
out for a solution. Yet all we have heard, as Mr. Neal said, is the
helter-skelter back and forth of who is winning politically, what is
happening with the Freedom Caucus, what is going to--if Trump loses, is
Ryan out?
The American people don't care about that. They care about their
families. And this is the institution that we were sent to to work on
their behalf. It is up to us to come together and work on behalf of the
American people.
This is not a healthcare bill. This is a tax bill. We are going to
work on that later on, but we shouldn't start by saying that we are
going to have a transfer of wealth in this Chamber from people who are
begging and pleading and showing up at the townhalls and asking for our
help, and our answer is a transfer of wealth in a tax bill. Everybody
wants to know why we are taking this up first and not taxes. Because it
is a tax bill, that is why.

{time} 1430

Mr. BRADY of Texas. Mr. Speaker, I would remind my friend from
Connecticut that 190,000 residents in Connecticut, two out of three
eligible for ObamaCare, believed it failed them so badly they paid a
tax or exempted themselves.
Mr. Speaker, I yield 2 minutes to the gentlewoman from South Dakota
(Mrs. Noem), who has weighed in in such a key way on health care.
Mrs. NOEM. Mr. Speaker, it is no surprise that the Democrats today
are upset, that they are complaining that they don't like this bill,
because their number one goal all along, and I have heard them say it
to me in conversations over the years, their number one goal was to go
to a single-payer system. They wanted government-run health care, and
we are on the track to that today.
In fact, in my home State of South Dakota, at one time, we had 17
options and companies that people could shop for their healthcare
policies from. Today we have two.
We are well down our road now to giving them exactly what they want.
They hate this bill because it puts people back in control of their own
health care. It doesn't let some bureaucrat in Washington, D.C., decide
what treatment they can get in the future. It lets people decide that
with their doctors.
This is a vote, today, for freedom for people who have lived under
the bureaucracy of the Federal Government not giving them options on
how to take care of themselves and their families.
Rising costs, shrinking options, increasing bureaucracy under
ObamaCare has taken healthcare control away from patients, away from
people, away from families struggling to pay their bills; and, against
their best and own common sense and household budgets, they are forced
to pay $10,000, $15,000, $20,000 more per year for health coverage,
health coverage which has a deductible so high that they don't even
utilize it then because they can no way meet the $6,500 deductible,
$10,000 deductible, $12,000 deductible. So they don't even use it at
all if they do have it. Their stories are reflected in all the data
that we have seen.
One hundred percent of the healthcare options on healthcare.gov in
South Dakota have seen double-digit rate increases. Meanwhile, the
number of providers families have to choose from has gotten much, much
worse.
We have a responsibility to eliminate ObamaCare's individual and
employer mandates, which today's legislation does. It also abolishes
the taxes that were included in ObamaCare, up to $1 trillion of taxes
that were put on health care in order to pay for the bill, which will
be eliminated as well.
If left in place, the health insurance tax alone will raise costs on
families up to $5,000 over the next decade.
Bipartisan congressional Members have repeatedly opposed taxpayer
funding of abortions, and that is fixed in this bill as well.
When we talk about health care, we are talking about something very
personal, which is why I want patients put back in control.
Mr. NEAL. Mr. Speaker, I would remind my colleague that her vote for
this bill will result in 63,000 people in South Dakota losing their
healthcare coverage and care.
Mr. Speaker, I yield 1 minute to the gentleman from Oregon (Mr.
Blumenauer), a visionary, certainly, a forward-looking individual who
also helped to write the ACA.
Mr. BLUMENAUER. Mr. Speaker, it has come to this: considering
hopelessly flawed legislation that the Republicans have had 7 years to
prepare for and still couldn't do it right. It may still pass, but it
is never going to be enacted because most people are figuring it out.
They don't like it and they are being heard. That is why this bill has
been stalled and the Republicans have been forced to twist the
legislation in this fashion.
But the bottom line remains: TrumpCare will cost more for people who
need it the most. It will hurt older and lower-income people in order
to create tax cuts for people who need them the least. TrumpCare will
destabilize health insurance and will slowly but surely destroy
Medicaid.
It didn't have to be that way, but as long as people continue
speaking out and fighting back with us, it won't be in the future, and
we can have a new era in health care and in politics.
With their help, it will be.
Mr. BRADY of Texas. Mr. Speaker, I remind my dear friend from Oregon,
153,000 Oregonians eligible for ObamaCare with generous subsidies said
thank you, but no thank you.
Mr. Speaker, I yield 2 minutes to the gentleman from South Carolina
(Mr. Rice), my good friend and a key member of the Ways and Means
Committee.
Mr. RICE of South Carolina. Mr. Speaker, I stand in strong support of
the American Health Care Act and urge my colleagues to vote in favor of
the bill.
ObamaCare was built on broken promises. President Obama said you
could keep your policy, keep your doctor, and it would bring down the
cost of the insurance for a family of four by $2,500 per year.
It is time for the lies to stop. Let me share with Members the
shameful reality of ObamaCare in South Carolina.
It turns out you couldn't keep your doctor. In fact, the Medical
University of South Carolina is not an accepted provider under
ObamaCare in South Carolina. That is right. South Carolinians cannot go
to the Medical University of South Carolina if they are

[[Page H2430]]

covered by ObamaCare exchange policies.
It turns out you couldn't keep your policy. It is hard to believe,
but more South Carolinians had their plans canceled by ObamaCare than
have enrolled in the exchanges. 237,000 South Carolinians' policies
were canceled in ObamaCare.

It turns out South Carolinians did not see a $2,500 reduction in
their healthcare premiums. In fact, premiums have increased by double
digits every year since the exchange opened; and this year, premiums
increased 28 percent and deductibles 26 percent.
I submit to you that if you have a health insurance policy with
$6,000 in deductibles and copays so high you can't afford to use your
policy, regardless of the fact that statistics say you are covered, you
are not covered.
206,000 South Carolinians have signed up for ObamaCare--4 percent of
the population. Ninety-six percent of South Carolinians are not on
ObamaCare. Three times as many people in South Carolina have chosen to
pay the mandate penalty rather than to pick up ObamaCare policies.
Mr. Speaker, President Obama promised South Carolinians we would have
many competitive plans to choose from, but after only 3 years of
Obama's damage to our healthcare system, only one provider remains, and
they are threatening to pull out.
The SPEAKER pro tempore. The time of the gentleman has expired.
Mr. BRADY of Texas. Mr. Speaker, I yield an additional 15 seconds to
the gentleman from South Carolina.
Mr. RICE of South Carolina. The CEO of a major hospital in South
Carolina stated, the way it is going right now, it is probably going to
implode in the next year or two. Our State's director of insurance,
last year, said companies have given their best shot and can't sustain
this business model, can't make a profit. The Affordable Care Act has
not worked, does not work, and cannot work under this structure in
South Carolina.
Mr. NEAL. Mr. Speaker, I would remind my colleague that his vote for
this bill will result in 70,000 people in his congressional district in
South Carolina losing their healthcare coverage.
Mr. Speaker, I now yield 1\1/2\ minutes to the gentleman from
Wisconsin (Mr. Kind), who is a thoughtful member of the Ways and Means
Committee and lucky enough to have been educated in the Commonwealth of
Massachusetts.
Mr. KIND. Mr. Speaker, we face a truly historic day today in the
United States Congress. For the first time in our Nation's history, we
have a Congress working with an administration offering the American
people a healthcare reform bill that, instead of reducing the number of
uninsured in this country, increases the uninsured by 24 million
people, including 431,000 in my home State of Wisconsin.
And we understand why. It is a simple explanation. This is a tax cut
bill for the most wealthy in the guise of healthcare reform. That is
unfortunate because it is a missed opportunity of fixing what isn't
currently working in the healthcare system.
If we wanted to be honest with the American people today, we would
admit that there are important, good features of the Affordable Care
Act that should remain and we should not end. But there are things that
need to be fixed, and we have to stay focused on reducing healthcare
costs for all Americans. Let's continue to work on delivery system
reform and payment reform so we get better results at a better price.
But a bill before us that increases the uninsured by 24 million, that
delivers huge tax breaks to the most wealthy, that applies a new older
American tax, especially in rural areas like mine in Wisconsin, and
that robs money from the Medicare trust fund is not only a missed
opportunity, it is bad legislation.
I encourage my colleagues to vote ``no.'' We can do better. We must
do better.
Mr. BRADY of Texas. Mr. Speaker, I remind my good and thoughtful
friend that 290,000 Wisconsinites that chose not to get ObamaCare were
willing to pay a tax to stay out of a failed healthcare system.
I am proud to yield 2 minutes to the gentlewoman from Indiana (Mrs.
Walorski), a new member of our committee who is doing tremendous things
in health care.
Mrs. WALORSKI. Mr. Speaker, I rise today in strong support of the
American Health Care Act.
Yesterday marked 7 years since the ObamaCare law was signed into law.
For 7 years, we have seen the same pattern: rising premiums, dwindling
options, broken promises, and a collapsing system.
In the State of Indiana, four insurers left the ObamaCare exchange
just this year in the past 3 months, forcing 68,000 Hoosiers to shop
for a new plan, making it even harder for them to choose and keep their
doctor.
But today we have the opportunity to repeal ObamaCare and replace it
with a patient-centered system, lowering costs, increasing choices, and
providing real protection.
This legislation dismantles ObamaCare's burdensome taxes, mandates,
and the job-killing medical device tax.
It gives individuals and families access to quality, affordable
health care through refundable tax credits and expanded health savings
accounts.

It provides resources for States to tailor solutions to the needs of
their citizens, protecting women's health, addressing the opioid
crisis.
It gives States flexibility to implement innovative reforms.
It allows my home State to continue building on its patient-centered
Healthy Indiana Plan.
It protects patients with preexisting conditions and ensures a stable
transition so no one has the rug pulled out from underneath them.
With the American Health Care Act, we are delivering on our promise
and acting on the policies of President Trump. This bill is just the
first step in a three-part effort to repair our Nation's healthcare
system. Coupled with administrative actions and additional legislation,
the AHCA will lower costs and build a marketplace with real choices
instead of a one-size-fits-all plan.
Mr. Speaker, 7 years of ObamaCare is long enough. Seven years of
families seeing their premiums rise, plans canceled, and doctors
dropped is enough. Today we can deliver on our promise and put our bold
solutions into decisive action. The AHCA is a bill 7 years in the
making. I urge my colleagues to join me in supporting it.
Mr. NEAL. Mr. Speaker, I remind my colleague that her vote for this
bill will result in 42,000 people in her congressional district in
Indiana losing their healthcare coverage and care.
I include in the Record a letter from Republican Governor Snyder of
the State of Michigan raising his concerns about this legislation.

State of Michigan,

Executive Office,

Lansing, MI, March 21, 2017.
Hon. Sandy Levin,
House of Representatives,
Washington, DC.
Dear Representative Levin: As Congress considers
legislation to repeal and replace the Affordable Care Act and
reform Medicaid, I want to ensure you are aware of the impact
that changes may have on beneficiaries in Michigan who rely
on these programs for access to care and overall health. I
also want to provide my perspective on priorities for federal
health reform and highlight how they have been utilized at
the state level to drive meaningful reform that has increased
access to cost-effective care.
In its current form, the American Health Care Act (AHCA)
shifts significant financial risk and cost from the federal
government to states without providing sufficient flexibility
to manage this additional responsibility. The proposed
legislation reduces federal resources that our state relies
on to assist 2.4 million Michiganders enrolled in traditional
Medicaid and the Healthy Michigan Plan, our state's
innovative Medicaid expansion program.
The current federal debate has largely focused on the
Medicaid expansion population, including over 650,000
childless adults and parents that are enrolled in the Healthy
Michigan Plan. However, half of all children in Michigan are
served by traditional Medicaid each year and roughly 67,000
of them currently reside in your district. Moreover, more
than 338,000 individuals with disabilities receive their
health care and support services through Medicaid and an
estimated 22,000 of these individuals reside in your
district. Altogether, there are 1.75 million children,
seniors, pregnant women and disabled individuals served by
traditional Medicaid in Michigan, and roughly 119,000 of them
reside in your district. As you know, these are our state's
most vulnerable citizens, friends and neighbors. The proposed
AHCA will adversely impact them.
While reforming the nation's health care system is vital,
it is imperative that gains in health coverage and access to
care are maintained. These ideas are not mutually exclusive.

[[Page H2431]]

In Michigan, innovative approaches to improving quality and
value are being utilized to support each individuals'
personal responsibility for their health. This has resulted
in significant reductions of nearly 50% in uncompensated
care, a dramatic decrease in the number of individuals using
the emergency room as a regular source of care, and nearly
85% of enrollees taking part in annual primary or preventive
care visits. As drafted, the AHCA would eliminate coverage
from the 49,000 individuals enrolled in the Healthy Michigan
Plan in your district, as Michigan taxpayers assume
responsibility over time for up to $800 million in additional
costs. This cost shift will trigger a provision in Michigan
law ending the Healthy Michigan program.
I believe Medicaid reform is necessary, however, that
reform must be approached deliberately to ensure that state
flexibility and innovation are valued, Michigan providers
remain strong, and our most vulnerable citizens do not fall
through the cracks. Ideally, this would be done by removing
prescriptive program requirements that require states to seek
waivers when implementing innovative ideas. Instead, states
would be given performance based outcomes with federal
involvement only when performance is lacking.
If Congress moves forward in passing the proposed AHCA,
which shifts financial risk to state taxpayers, my
administration and the Michigan Legislature must possess the
flexibility necessary to manage that risk. The Trump
Administration may provide additional flexibility to states,
however, I am concerned that federal agencies may encounter
limitations in federal statute. Ultimately, Michigan cannot
rely solely on the promise of future action without seeing
all of the tools that will be at our disposal to manage the
program.
In addition, under the proposed AHCA, I remain concerned
about the affordability of insurance coverage in the
individual market. I am particularly concerned about the
impact this legislation may have on older Michiganders who
could see significant cost increases.
I welcome the opportunity to partner with you to provide
greater federal budget predictability and improve health
outcomes of Michiganders, which in turn relieves pressure on
other social programs. I have worked with other Governors to
develop a proposal to accomplish these objectives while also
preserving coverage for Michiganders, and I hope this can
serve as a blueprint for you as we work together to
accomplish these goals.
I look forward to continuing our partnership to help
Michiganders lead healthy and productive lives.
Sincerely,
Rick Snyder,
Governor.

Mr. NEAL. Mr. Speaker, I yield 2 minutes to the gentleman from New
Jersey (Mr. Pascrell), who is a well-regarded member of the Ways and
Means Committee. I think it is fair to say that everybody in this
institution looks forward to his time when he gets up to speak.
Mr. PASCRELL. Mr. Speaker, the question I get asked is: What the heck
were they thinking about?
Let me tell you what they are thinking about. Medicaid is the source
of 25 percent of all projected public and private spending for drug
abuse treatment. It is about $8 billion.
Let's consider James Suber from my hometown of Paterson, New Jersey.
Mr. Suber began seeking treatment when New Jersey expanded its Medicare
program and provided more comprehensive access to treatment.
At least New Jersey got it half right.
Each morning Mr. Suber receives treatment at Paterson Counseling
Center, which allows him to go to work as a cleaner at Well of Hope,
another treatment center in Paterson serving the homeless.
Without the treatment he receives through Medicaid, he wouldn't be
working. He would be using the emergency department at St. Joseph's
hospital, the most expensive part of the hospital. Or maybe he wouldn't
have survived.
So, Mr. Speaker, for the life of me, I don't understand why we would
jeopardize treatment for James and the millions of other Americans
facing similar challenges. What were they thinking?
Will this bill improve Medicaid? Nope.
Will this bill increase the number of Americans with health coverage?
Nope.
Will it lower costs on the exchanges? Nope.
Will this bill bolster employer coverage? No.
Will coverage now provide more access to care, a promise time and
time again by Mr. Trump, himself? No.
Will it strengthen Medicare? No.

{time} 1445

Mr. Speaker, it is obvious. We know we are trying to change things
and make them better.
We changed Medicare. We did it together.
We changed Medicaid. We did it together.
We changed a lot of things together, but you chose the only lonely
path.
Mr. BRADY of Texas. Mr. Speaker, I remind my good friend from New
Jersey that 314,000 residents of New Jersey said ``no thank you'' to
ObamaCare because it failed them.
I yield 2 minutes to the gentleman from Michigan (Mr. Bishop), a new
member of the committee, who dove into this issue with great thoughtful
and conscientious work.
Mr. BISHOP of Michigan. Mr. Speaker, I rise today in support of the
American Health Care Act, and I want to thank the chairman for his
leadership on this measure.
Mr. Speaker, I came to Washington, D.C., to make a difference. When
it comes to health care, it is readily apparent that ObamaCare does not
work for most Americans. We know for a fact, as we are standing here
today, that the current system is collapsing upon itself.
Our Nation has endured 7 long years of this mess, and today we have
the obligation and the responsibility to act. I have heard many critics
of this proposal, but I was raised to do what is right, to be a part of
the solution, and not sit idly by on my hands as a spectator and watch
Rome burn.
I came to Congress to make a difference, to find solutions to the
many issues that vex our country. I came here to reduce the size and
scope of an unwieldy government, to get government out of the way of
everyday citizens. I came here to address spending, a $20 trillion debt
in this country, to bring back free-market principles. I came here to
defend the Constitution and our founding principles, and turn power
back to the States and to the people.
All that said, every single one of these principles can be found in
this bill. The American Health Care Act reduces spending and cuts the
taxes that have strangled businesses and individuals for the last 7
years. It represents the first real entitlement reform in the 52-year
history of Medicaid. It deletes Federal mandates that rob citizens of
their individual liberty.
Mr. Speaker, this bill may not be perfect, but it is a dramatic step
in the right direction. And before I am lectured as to unsubstantiated
facts and fear tactics as to how this is going to impact my State, I
would suggest to you that 420,000 Michiganders eligible for Medicare
said ``thanks, but no thanks'' to the broken promise of affordable
health care.
And that is why, Mr. Speaker, I am going to vote for this bill, and I
would ask my colleagues to support it.
Mr. NEAL. Mr. Speaker, I would remind my colleague that his vote for
this bill will result in 38,200 people from his congressional district
in Michigan losing their healthcare coverage, and 313,123 people in the
State of Michigan, indeed, did sign up for the Affordable Care Act.
Mr. Speaker, I yield 2 minutes to the gentleman from New York (Mr.
Crowley), a long-time friend, a very sound member of the committee, and
also the well-regarded chairman of the Democratic Caucus.
Mr. CROWLEY. Mr. Speaker, this bill is a bad policy built on horrible
process. Twenty-four million Americans will lose their coverage if this
bill becomes law. Premiums and out-of-pocket expenses will skyrocket,
especially for older Americans because of the age tax, as hardworking
Americans are forced to subsidize tax cuts for the wealthy.
It is no wonder this bill was crafted in the dead of night behind
closed doors. It is so bad, even Members of the Republican Party are
rejecting this bill, but President Trump and Republican leadership
insisted they need to repeal ObamaCare at any cost, even if the price
will be making health care out of reach for veterans, for seniors, and
many of the hardest-working Americans.
So the majority made it worse, and then they made it worse again. Now
they have taken away the bare minimum requirements for insurance like
covering emergency room visits or prescription drugs. It will crush any
protections for preexisting conditions.

[[Page H2432]]

There is no guarantee the treatment you need for your condition will
even be covered under this bill. Image that: healthcare coverage that
doesn't cover your health. Insurance that insures absolutely no peace
of mind for what life may bring you.
This body blow to critical health protections was done just to win
votes, like so many of the other provisions and political favors, like
the Empire State kickback, the Buffalo bribe, and the Syracuse sellout.
I call it simply a political ploy.
That provision, which will cut $2 billion from only New York State,
has been blasted by newspapers from The Buffalo News to Newsday on Long
Island. They have called it a train wreck. They have called it bloody
money. Like everything else in this bill, it represents the worst kind
of backroom, shady maneuvering.
This bill is bad for New York, bad for the democratic system, and bad
for America. My colleagues on the other side of the aisle should be
ashamed of themselves. I know many of you are. But this bill is
appalling, and I urge everyone in this Chamber to vote it down. And,
Mr. Chairman, I know that 2.7 million New Yorkers will lose their
health care if this bill becomes law.
Mr. BRADY of Texas. I remind my friend from New York, nearly four out
of five New Yorkers said no to ObamaCare because it failed them.
Mr. Speaker, I yield 1 minute to the gentleman from Iowa (Mr. King),
my dear friend.
Mr. KING of Iowa. Mr. Speaker, I want to thank the chairman for
yielding to me.
Seven years ago today, I brought the first repeal of ObamaCare here
to this Congress. Forty words, to rip it out by the roots as if such
act had never been enacted. I would like to be here today passing the
full repeal of ObamaCare. We are not, but this is the first bite at the
repeal apple in a process to hopefully get all of this thing done in
one day.

If I thought we could do it all in one bite, I would stand for that,
but instead, here is what we have got. We have got a $1 trillion tax
cut. We have got a $1.15 trillion spending cut. We have got a $150
billion deficit reduction. We have got a bill that eliminates the
employer mandate, eliminates the individual mandate, and it eliminates
Federal mandates in the essential health benefits package of those 10
mandates--that I despise, by the way.
It expands health savings accounts--doubles them--it allows for us to
pass selling insurance across State lines, and it enables catastrophic
health insurance. That is a pretty good list, and that is the list of
things that I am going to support here when this goes up for a vote.
Mr. Speaker, I urge its adoption.
Mr. NEAL. Mr. Speaker, I remind my colleague that his vote for this
bill will result in 40,900 people from his congressional district in
Iowa losing healthcare coverage. I also want to thank the gentleman for
being the first speaker on the Republican side to acknowledge that this
is a tax cut.
Mr. Speaker, I yield 1 minute to the gentleman from Chicago, Illinois
(Mr. Danny K. Davis), a distinguished member of the Ways and Means
Committee and my friend.
Mr. DANNY K. DAVIS of Illinois. Mr. Speaker, I rise in strong
opposition to this draconian, Dracula-inspired health bill. It is not
really a health bill at all. As a matter of fact, it is a tax cut for
the wealthiest individuals in our country. This bill will decimate all
of the public health gains that professional health personnel and
activists have fought for the last 50 years.
This bill will take out the opportunity for those low- and moderate-
income individuals who fall between the gap created by Medicaid and
nothing. They are the least of those in our society. And when you take
away health care for that group of individuals, history will not regard
you well.
I believe that the best way to measure the effectiveness of a society
is by how well it treats its young, how well it treats its old, and how
well it treats those who have difficulty caring for themselves.
I will vote ``no.'' I urge us all to do so.
Mr. BRADY of Texas. Mr. Speaker, I remind my good friend from
Illinois, half a million Illinoisans have said no to ObamaCare because
it failed them.
Mr. Speaker, I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, I yield 2 minutes to the gentlewoman from
California (Ms. Sanchez), the vice chair of the Democratic Caucus, and
a very strong performer on the Ways and Means Committee.
Ms. SANCHEZ. Mr. Speaker, I rise today in opposition to the
Republican's so-called healthcare bill.
It pains me to even call it a healthcare bill because it is actually
a massive tax cut for insurance CEOs that provides nearly zero
healthcare benefits for the American people.
In fact, TrumpCare ensures that 24 million Americans will lose their
health insurance coverage. Seniors will be charged more, and insurance
companies will once again dictate the health of the American people. On
the very day that the majority tax cuts for the rich come into effect,
on January 1, 2018, at least 40,000 of my own constituents would
immediately lose their health care.
But that is not all. The Republican idea of health coverage will
leave millions of Americans without the basic health services that they
expect and that they deserve. That means that the monthly premium you
pay won't cover all of the services you will need to get better if you
get sick. The Republican healthcare plan won't cover your emergency
room visit, the X-rays, or even the prescription drugs you need to
recover.
Heaven forbid if you need prenatal or pediatric care, too. Basically,
under this plan, one illness is enough to bankrupt a family for a
lifetime. If you asked anyone on the street, no one in America would
call this health insurance. Yet, my Republican colleagues hail this as
choice--the choice to go bankrupt if you get sick or, God forbid, have
an accident.
So, Mr. Speaker, I have to ask: How many Republicans are left who
actually support the bill? Who wants to kick thousands of people off of
Medicaid, reduce care for the disabled, and strip children of their
health care because that is exactly what you are going to do if you
vote for this bill. It does the exact opposite of what you, your party,
and President Trump have promised the American people.
This bill doesn't provide better, cheaper health care for everyone.
And guess what? Everybody knows that. By voting for this bill, you will
literally force millions of Americans to pay more for less and
jeopardize the health of our country for generations.
So if you vote to break all of the promises you made to the American
people, then you are going to own it, and you are going to be
responsible for whatever happens. Vote down this bill.

Mr. BRADY of Texas. Mr. Speaker, I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, I yield 1 minute to the gentlewoman from
Alabama (Ms. Sewell), a valued member of the Ways and Means Committee.
Ms. SEWELL of Alabama. Mr. Speaker, for 7 years, our Republican
colleagues have railed against the Affordable Care Act, but is this the
best they can offer now: TrumpCare? The Republican bill, TrumpCare, is
a bad deal for Americans, and it is a bad deal for Alabamians.
By every matrix, cost, coverage, and care, it is a bad deal. On cost,
TrumpCare will cost more and give us less. For Alabama hospitals,
TrumpCare will mean a $97 million increase in uncompensated cost care,
and it is an age tax for seniors. Seniors will pay five times more than
the young for their health insurance.
On coverage, TrumpCare will mean 24 million Americans and 243,000
Alabamians will lose their healthcare coverage. On quality of care,
TrumpCare will mean that essential benefits will be lost: essential
benefits like rehabilitative care, mental health, and preventive
services.
Mr. Speaker, what is clear, TrumpCare is not a healthcare bill. It is
a tax-cut-for-the-wealthy bill--$600 billion in tax cuts. So I say to
you, my Republican colleagues know what they are against, the
Affordable Care Act. But what are they for? What are they for? I ask
all of you.
Mr. BRADY of Texas. Mr. Speaker, I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, might I inquire as to how much time remains?
The SPEAKER pro tempore. The gentleman from Massachusetts has 5\3/4\

[[Page H2433]]

minutes remaining under this committee time allocation.
Mr. NEAL. Mr. Speaker, I yield 1 minute to the gentlewoman from
California (Ms. Chu), a new member on the Ways and Means Committee, and
a very thoughtful Member of Congress.

{time} 1500

Ms. JUDY CHU of California. Mr. Speaker, my constituent Patty never
had to worry about health care. Her husband had insurance through his
job. But last year, Patty's husband passed away suddenly. Overnight,
Patty found herself without health coverage for herself and her 20-
year-old son, who had a preexisting condition.
Even though she was grieving over the sudden loss of her husband,
Patty couldn't afford COBRA and had less than a month to find health
care for her family. Thank goodness she was able to get coverage
through the ACA.
Under TrumpCare, Patty could have her life upended all over again.
Patty is 62 years old, and TrumpCare would cause premiums for people
over 60 to increase by more than $6,000 a year, making insurance
unaffordable. And under the age tax created in this bill, insurance
companies could charge Patty five times as much as a young person. She
could see skyrocketing costs for her hypertension and doctor's visits.
TrumpCare is a bad deal for Americans like Patty.
Mr. Speaker, I urge my colleagues to vote a resounding ``no'' to this
downright cruel bill.
Mr. BRADY of Texas. Mr. Speaker, I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, I yield 1 minute to the gentleman from Oregon
(Mr. DeFazio).
Mr. DeFAZIO. Mr. Speaker, this so-called health bill is actually just
mostly targeted for tax cuts for the wealthiest among us.
Let's look at it this way: a millionaire will get a $30,000-a-year
tax cut. A 64-year-old senior who earns $30,000 a year--that is all he
earns, just the tax cut the millionaire gets--they will see their
premium go from $1,700 a year, to $15,000 a year. That is half their
income.
They are going to have a choice: give up their house so they can buy
health insurance or don't buy health insurance, pray you don't have a
health emergency, and go bankrupt or die. Those are great choices.
This says a lot about the values of the Republican leadership and
their obsession. Instead of fixing the problems with the Affordable
Care Act, they want to kill it. It says a lot about their values. They
are pathetic.
Mr. BRADY of Texas. Mr. Speaker, I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, I yield 1 minute to the gentleman from Arizona
(Mr. O'Halleran).
Mr. O'HALLERAN. Mr. Speaker, I rise in strong opposition to the so-
called American Health Care Act. I am alarmed at the real consequences
this bill will have on rural Arizona and rural America.
These communities will be disproportionately harmed by this bill. In
Coconino County, a 40-year-old making $30,000 a year will go from a
$2,400 payment to a $6,000 payment.
Getting away from my script for a second, I spent many years on the
west side of Chicago looking at what the core side of poverty looks
like night after night, family after family, in our cities and our
towns in this wonderful America. I know a little bit about math, and I
know that 20 million people insured is better than 24 million people
uninsured.
Please vote ``no.''
Mr. BRADY of Texas. Mr. Speaker, I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, I yield 30 seconds to the gentleman from
Tennessee (Mr. Cohen).
Mr. COHEN. Mr. Speaker, this is not a healthcare bill. This is a
wealth care bill.
Unfortunately, President Trump, when he spoke in Louisville, said we
had to pass this bill to get the big tax cuts. It is about wealth care.
It is the Ebenezer Scrooge law of this Congress.
The insurance you will get with the amendments made will be as
worthless as the degree from Trump University. We do not need wealth
care, but we need health care.
Mr. BRADY of Texas. Mr. Speaker, I reserve the balance of my time.
Mr. NEAL. Mr. Speaker, I yield myself the balance of my time.
In closing, I want to make sure the people of America understand what
we are doing here in about 1 hour. We heard during the course of a
Presidential campaign the promise that everything was going to be
covered and we would be tired of winning.
If winning means that 24 million Americans are going to lose their
healthcare coverage, if winning means imposing an age tax on seniors,
if winning means higher out-of-pocket costs for working Americans, and
if winning means robbing $75 billion from the Medicare trust fund, we
don't want to be part of that victory lap.
This isn't about one person making up alternative facts. Our
statements today have been based upon the CBO, the National Rural
Health Association, the American Medical Association, the American
Association of Retired Persons, and the March of Dimes.
This bill has fewer covered, weaker protections, and higher costs.
Let's call this what it is today; it is a $1 trillion tax cut for the
richest amongst us.
The Republicans are now facing the art of the ordeal. They have a bad
plan, and they know it. They have scrambled for the last week to try to
figure out how to stitch it together, and it hasn't worked.
For those across this country, think of the following: no maternity
care, fewer hospital visits, no mental health services for those
families who are struggling with a family member who has an opiate
addiction, which is the crisis of our time.
This is more of the same: tax cuts for the wealthiest amongst us and
healthcare cuts for everyone else.
Mr. Speaker, I reserve the balance of my time.

=========================== NOTE ===========================

March 24, 2017, on page H2433, the following appeared: Mr.
Speaker, I yield back the balance

The online version has been corrected to read: Mr. Speaker, I
reserve the balance

========================= END NOTE =========================

Mr. BRADY of Texas. Mr. Speaker, I yield myself the balance of my
time to close.
Mr. Speaker, do you want to know how bad ObamaCare is?
Twice as many Americans have exempted themselves, have paid a fine,
or found another way out of ObamaCare for everyone who took it.
I am a conservative, and I am proud of the conservative win in this
bill. I am proud of the $1 trillion in tax relief on our small
businesses, our patients, and our families. I am proud of the more than
$1 trillion of spending cuts that Washington cannot afford nor sustain.
I am proud of the first reforms in Medicaid since the program was
created in giving States back control of that plan, including the
option of a work requirement.
I am proud to repeal ObamaCare mandates that have forced Americans
into health care they can't afford and don't want. I am proud to defund
Planned Parenthood once and for all. And I am proud of the $150 billion
of deficit reduction.
This is a clear choice, and we will stand where we stand today: the
choice between President Trump and more freedom or ObamaCare and less
freedom. I stand with President Trump.
Mr. Speaker, I yield back the balance of my time.
Mrs. BLACK. Mr. Speaker, I yield myself such time as I may consume.
I include in the Record a letter dated March 7, 2017, from Dr. Thomas
Price, the Secretary of Health and Human Services, who sent a letter of
support for the American Health Care Act to Chairmen Walden and Brady.

The Secretary of

Health and Human Services,

Washington, DC, March 7, 2017.
Hon. Greg Walden,
Chairman, Committee on Energy & Commerce,
Washington, DC.
Hon. Kevin Brady,
Chairman, Committee on Ways & Means,
Washington, DC.
Dear Chairman Walden and Chairman Brady: On behalf of the
Trump Administration, I am writing in support of the
reconciliation recommendations recently released for
consideration by your Committees. Together, they align with
the President's goal of rescuing Americans from the failures
of the Affordable Care Act. These proposals offer patient-
centered solutions that will provide all Americans with
access to affordable, quality healthcare, promote innovation,
and offer peace of mind for those with pre-existing
conditions.
Your legislative proposals are consistent with the
President's commitment to repeal the Affordable Care Act;
provide advanceable, refundable tax credits for Americans who
do not already receive such tax benefits through health
insurance offered by their employers; put Medicaid on a
sustainable path and remove burdensome requirements in the
program to better target

[[Page H2434]]

resources to those most in need; empower patients and put
healthcare dollars and decisions back into their hands by
expanding the use of health savings accounts; ensure a stable
transition away from the Affordable Care Act; and protect
people with pre-existing conditions.
Achieving all of the President's goals to reform healthcare
will require more than what is possible in a budget
reconciliation bill, as procedural rules on this type of
legislation prevent inclusion of key policies such as selling
insurance across state lines, lowering drug costs for
patients, providing additional flexibility in Medicaid for
states to manage their programs in a way that best serves
their most vulnerable citizens, or medical legal reforms.
Your proposals represent a necessary and important first step
toward fulfilling our promises to the American people. We
look forward to working with you throughout the legislative
process, making necessary technical and appropriate changes,
and ensuring eventual arrival of this important bill on the
President's desk.
Yours truly,
Thomas E. Price, M.D.,
Secretary.

Mrs. BLACK. Mr. Speaker, I include in the Record a letter that comes
from 24 of our Governors in support of the repeal of ObamaCare, and I
would like to read just two quick paragraphs out of the letter:
``We support efforts to Reform the system.
``To provide access to affordable and quality health care, we must
reform the system. We support a plan that gives state governments
maximum flexibility to reform Medicaid and the system surrounding it.
The states are more effective, more efficient and more accountable to
the people. What works in one state may not work in another location,
and true reform will allow states to recognize and meet the unique
needs of the people all across America.
``We recognize that a vote in the House of Representatives is the
first step in the Repeal, Replace and Reform process. The members of
the United States Senate will undoubtedly make additional improvements
before final approval by the President. We also recognize that the
Secretary of Health and Human Services is committed to working with
state leaders to provide maximum flexibility for true reform.''

March 24, 2017.
Hon. Mitch McConnell,
Majority Leader, U.S. Senate,
Washington, DC.
Hon. Paul D. Ryan,
Speaker, House of Representatives,
Washington, DC.
Dear Leader McConnell and Speaker Ryan: Thank you for your
service to our country. Please allow us to offer our thoughts
about the pending vote on the American Health Care Act.
Americans want personalized, patient-centered healthcare that
treats them as individuals not a statistic, and that demands
we repeal Obamacare, replace it, and reform the system.

We support the Repeal of Obamacare

Obamacare is collapsing. If we do nothing, people will lose
access to health care coverage. As it stands now, one-third
of the counties nationwide have only a single insurance
carrier. Americans in these areas have essentially no
choices, while they watch their premiums rise dramatically.
The Congressional Budget Office estimates that 28 million
Americans will lose coverage over the next decade if changes
are not made to the Affordable Care Act.
As the Affordable Care Act continues to deteriorate, and as
insurance premiums skyrocket across the nation, opposition to
this failed policy grows. Governor Mark Dayton (D-MN) said,
``the Affordable Care Act is no longer affordable.''
Similarly, Bill Clinton called ObamaCare, ``. . . the
craziest thing in the world.'', adding that people ``wind up
with their premiums doubled and their coverage cut in half.''
The President and Congress must act now to repeal the
Affordable Care Act to protect the citizens we serve in the
states.

We support efforts to Replace Obamacare

Most Americans receive their health insurance coverage
through their employer or through Medicare. These individuals
will not see a direct change from the repeal of Obamacare.
For those Americans who do not receive coverage through their
employer, Medicare or Medicaid, we support a refundable tax
credit they can use to obtain affordable health care coverage
within the marketplace.

We support efforts to Reform the system

To provide access to affordable and quality health care, we
must reform the system. We support a plan that gives state
governments maximum flexibility to reform Medicaid and the
system surrounding it. The states are more effective, more
efficient and more accountable to the people. What works in
one state may not work in another location, and true reform
will allow states to recognize and meet the unique needs of
people all across America.
We recognize that a vote in the House of Representatives is
the first step in the Repeal, Replace and Reform process. The
members of the United States Senate will undoubtedly make
additional improvements before final approval by the
President. We also recognize that the Secretary of Health and
Human Services is committed to working with state leaders to
provide maximum flexibility for true reform.
Governors are pleased to have an administration and a
Congress willing to collaborate with the states to address
the legitimate needs of our people. We have compassion for
those concerned about the uncertainty surrounding the
changes. This is why it is imperative that the Congress act
quickly on Repeal, Replace and Reform.
This is a multi-stage process. There is much more work to
be done, and process can only begin with a vote in the House
of Representatives. With this in mind, we humbly request that
you vote to repeal and replace Obamacare and to reform the
system going forward. Thank you.
Sincerely,
Governor Scott Walker, Wisconsin; Governor Robert Bentley,
Alabama; Governor Rick Scott, Florida; Governor C.L.
``Butch'' Otter, Idaho; Governor Eric Holcomb, Indiana;
Governor Terry E. Branstad, Iowa; Governor Sam Brownback,
Kansas; Governor Matt Bevin, Kentucky; Governor Paul R.
LePage, Maine; Governor Phil Bryant, Mississippi; Governor
Eric R. Greitens, Missouri; Governor Pete Ricketts, Nebraska;
Governor Christopher T. Sununu, New Hampshire; Governor Doug
Burgum, North Dakota; Governor Ralph Torres, Northern Mariana
Islands; Governor Mary Fallin, Oklahoma; Governor Henry
McMaster, South Carolina; Governor Dennis Daugaard, South
Dakota; Governor Bill Haslam, Tennessee; Governor Gary R.
Herbert, Utah; Governor Matthew H. Mead, Wyoming.

Mrs. BLACK. Mr. Speaker, I include in the Record a list of groups
supportive of the American Health Care Act. We have many groups, from
conservative groups to pro-life groups, to industry groups; and among
those would be several insurance providers, such as Blue Cross Blue
Shield, Anthem, and others.

Groups Supportive of the American Health Care Act

conservatives

American Legislative Exchange Council
Americans for Tax Reform
Association of Mature American Citizens
Center of the American Experiment
Citizens Against Government Waste
Independent Women's Voice
Institute for Liberty
Log Cabin Republicans
Market Institute
National Taxpayers Union--Key Vote
Obamacare Repeal Coalition
Six Degrees Project
Small Business & Entrepreneurship Council
Taxpayers Protection Alliance

Pro-life groups

American Center for Law and Justice
Catholic Medical Association
Concerned Women for America
Faith & Freedom Coalition--Key Vote
National Right to Life--Key Vote
Susan B. Anthony List

Industry

Advanced Medical Technology Association (AdvaMed)
America's Health Insurance Plans (AHIP)
American Benefits Council
American Builders and Contractors
American College of Cardiology
American Supply Association
Anthem Insurance
Associated General Contractors of America--Key Vote
Blue Cross Blue Shield
Consumer Healthcare Products Association
Corporate Health Care Coalition
Employers Council on Flexible Compensation
ERISA Industry Committee (ERIC)
Food Marketing Institute
Health Leadership Council
HSA Council
International Franchise Association (IFA)
Medical Device Manufacturers Association (MDMA)
National Association of Manufacturers (NAM)
National Association of Wholesale Distributers (NAW)--Key
Vote
National Business Group on Health
National Club Association
National Council of Chain Restaurants
National Federation of Independent Businesses--Key Vote
National Grocers Association
National Restaurants Association
National Retail Federation--Key Vote
National Roofing Contractors Association
One Nation Health
Self-Insurance Institute of America, Inc.
The Association of Chief Human Resource Officers (HR
Policy)
US Chamber of Commerce--Key Vote

Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from
Texas (Mr. Hensarling), the chair of the Financial Services Committee.
Mr. HENSARLING. Mr. Speaker, tragically, I receive correspondence
every week like this. I heard from Rita in east Texas, who writes me:

Since ObamaCare took effect, my insurance no longer covers
my colonoscopies as

[[Page H2435]]

preventative care. I now pay $1,000 and more out of pocket
versus $100 outpatient fee.

I heard from Frances in the Dallas area near where I live. A few
years ago she was tragically diagnosed with tonsil cancer. The good
news is she had a good policy; $600-a-month premium and a maximum out
of pocket of $3,500. But thanks to ObamaCare, her insurance company
dropped her twice, and she wrote:

They dropped me again because they are leaving the Dallas
market.

Her premiums and deductibles doubled. She lost her oncologist, and
she writes that this is all because of ObamaCare, the Affordable Care
Act.
I heard from Tonya in Van Zandt County, in my district:

We had five family members covered by insurance at around
$800 a month until ObamaCare. Our insurance premiums
skyrocketed to $1,500 a month, equivalent to a house payment,
with a $15,000 deductible, and we cannot see the doctors that
know our medical history. Repeal it. I should not be forced
to pay for something I cannot use. This has been a nightmare.

Mr. Speaker, ObamaCare has been a nightmare. It is collapsing as we
speak. People are losing their coverages. Insurance plans are pulling
out of States and counties. Tens of millions of our fellow countrymen
have been forced to buy health insurance plans they cannot afford, they
do not want, and that do not work for them.
Right here, right now, we have a choice: failed ObamaCare or the
American Health Care Act that begins the process of providing Americans
with guaranteed access to quality, affordable, patient-centered health
care.
It clearly advances the cause of freedom, and all Members should
support it and end the nightmare of ObamaCare.
Mr. SCOTT of Virginia. Mr. Speaker, I ask unanimous consent that I be
allowed to manage the balance of the time remaining.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from Virginia?
There was no objection.
Mr. SCOTT of Virginia. Mr. Speaker, I yield myself such time as I may
consume.
Mr. Speaker, as we talk about the Affordable Care Act, I think it is
important to remind ourselves of the situation before it passed: costs
were going through the roof, those with preexisting conditions could
not get insurance, women were paying more than men, and every year
millions of people were losing their insurance.
We passed the Affordable Care Act. Since then, the costs have
continued to go up, but at the lowest rate in 50 years. Those with
preexisting conditions can get insurance at the standard rate. Women
are no longer paying more than men. Instead of millions of people
losing their insurance every year, more than 20 million more people now
have insurance.
The full name of the Affordable Care Act is the Patient Protection
and Affordable Care Act.
Now your coverage can't be canceled if your insurance company decides
that it has paid too much. Preventive services, such as cancer
screenings, are free with no copays and deductibles. We are closing the
doughnut hole. Those under 26 can stay on their parents' policies.
We also funded community health centers, made investments in
education to produce more doctors, nurses, and other professionals.
Through all of that, the Medicare trust fund is more solvent than it
was before.
Still, the law is not perfect. But if we are going to make any
changes, we ought to improve the law, not make it worse.
Incredibly this bill makes it worse. Now, the CBO has separated
promises and press releases from reality. Twenty-four million fewer
people will have insurance, and the Republicans call this choice in
freedom to be uninsured. Most everybody else will pay more and get
fewer benefits. All of those consequences will occur if the proposal
actually works.

{time} 1515

A number of States have done what this bill tries to do, and that is
cover people with preexisting conditions without universal coverage.
All of those attempts failed.
So the question we must ask is: Who will be better off if this bill
passes? Certainly not older people who will face the bill's age tax.
Certainly not veterans who will lose benefits. Certainly not senior
citizens in nursing homes and people with disabilities because Medicaid
is cut. Even the solvency of the Medicare trust fund will be worse.
But millionaires will get tax cuts.
Mr. Speaker, we have been hearing a lot of complaints and
shortcomings about the Affordable Care Act, but if we are going to make
any changes, we should improve it. Unfortunately, this bill makes
things worse: 24 million will lose their insurance, most everybody else
will pay more and get less. This bill should be defeated.
Mr. Speaker, I reserve the balance of my time.
Mrs. BLACK. Mr. Speaker, it is now my honor to yield 2 minutes to the
gentleman from Virginia (Mr. Goodlatte), the distinguished chairman of
the Judiciary Committee.
Mr. GOODLATTE. Mr. Speaker, I want to tell you why I am supporting
this legislation, the American Health Care Act.
Kaye, from Roanoke, contacted me about President Obama's promise that
she could keep her health care. She shared that she received a letter
from her insurer stating that her policy was going to increase by $600
per month--increase by $600 per month. Since she wasn't of age to be on
Medicare but wasn't working because she was at home caring for her sick
husband, she was frustrated with her situation.
Kaye couldn't afford the extra money she owed on top of the bills for
her husband's medical treatment. She told me: ``So I will now have to
pay the fine, drop my insurance, and hope I do not get sick.''
I told Kay I would vote to repeal and replace ObamaCare.
A nurse from Warren County wrote to me: ``The care that I give my
patients is founded on their ability to choose their course of care. We
advocate every day for our patients to have more choices in their care,
and it will be very painful for us to deny them those options and to
deny them care.'' She asked me to stand against ObamaCare, and I told
her I would.
Susan, from Bedford County, told me her health insurance premium
increased 156 percent and her deductible increased 766 percent in just
2 years. She asked how we could make her pay such high rates. I told
Susan I would vote to repeal ObamaCare.
Mr. Speaker, I told my constituents that I would stand for them to
repeal this law that has hurt their ability to get the affordable care
they want and need. Passing the American Health Care Act is the first
step in repealing ObamaCare and replacing it with solutions that put
patients first. I urge my fellow Members to support this bill.
ObamaCare has failed far too many in the Sixth District of Virginia.
The status quo cannot continue.
Mr. SCOTT of Virginia. Mr. Speaker, I remind my distinguished
colleague from Virginia that his vote for this bill will result in
56,100 more people from his congressional district in Virginia losing
health care.
Mr. Speaker, I yield 1 minute to the gentleman from the Mariana
Islands (Mr. Sablan).
Mr. SABLAN. Mr. Speaker, I oppose the American Health Care Act
because it fails to increase coverage for 3.8 million Americans in the
insular areas: American Samoa, Guam, the U.S. Virgin Islands, Puerto
Rico, and my own district, the Mariana Islands.
President Trump promised, ``Everybody's going to be taken care of
much better than they're taken care of now,'' but that is not
happening. Instead of taking the opportunity to take care of all
Americans, the American Health Care Act ignores the insular areas:
We are not included in the new Medicaid per capita funding proposal.
As a matter of fact, in a year, we would see our Medicare funding
reduced by 68 percent.
We are not included in the new Patient and State Stability Fund. And
the new tax credit for insurance premiums is actually a new cost, an
unfunded Federal mandate, imposed by Congress on territorial
governments.
Everyone in this Chamber wants affordable, quality health care for
all Americans. This bill fails to do that. So let us begin again. Let
us work together on legislation to reach the goal the President has set
and many of us share: insurance for everyone, not just the rich.

[[Page H2436]]

Mrs. BLACK. Mr. Speaker, I yield 1\1/2\ minutes to the distinguished
gentleman from Florida (Mr. Dunn).
Mr. DUNN. Mr. Speaker, I rise to repeal ObamaCare by supporting the
American Health Care Act. We are here to take health care back from the
bureaucrats and give it to the people.
The previous administration enacted ObamaCare, and we saw its
effects: higher premiums, less choice, lost coverage, and broken
promises. The deductibles are so high it is like not having insurance
at all.
The people who sent me to Congress sent me with strict orders: End
this law. And on the American Health Care Act, I can report, it does.
With this bill, the Federal Government no longer forces you to buy a
product you can't use and don't want. The individual mandate is gone,
so is the job-killing employer mandate. Gone are a host of taxes on
prescription meds, over-the-counter drugs, insurance premiums, and
lifesaving medical devices.
It ends ObamaCare's Medicaid expansion, and it puts Medicaid on a
budget and focuses State efforts on those people truly in need. This is
the biggest entitlement reform in a generation.
Of course the bill is not perfect. There is more to do. But I spent
30 years as a surgeon. In medicine, as in life, you do not get to
choose the perfect option. You learn not to make perfect the enemy of
great.
With this vote we decide whether ObamaCare is our healthcare future
or not. We can live with its failures and broken promises or create a
market-based system that actually lowers the cost of health care and
serves patients, not bureaucrats.

So I support the American Health Care Act, Mr. Speaker, and I urge
that all Members do the same.
Mr. SCOTT of Virginia. Mr. Speaker, I remind my colleague that his
vote for this bill will result in 63,900 people from his congressional
district in Florida losing healthcare coverage and care.
I yield 1 minute to the gentleman from Connecticut (Mr. Courtney).
Mr. COURTNEY. Mr. Speaker, in a few minutes, the American people will
see clearly what each and every Member of this House is made of. Will
we vote to willfully strip healthcare coverage for 24 million
Americans, older Americans, working Americans, Americans with chronic
illness and developmental disabilities and now, incredibly, we even
know, Americans who wore the uniform of this Nation?
In a few minutes, we will see who will vote to raid the Medicare
trust fund in order to cut Medicare taxes for the rich, and we will see
who will vote to cut Medicaid's coverage for patients struggling with
the curse of opioid addiction.
Mr. Speaker, this is not just a vote. This is a gut check of who we
are as people and whether our purpose, as elected officials, is to
serve the public interest or, rather, feckless special interests.
Show the Nation that we care more about people than politics, that we
care more about the long arc of American history toward justice rather
than the short news cycle of who is up and who is down in Washington.
Make no mistake: History is watching this vote. Vote ``no.''
Mrs. BLACK. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from
Louisiana (Mr. Abraham), who is a family practitioner and knows a
little about medicine.
Mr. ABRAHAM. Mr. Speaker, as a practicing physician in the Louisiana
and Mississippi delta, I have some of the best patients, but some of
the poorest. They can't afford to see me because they can't afford
ObamaCare, increased costs, skyrocketing premiums, high deductibles. I
can't cure a disease if I can't see the patient. The cost is just too
high for ObamaCare.
We have heard about Medicaid expansion here today. That is a second-
class insurance for first-class people. I can't get my patients to see
a specialist. They have to go to the hospital. They have to go to the
emergency room. Prices go through the roof.
I have heard my colleagues on the other side of the aisle reference
the Hippocratic Oath. With all due respect, I don't think they would
know what the Hippocratic Oath says if their life depended on it. Guess
what? It does. Google it.
Let me educate you. Let me educate our colleagues. It says I will
always seek a path to a cure for all diseases. ObamaCare will not let
me do that.
We have got to do better. We cannot cram people into a healthcare
system that has failed just so politicians can thump their chest and
have some type of mysterious victory that is hollow and very, very
small.
We need to pass this American Health Care Act. ObamaCare has failed.
It is a sham of an insurance. Americans deserve better. We deserve
better as Americans. My patients deserve better.
Mr. SCOTT of Virginia. Mr. Speaker, I remind my colleague that his
vote for this bill will result in 51,700 people in his district losing
their coverage and care.
Mr. Speaker, I include in the Record a letter from the American
Academy of Family Physicians, the American Academy of Pediatrics, the
American College of Physicians, the American Congress of Obstetricians
and Gynecologists, and the American Osteopathic Association in
opposition to the legislation.

[From the American Academy of Family Physicians, American Academy of
Pediatrics, American College of Physicians, The American Congress of
Obstetricians and Gynecologists, American Osteopathic Association, Mar.
7, 2017]

America's Front Line Physicians Express Serious Concerns With the
American Health Care Act

Washington, DC--After the release of the two budget
reconciliation bills today, the physician leaders of our
organizations, representing over 500,000 physicians and
medical students, visited with members of the House of
Representatives to urge that they ``First, do no harm'' to
our patients by rolling back key coverage, benefits and
consumer protections as required under current law, including
the Affordable Care Act. We are concerned that by rushing to
a mark-up tomorrow in the Energy and Commerce and Ways and
Means Committees, there will be insufficient time to obtain
non-partisan estimates of this legislation's impact by the
Congressional Budget Office, or for medical organizations
like ours and other key stakeholders in the health care
community to offer substantive input on the bill.
During our meetings with members of the House of
Representatives today, we shared our joint principles for
health care reform. They reflect our collective expertise,
and represent the health care needs patients present to our
members every day. We urge Representatives to utilize these
principles to evaluate any legislation to modify current law,
and ensure that patients and providers are not adversely
affected. While each of our organizations individually are
still reviewing the changes proposed by the American Health
Care Act, released just hours ago, we share a concern that it
will not meet our principles because it will likely result in
less access to coverage and higher costs for millions of
patients.
We urge House Speaker Paul Ryan (R-WI) and the chairs of
these two committees to reconsider the decision to move
forward with mark-up, and instead allow the time needed for a
thorough review of the bill to ensure that it meets our
overarching principle, ``First, do no harm'' to patients.

About the American Academy of Family Physicians

Founded in 1947, the AAFP represents 124,900 physicians and
medical students nationwide. It is the only medical society
devoted solely to primary care. Family physicians conduct
approximately one in five office visits--that's 192 million
visits annually or 48 percent more than the next most visited
medical specialty. Today, family physicians provide more care
for America's underserved and rural populations than any
other medical specialty. Family medicine's cornerstone is an
ongoing, personal patient-physician relationship focused on
integrated care. To learn more about the specialty of family
medicine, the AAFP's positions (5 page PDF) on issues and
clinical care, and for downloadable multi-media highlighting
family medicine, visit www.aafp.org/media. For information
about health care, health conditions and wellness, please
visit the AAFP's award-winning consumer website,
www.FamilyDoctor.org (www.family
doctor.org).

About the American Academy of Pediatrics

The American Academy of Pediatrics is an organization of
66,000 primary care pediatricians, pediatric medical
subspecialists and pediatric surgical specialists dedicated
to the health, safety and well-being of infants, children,
adolescents and young adults. For more information, visit
www.aap.org and follow us on Twitter @AmerAcadPeds.

About the American College of Physicians

The American College of Physicians is the largest medical
specialty organization in the United States. ACP members
include 148,000 internal medicine physicians (internists),
related subspecialists, and medical students. Internal
medicine physicians are specialists who apply scientific
knowledge and clinical expertise to the diagnosis, treatment,
and compassionate care of adults across the spectrum from
health to complex illness. Follow ACP on Twitter and
Facebook.

[[Page H2437]]

About the American Congress of Obstetricians and Gynecologists

The American College of Obstetricians and Gynecologists
(The College), a 501(c)(3) organization, is the nation's
leading group of physicians providing health care for women.
As a private, voluntary, nonprofit membership organization of
more than 57,000 members. The College strongly advocates for
quality health care for women, maintains the highest
standards of clinical practice and continuing education of
its members, promotes patient education, and increases
awareness among its members and the public of the changing
issues facing women's health care. The American Congress of
Obstetricians and Gynecologists (ACOG), a 501(c)(6)
organization, is its companion.

About the American Osteopathic Association

The American Osteopathic Association (AOA) represents more
than 129,000 osteopathic physicians (DOs) and osteopathic
medical students; promotes public health; encourages
scientific research; serves as the primary certifying body
for DOs; and is the accrediting agency for osteopathic
medical schools. Visit DoctorsThatDo.org to learn more about
osteopathic medicine.

Mr. SCOTT of Virginia. Mr. Speaker, I yield 1 minute to the
gentlewoman from Ohio (Ms. Fudge).
Ms. FUDGE. Mr. Speaker, what is a life worth? What does it cost to
save the life of a sick child or a senior citizen?
For all of the rhetoric about freedom and choices, this bill sends a
clear message to every American as to where Republican priorities lie.
Tax breaks to the wealthy have been deemed more valuable than
lifesaving care.
They are telling hardworking families that insurance that only
benefits the wealthy, the healthy, and the young is more important than
access to nursing homes, to pediatric care, mental health services,
substance abuse treatment, and the overall peace of mind that, if you
get sick, you can afford care.
Speaker Ryan calls this ``an act of mercy.'' This is by no means
merciful, Mr. Speaker. Mercy is caring for the sick, the poor, for our
elders. Mercy is extending a hand to those in need. This is heartless.
Human decency demands a ``no'' vote on TrumpCare. Vote ``no.''
Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from
Texas (Mr. Conaway), the chairman of the Agriculture Committee.
Mr. CONAWAY. Mr. Speaker, we are faced with an unenviable choice of
the fact that there is infinite demand for health care. There is no top
on the amount of healthcare cost necessary to provide all the health
care that we want for everybody in this country, and we have limited
resources within which to do that.
The real question is: Does ObamaCare take up that task by asking
government to make those hard choices, or do we as individuals and
families and caregivers make those harder choices for ourselves?
I believe that the bill that we will get to vote on today moves us
toward that direction. This isn't about health care, per se; this is
about how do you pay for it.
Insurance is not a magic bullet anywhere across the spectrum.
Insurance is simply a scheme in which we risk-manage together. We put a
certain amount of money into a bucket, assuming not all of us will
suffer the risks that we want to cover. If we do, we have got to put
more money in; if we don't, then the system works.
This is about having to confront that choice that there is way too
much cost for the amount of resources that are available in any of
these circumstances, and it is hard.
Many of my constituents ask: Why did Republicans spend 6 years
railing against ObamaCare and not have the fix available on
Inauguration Day? Well, this is Exhibit A. This is hard stuff. Even
among Republicans, we have got more than 218 votes among us, and we
can't agree among ourselves necessarily what ought to go forward.
But I do know this, that we are down to the final choice: Do we keep
ObamaCare and the failure that is confronting us and will continue to
be there, or do we take a chance on moving toward something different,
moving toward freedom, moving toward choice, giving States back the
opportunity to decide for their indigent population how they should
take care of them?
I don't think anybody in Washington, D.C., can come up with a plan
that fixes that for all 50 States. I trust my colleagues in Austin to
make that happen far better than anybody I would trust in D.C., and
this bill moves that direction, and that is the right direction for us
to go.
This is a hard choice, but for me it is relatively straightforward.
You keep ObamaCare with a ``no'' vote. You move toward a brighter
future for health care in this country and the way we pay for it, who
pays for it, and how we get that done by a ``yes'' vote. I encourage my
colleagues to vote ``yes'' on this bill.
Mr. SCOTT of Virginia. Mr. Speaker, I remind my colleague that his
vote for this bill will result in making things worse by 58,600 people
in his district losing their healthcare coverage and care.
Mr. Speaker, I yield 1 minute to the gentlewoman from Florida (Ms.
Wilson).
Ms. WILSON of Florida. Mr. Speaker, I would like to begin by asking
my Republican colleagues one simple question: Don't you have
constituents who get sick and need insurance?
Everyone gets sick, rich and poor, Black and White, men, women, and
children.
Having insurance gives us peace of mind. It helps ensure that a
medical crisis is not exacerbated by a financial crisis. It often makes
a difference between life and death. If the Affordable Care Act is
repealed, your constituents and millions of people will be kicked off
the insurance roll, and that is a shame. They will suffer, and their
families will suffer.
I have health insurance, and so does every Member of Congress. We
even have a clinic and doctors at our disposal right here in this
Capitol.
Doesn't every American deserve the same treatment as Members of
Congress?
Instead of moving backwards, Republicans should partner with
Democrats to amend and strengthen the existing law. By working
together, we can create a plan that works for all Americans, not just
the Members of Congress. Vote ``no.'' Vote ``no.''
Ms. KAPTUR. Mr. Speaker, the Affordable Care Act needs to be
repaired, not repealed. In 2010, Democrats passed health care reform in
an effort to move toward health insurance for all Americans. Though we
have made progress and more work to do, we cannot move America
backward. Tens of thousands of people in northern Ohio and millions
across America will lose insurance if TrumpCare becomes law.
This bill is cruel. It will take away care from some of our most
vulnerable citizens like those who suffer from opioid addiction, mental
illness or have disabilities. This bill will undermine Medicare and cut
$28 billion from Ohio's Medicaid program, the majority of which is
spent on nursing home care. If Republicans succeed in repealing the
Medicaid expansion, one in four Ohio hospitals would close according to
the Ohio Hospital Association.
Our goal should be to make our health care system better, not worse.
This merciless bill is not a health care bill. This bill is an $800
billion tax cut for corporations and the very rich. How that giveaway
provides better health care to working and middle-class families is
beyond me.
For Lent I gave up chocolate, I recommend the Republicans try giving
up tax cuts to the rich!
Let me share a story about a young man in Ohio who was diagnosed with
an extremely rare form of cancer one month before his 26th birthday.
Once he turned 26 he lost coverage under his parent's health care
policy.
But after visiting an Ohio Jobs and Family Services office, he
learned about his eligibility for the Ohio Medicaid expansion, which
allowed him to receive the cancer treatment he needed to survive.
Frankly, without the Affordable Care Act's multi-layered protections,
he would be dead.
The Affordable Care Act and its Medicaid expansion has allowed him to
return to finish law school.
This bill shifts the burden of health costs to the working and middle
class, all so the rich can have a trillion dollar tax cut. A tax cut
for the super rich doesn't help working people and seniors pay for
health care. Astoundingly, the falsely labeled, so called ``health''
bill actually rewards billionaires and corporations with hundreds of
billions in tax giveaways.
This bill does nothing to control costs for health insurance.
Millions will lose coverage. It will actually result in higher costs
too all while undermining Medicare and slashing Medicaid.
Congress ought to repair not repeal the ACA. We cannot move backward.
This GOP bill is cruel and some of our most challenged

[[Page H2438]]

citizens like the mentally ill or disabled will lose care. Premiums for
those over 50 could increase by 5 fold. As the old saying goes; ``this
dog won't hunt.''
Ohio embraced the ACA and 866,000 people were finally able to receive
health care coverage. What will this poorly conceived Republican tax
giveaway bill do to Ohio:
1. About 47,000 people will lose health insurance because they are
insured through the ACA in Ohio's 9th district.
2. The district's uninsured rate has gone from 13.3% to 7.0% since
the ACA was implemented. This 6.3 percentage point drop in the
uninsured rate could be reversed if the ACA is entirely or partially
repealed.
3. 318,900 individuals in the district who now have health insurance
that covers preventive services like cancer screenings and flu shots
without any co-pays, coinsurance, or deductibles stand to lose this
access if the Republican Congress eliminates ACA provisions requiring
health insurers to cover important preventive services without cost-
sharing.
4. 370,700 individuals in the district with employer-sponsored health
insurance are at risk of losing important consumer protections like the
prohibition on annual and lifetime limits, protection against unfair
policy rescissions, and coverage of preexisting health conditions, if
the ACA is entirely or partially repealed.
This Republican bill, hastily prepared, should be defeated. It is
cruel, will leave millions of our fellow citizens bankrupt and
destitute, and if implemented, will be responsible for more death and
illness coast to coast. Vote no on TrumpCare.
Mr. LYNCH. Mr. Speaker, I rise in strong opposition to H.R. 1628, the
American Health Care Act of 2017.
Mr. Speaker, I have received countless visits, calls, letters and
emails from constituents about this bill. I have heard from hospitals,
doctors, patients, nurses, parents of children with serious illnesses,
researchers and the list goes on. They have one thing in common: they
are afraid of what TrumpCare could do to their patients and to their
families.
H.R. 1628 will not bring down health care costs or improve access.
Indeed, by slashing Medicaid by $880 billion, it will force States to
ration care for our most vulnerable populations. In Massachusetts, this
cut will put the health of 1.9 million people at risk, including
650,000 children, 170,000 seniors and 280,000 people with disabilities.
My state is also being hit hard by the opiate addiction crisis and
cutting Medicaid will cripple our ability to address that problem. It
is also a disgrace that the funding being cut out of Medicaid is being
handed over to insurance companies and the wealthiest Americans in a $1
trillion tax break for the rich.
TrumpCare slashes $175 billion from the Medicare Trust Fund, cutting
its solvency by three years and hurts seniors by letting insurance
companies charge older Americans five times more than they do young
ones. The yearlong bar on reimbursements to Planned Parenthood for non-
abortion services means that women will have to go without health
screenings, pre-natal care and well-woman visits. And according to the
C.B.O., 24 million Americans will no longer have health insurance
coverage.
All this begs the question, how does this bill provide better care
for Americans?
But you do not have to take my word for it when I say that this bill
will hurt Americans. Groups like the American Medical Association, the
American College of Physicians, the American Academy of Pediatrics and
the American Nurses Association, just to name a few, are urging
Congress to stop TrumpCare. These are the men and women who are out
there on the front lines everyday treating and healing our fellow
Americans.
To make things worse, TrumpCare is being rushed to the floor with
minimal deliberation. It was introduced less than three weeks ago and
we have not held a single hearing or heard from a single expert witness
on it. Now we are being asked to vote on it despite receiving the
newest version of the manager's amendment late last night. This is not
the regular order and transparency that the Republicans promised.
Mr. Speaker, this bill pushes the cost of health care onto those who
can least afford it while providing massive tax cuts for the wealthy. I
urge my fellow members to defeat this misguided bill and let us begin
the serious work of making real improvements in the Affordable Care Act
for all Americans.
Mrs. BEATTY. Mr. Speaker, I rise today to express my opposition to
TrumpCare and my strong support for the Affordable Care Act.
Since the ACA was enacted seven years ago, more than 20 million
Americans have gained access to affordable and high quality health
insurance, including nearly one million Ohioans.
We thought 129 million Americans with pre-existing conditions would
be able to keep their health care coverage. We thought 105 million
Americans would no longer have to worry about annual or lifetime
limits. Yet, we are here today winding back the clock on all the
progress we have made based on a bill that wasn't released to the
public until last night.
What's the rush to pass a bill that affects so many people without
letting the public view it? What's the rush to pass a bill that affects
so many people without a new CBO score?
Mr. Speaker, we know that TrumpCare will cause Americans to pay more
for less coverage. We know that TrumpCare will provide a massive tax
cut to the super rich 400 families and leave the other 99.9 percent of
people behind. We know that TrumpCare will cause 24 million Americans
to lose their health insurance, including tens of thousands of my
constituents in the Third Congressional District of Ohio. We know that
TrumpCare will slash Medicaid funding by $880 billion. We also know
that TrumpCare will put 13 million children, people with disabilities
and adults just one emergency visit away from financial catastrophe.
Mr. Speaker, these cuts hurt people all across the country. TrumpCare
will not make healthcare more affordable.
Democrats believe healthcare is a right, not a privilege. I join my
colleagues in fighting for affordable healthcare for all Americans. I
will vote no, and urge all my colleagues to vote no as well.
Mr. SMITH of New Jersey. Mr. Speaker, while the Affordable Care Act
has been in effect since 2010, it has only provided actual access to
health insurance benefits through the exchange and Medicaid expansion
for a little over 3 years--beginning in 2014.
In that short period of time, however, serious problems and flaws
have been exposed, yet in recent months the law's systemic problems
have been trivialized or ignored by many.
Today, buying an insurance policy on the exchanges with high
premiums, high copays, and most importantly, exceedingly high
deductibles make the actual utilization of health benefits far costlier
than originally advertised.
Americans were told repeatedly that the ACA would save up to $2,500
in premium payments per family per year. President Obama said: ``I will
sign a universal health care bill into law by the end of my first term
as president that will cover every American and cut the cost of a
typical family's premium by up to $2,500 a year.''
That didn't happen--not even close.
Nationwide, since 2016, gross premiums before subsidies in the
Bronze-priced tier rose a whopping 27 percent, silver 24 percent and
gold 32 percent.
That should come as no surprise. As early as August 2012, Politifact
found President Obama's promise to be untrue and labeled the statement
a ``promise broken'' in a Politifact report entitled: NO cut in
premiums for typical family.
Health insurance consumers were promised they could keep their
insurance plan if they liked it and keep their trusted doctors as well.
That didn't happen either.
As a matter of fact, several million were kicked off insurance plans
they were very satisfied with--like my wife and I--only to be forced
into an Obamacare plan that we didn't want and was more expensive.
Also, in New Jersey--like much of the nation--insurance companies are
pulling out of the exchanges. Insurers continue to exit the individual
market and the exchange has experienced a net loss of 88 insurers.
Today, five states only have one insurer option. At home, last year
five insurance carriers offered plans on the New Jersey exchange, today
only two remain. The exodus of insurance companies from the individual
market is an unsustainable and ominous trend.
Mr. Speaker, almost twice as many Americans have paid the financial
penalty--pursuant to what is euphemistically called the ``individual
mandate''--for not buying a health insurance plan--or have received an
exemption from the individual mandate as those who have actually
purchased a plan through the exchange. By the numbers that means 19.2
million taxpayers either paid the individual mandate penalty or claimed
an exemption, compared to 10.3 million individuals who paid for plans
on the Obamacare exchanges.
Obamacare also increased taxes by about one trillion dollars.
For example, beginning in 2020, a new 40% excise tax on employer
provided comprehensive health insurance plans is scheduled to take
effect. Any plan provided by an employer exceeding $10,200 for
individuals and $27,500 for families will be taxed at 40 percent for
each dollar above those numbers. According to the Kaiser Family
Foundation this so-called Cadillac tax will hit 26 percent of employers
by 2020.
According to the IRS, approximately 10 million families took
advantage of the chronic care tax deduction which is now been redefined
out of reach for many. New taxes combined with skyrocketing premiums,
copays and deductibles underscores the need for serious review,
reevaluation and reform.
That said Mr. Speaker, I remain deeply concerned--and will vote no
today--largely because the pending bill cuts Medicaid funding

[[Page H2439]]

by an estimated $839 billion over ten years according to the
Congressional Budget Office (CBO), rolls back Medicaid expansion,
cancels essential health benefits such as maternity and newborn care,
hospitalization, pediatric services, and mental health and substance
use treatment, and includes ``per capita caps''--all of which will
likely hurt disabled persons, the elderly and the working poor.
For years, I have supported Medicaid expansion as a meaningful way of
providing access to health care for struggling individuals and families
living above the poverty line but still poor despite being employed--80
percent of all Medicaid enrollees in New Jersey are families with at
least one working adult in 2017.
Although more than 800,000 children are served by Medicaid in my
state, the bulk of Medicaid funds are spent assisting the disabled and
the elderly. In New Jersey approximately 74 percent of all Medicaid
spending goes directly to assist persons with disabilities and senior
citizens. Two out of every five people in nursing homes are on
Medicaid.
According to the New Jersey Department of Human Services, in New
Jersey total enrollment in Medicaid in February 2017 was 1.77 million
people. Of that a significant number are newly enrolled under Medicaid
expansion--663,523 ``newly eligible.''
These people are in need and deserve our support. Current law
provides states that opted to embrace Medicaid Expansion--like New
Jersey--95 percent of the costs for the ``newly enrolled.'' The federal
share drops to 90 percent by 2020.
The proposed American Health Care Act continues Medicaid expansion
however only until 2020. Those enrolled before December 31, 2019 would
be grandfathered in at the 90 percent match rate but the federal-state
match formula would then be reduced to a range between 75 percent-25
percent to 50 percent-50 percent or any new enrollee.
What does that mean?
The United State Conference of Catholic Bishops wrote each of us on
March 17th: ``. . . it is our assessment that some provisions are
commendable (and they reference the pro-life safeguards and other
noteworthy provisions in the bill) . . . while others present grave
challenges that must be addressed before passage . . . millions of
people who would be eligible for Medicaid under current law will be
negatively impacted due to reduced funding from the per capita cap
system proposed in the legislation, according to the CBO. Those
struggling families who currently receive Medicaid coverage from the
recent expansion will see dramatic changes through the AHCA as well,
without clear indication of affordable, adequate coverage to replace
their current options. Many states begin their legislative sessions
every cycle by attempting to overcome major deficits. State and local
resources are unlikely to be sufficient to cover the gaps that will be
created in the health care system as financial responsibility is
further shifted to the states. Congress must rework the Medicaid-
related provisions of the AHCA to fix these problems and ensure access
for all, and especially for those most in need.''
A letter led by the Consortium For Citizens with Disabilities, and
signed by over 60 organizations states:
``Dramatic reductions in federal support for Medicaid will force
states to cut services and/or eligibility that puts the health and
wellbeing of people with disabilities at significant risk. In fact,
people with disabilities are particularly at risk because so many
waiver and home- and community-based services are optional Medicaid
services and will likely be the first services cut when states are
addressing budgetary shortfalls. The health, functioning, independence,
and wellbeing of 10 million enrollees living with disabilities and,
often, their families, depends on funding the services that Medicaid
provides. Likewise, Medicaid Expansion provides coverage for millions
of people with disabilities and their caregivers who previously fell
into healthcare coverage gaps. For many people with disabilities, being
able to access timely, needed care is a life or death matter. The
drastic cuts to Medicaid that will result from per capita caps and the
ultimate elimination of Medicaid Expansion will endanger millions.''
Autism Speaks, a leading autism awareness, science, and advocacy
group, further articulated another concern, that ``the choice of 2016
as a baseline year for per capita caps may prevent states from
addressing the needs of children with autism. In July 2014 the Center
for Medicaid and CHIP Services issued an informational bulletin
clarifying Medicaid coverage of services to children with autism,
including benefit requirements for the Early and Periodic Screening,
Diagnostic, and Treatment (EPSDT) program. Although EPSDT is a
mandatory Medicaid program, few states in 2016 funded autism services
at the required standard of care. Locking in 2016 as a baseline year
can only perpetuate this historic underfunding of EPSDT benefits.''
Ms. ROYBAL-ALLARD. Mr. Speaker, for my constituents and all
Americans, Trumpcare would result in higher costs, less coverage, a
crushing age tax for persons 50 to 64, a shorter Medicare life span,
and the ransacking of the Medicaid funds that enable seniors to get the
long term care they need. And last night, Republicans added a provision
that would prohibit our veterans who are eligible to receive VA care
from receiving any tax credits to help pay for their care outside the
VA, even if they are not enrolled in the VA.
In my congressional district, the uninsured rate dropped from 31.7 to
17.5 percent due to Obamacare.
Among my constituents who benefited are a young mother from Bell
Gardens, California, and her 15-month-old daughter, Olivia, who was
born with Down Syndrome.
Because of Obamacare's Medicaid expansion in California, Olivia was
able to have her congenital heart defect repaired shortly after birth.
She is now being followed by a cardiologist to ensure her ongoing care
for a healthy heart.
Obamacare's Medicaid expansion also makes it possible for baby Olivia
to receive early intervention and physical therapy services to enhance
and accelerate her development.
Olivia's mom is terrified that if Trumpcare passes, her daughter may
not be able to receive these services, which help her remain healthy
and make it possible for her to reach critical developmental
milestones.
Republicans like to call Obamacare a failed disaster. That is simply
one more example of their ``alternative facts.''
The Republican Trumpcare bill before us is the disaster waiting to
unfold for countless families like Olivia's, and millions of Americans
across our country.
I urge my colleagues to vote no on behalf of the American people.
Ms. EDDIE BERNICE JOHNSON of Texas. Mr. Speaker, I rise in strong
opposition to H.R. 1628, the American Health Care Act, which not only
seeks to repeal the Patient Protection and Affordable Care Act, but
reform entitlements, redistribute wealth, and strip coverage from
millions of people.
The American Health Care Act would reduce coverage for Americans
while increasing out-of-pocket costs for the sickest and the elderly.
Health plans would fail to meet the needs of Americans with chronic or
complex conditions. The bill also eliminates protections against annual
and lifetime caps. With a last-minute manager's amendment to repeal the
Essential Health Benefits, the ten coverage rules set up by the
Affordable Care Act, this ruthless bill has gotten even worse.
The Affordable Care Act required insurers to cover ten ``Essential
Health Benefits'' from maternity care, mental health, and prescription
drugs, to hospitalization and outpatient care. If this is repealed,
comprehensive health insurance will become virtually unavailable in the
individual market. This means that individuals with pre-existing
conditions would not be protected. Younger and healthier people
benefit, older and sicker people suffer.
While the new additions to this measure are startling, the original
bill is just as shocking. Slashing and capping the Medicaid program
will ration care and give tax breaks to the wealthy. This bill cuts
$880 million from Medicaid and then caps the program so that it cannot
expand and contract as needed. By the end of 2019, the Medicaid
expansion program will freeze and this bill will shift costs to states
for the elderly, children, individuals with disabilities, and low-
income adults.
This bill will kick 24 million people off their health insurance by
2026, and 7 million people will lose their employer-based coverage.
While the Affordable Care Act subsidies were based on income and when
premiums rose, the federal subsidy also rose to pay for premium costs,
the American Health Care Act replaces those subsidies with a fixed
credit amount. The age-based tax credits are a refundable tax credits
that is larger for older individuals, however, it allows insurers to
charge older enrollees five times more than a younger enrollee.
Mr. Speaker, the public has spoken about this so-called
``replacement'' bill. People will live or die as a result of this
legislation. This bill will force Americans to pay more for their
premiums, more for their care, more on out-of-pocket expenses and
deductibles; all the while giving tax breaks directly to the wealthy.
The Republican leadership has rushed this bill to the floor without any
consideration and I urge you all to consider its harmful effects. Your
constituents are asking you to work with us to repair the Affordable
Care Act. Work with us.
Mr. AL GREEN of Texas. Mr. Speaker, although Trumpcare is a terrible
Healthcare plan, it is a terrific Wealthcare plan.
Trumpcare is terrific Wealthcare because in the final analysis, it
allows the 400 richest families to get $7 million a year ad infinitum,
$7 million a year forever.
In the final analysis, 79% of the cuts become Wealthcare dollars for
the very rich, not healthcare dollars for the very poor.

[[Page H2440]]

In the final analysis, it sacrifices $1 trillion from Medicare and
Medicaid to enrich the lives of millionaires and billionaires.
In the final analysis, it provides more money for Wealthcare and less
money for Healthcare.
Mr. Speaker, Trumpcare is more Wealthcare and less Healthcare.
Mr. CONYERS. Mr. Speaker, I've been here a while and it's hard for me
to recall a time when we've voted on something so obviously and
willfully harmful to children, seniors and working Americans.
This bill strips healthcare from 24 million people.
It requires some seniors to pay 100 percent or more of their income
in premiums.
This legislation dramatically cuts Medicaid, directly contradicting
President Trump's claim not to.
In Michigan, HALF of all children rely on Medicaid.
In my district alone, 56,000 people will lose coverage, including
16,000 children.
Let's be clear: if we pass this bill, children, seniors, and working
people will suffer and some will die, so that the wealthy can get a tax
cut.
Healthcare is a right, not a privilege. That's why I support a
single-payer, Medicare-for-All plan, and why I will be voting ``no'' on
this mean spirited legislation.
Mr. Speaker, as Ranking Member on the House Judiciary Committee, I
include in the Record a legal analysis prepared by committee staff that
concludes that the provision of H.R. 1628 that requires New York State
to change how its counties fund the State's portion of Medicaid
expenses is not related to a legitimate Federal interest, that no
rational Federal purpose has been proffered for the provision, and that
it would severely intrude on traditional state prerogatives. As such,
this provision would violate Constitutional limits on the Federal
Spending Power, the Due Process and Equal Protection Clauses and the
Tenth Amendment (reserving all undelegated powers to the States) and
would likely be held unconstitutional if challenged in court.

Memorandum

To: Interested Members.
From: House Judiciary Committee Democratic Staff.
Re: Constitutionality of Faso-Collins Amendment.
Date: March 24, 2017.
The Faso-Collins amendment, incorporated into the Manager's
amendment, would violate Constitutional limits on the Federal
Spending Power, the Due Process and Equal Protection Clauses
and the Tenth Amendment (reserving all undelegated powers to
the States). Requiring New York State to change how its
counties Fund its portion of Medicaid expenses is not related
to a legitimate Federal interest, no rational Federal purpose
has been proffered for the provision, and it would severely
intrude on traditional state prerogatives.
If the Faso-Collins amendment were ever enacted, it quickly
would be invalidated by the Federal courts. The irony of this
``buyout'' is that the ``payment'' supposedly being delivered
in exchange for votes--the unconstitutional provision--is the
legislative equivalent of a check on a closed bank account,
which will never deliver the promised benefits.
For the last 51 years, New York State has chosen to fund a
portion of its share of the Medicaid Program by using funds
from county property taxes. Fifteen other States structure
Medicaid funding through a similar legally authorized system.
The Faso-Collins amendment specifies that any State that
had an allotment of Disproportionate Share Hospital (DSH)
funds that was more than 6 times the national average, and
that requires subdivisions with populations of less than
5,000,000 to contribute toward Medicaid costs, shall have its
reimbursement reduced by the amount of contributions by such
subdivisions. (This effectively limits the application to New
York State, and carves out New York City.) Under the
amendment, New York State is at risk of losing $2.3 billion
of its $32 billion in Federal Medicaid funds.
This provision is unconstitutional, and could be struck
down for several reasons:
Violation of Limits on Spending Power--Article I of the
Constitution grants Congress spending power to ``provide for
the . . . general Welfare.'' In South Dakota v. Dole, 483
U.S. 203 (1987), the Supreme Court held that any spending
condition imposed on the States must be related to the
Federal interest in that particular project or program and
that Congress cannot coerce the States into compliance with
the Federal government's objectives. In NFIB v. Sebelius, 132
S. Ct. 2566 (2012), the Supreme Court found provisions of the
Affordable Care Act which required all States to comply with
the law's Medicaid expansion violated this spending
authority, noting the ``Constitution has never been
understood to confer upon Congress the ability to require the
States to govern according to Congress' instructions.'' The
Faso-Collins language does not appear to be related to any
Federal interest in the use or allocation of Federal Medicaid
funds: it does not further Medicaid's purposes and has
nothing to do with ensuring the proper disbursement of
Federal funds. Indeed, because the provision applies to
counties in a single State--and leaves the very same system
undisturbed in 15 other States--it could not possibly be
justified by any legitimate Federal interest.
An additional line of Supreme Court cases, including New
York v. United States, 505 U.S. 144, 167, 172 (1992), has
held that conditions on Federal grants must be ``reasonably
related to the purpose of the [Federal] expenditure'' because
otherwise ``the spending power could render academic the
Constitution's other grants and limits of Federal
authority.'' Likewise, in Massachusetts v. United States, 435
U.S. 444, 461 (1978), the Supreme Court noted that it has
``repeatedly held that the Federal Government may impose
appropriate conditions on the use of Federal property or
privileges and may require that State instrumentalities
comply with conditions that are reasonably related to the
Federal interest in particular national projects or
programs.'' Under these precedents, the Faso-Collins language
would be held to be an arbitrary exercise of Federal power
which intrudes on only one particular State's sovereign tax
powers, and is unrelated to any Federal interest or purpose
in the Medicaid Program.
As Yale Law School Professor Abbe Gluck wrote in a post on
the Balkinzation blog today, the Faso-Collins ``amendment is
likely unconstitutional. The protection from federal
interference of the internal functions of a state government
is one of the bedrocks of state sovereignty protected by the
limitations on Congress's powers in Article I of the
Constitution and the reservation of power to the states in
the Tenth Amendment.'' She further reasoned that ``Even if
one could argue that this is an exercise of the federal
spending power under Article I, for Congress to legally use
that power, the conditions on a state's use of federal
funding have to be tied to a reasonable federal propose . . .
It is hard to see a reasonable federal purpose here other
than garnering more GOP votes for the struggling repeal
bill.'' (available at https://ballkin.blogspot.com/2017/03/
is-gop-aca-repealer-unconstitutional-on.html?m=1)
Violation of Due Process and Equal Protection--Under the
Fifth Amendment, the Federal government is not permitted to
deprive its citizens of equal protection or due process of
law. Those clauses have been interpreted on numerous
occasions to prevent the government from discriminating
between the treatment of the sovereign States absent a
rational basis. For example, in Helvering v. David, 301 U.S.
619, 640 (1937), the Supreme Court warned that Congress does
not possess the right to demonstrate a ``display of arbitrary
power'' in its treatment of the various States. In this
regard, in 2009, when an earlier Senate version of the
Affordable Care Act sought to provide special treatment for
Nebraska with respect to Medicaid reimbursements, 13
Republican State attorneys general wrote to Congress
(available at http://www.law.columbia.edu/sites/default/
files/microsites/career-servicesifiles/Letter%20to%
20the%20 Honorable%20Nancy %20Pelosi%20 and%20the
%20Honorable%20Harry %20Reid.pdf) asserting the provision was
unconstitutional (the provision was ultimately dropped). In
the case of the Faso-Collins language, there is no legitimate
policy justification for developing a special rule limiting
Medicaid funds for New York as compared to all other States,
including 15 States which have sharing agreements with their
counties. Nor has a justification been offered for why New
York City should be excluded from the application of the
special rule. As such, it is clear that the provision is
discriminatory, ``arbitrary'' and has no rational basis.
Abrogation of Tenth Amendment Principles--The Tenth
Amendment provides in relevant part that powers not delegated
to the Federal government or prohibited to the States are
reserved for the States. This has been read to prevent the
federal government from ``commandeering'' the states to serve
its own purposes. In Printz v. United States, 521 U.S. 898
(1997), the Supreme Court held that Congress cannot
commandeer State officers to implement Federal policy--in
that case requiring criminal background checks for handgun
purchases pursuant to the Brady Handgun Violence Prevention
Act. The Faso-Collins language commandeers New York State
government to facilitate the partisan political ends of a
faction in the U.S. Congress, which would seem well outside
the proscriptions of Printz. In fact, by essentially ordering
New York to reorganize its internal affairs, the Faso-Collins
amendment may run even further afoul of Tenth Amendment
principles than was the case in Printz given the lack of a
Federal purpose and the interference with the core sovereign
function of how a State chooses to use its taxing power.
It is of particular constitutional concern that the Faso-
Collins provision directly interferes with New York's
internal decisions about how to structure its own tax and
spending policies, and how to allocate those responsibilities
between the State and its subdivisions--which is a core
function of a sovereign entity protected by the Tenth
Amendment (and potentially Article IV Sec. 4 of the
Constitution, which provides that the ``United States shall
guarantee to every State in this Union a Republican Form of
Government.''). This is constitutionally significant because
in Reynolds v. Sims, 377 U.S. 533, 575 (1964), the Supreme
Court held that political subdivisions such as counties and
cities ``have been traditionally regarded as subordinate
governmental instrumentalities created by the State to assist
in the carrying

[[Page H2441]]

out of State governmental functions.'' In Hunter v. City of
Pittsburgh, 207 U.S. 161, 178 (1907), the Court noted that
these subdivisions are ``created as convenient agencies for
exercising such of the governmental powers of the state, as
may be entrusted to them'' and that the ``number, nature, and
duration of powers conferred upon these [entities] and the
territory over which they shall be exercised rests in the
absolute discretion of the state.'' The Faso-Collins
amendment purports to invoke Federal power to displace New
York's sovereign exercise of this ``absolute discretion''
and, for that reason, violates the Constitution. As Chief
Justice John Marshall long ago explained in Gibbons v. Ogden,
22 U.S. 1, 198-200 (1824), the States' ``power of taxation is
indispensable to their existence. . . . In imposing taxes for
State purposes, [States] are not doing what Congress is
empowered to do. Congress is not empowered to tax for those
purposes which are within the exclusive province of the
States.''
____

Office of the Attorney General,

State of South Carolina,

December 30, 2009.
Hon. Nancy Pelosi,
Speaker, House of Representatives,
Washington, DC.
Hon. Harry Reid,
Majority Leader, U.S. Senate,
Washington, DC.
The undersigned state attorneys general, in response to
numerous inquiries, write to express our grave concern with
the Senate version of the Patient Protection and Affordable
Care Act (``H.R. 3590''). The current iteration of the bill
contains a provision that affords special treatment to the
state of Nebraska under the federal Medicaid program. We
believe this provision is constitutionally flawed. As chief
legal officers of our states we are contemplating a legal
challenge to this provision and we ask you to take action to
render this challenge unnecessary by striking that provision.
It has been reported that Nebraska Senator Ben Nelson's
vote, for H.R. 3590, was secured only after striking a deal
that the federal government would bear the cost of newly
eligible Nebraska Medicaid enrollees. In marked contrast all
other states would not be similarly treated, and instead
would be required to allocate substantial sums, potentially
totaling billions of dollars, to accommodate H.R. 3590's new
Medicaid mandates. In addition to violating the most basic
and universally held notions of what is fair and just, we
also believe this provision of H.R. 3590 is inconsistent with
protections afforded by the United States Constitution
against arbitrary legislation.
In Helvering v. Davis, 301 U.S 619, 640 (1937), the United
States Supreme Court warned that Congress does not possess
the right under the Spending Power to demonstrate a ``display
of arbitrary power.'' Congressional spending cannot be
arbitrary and capricious. The spending power of Congress
includes authority to accomplish policy objectives by
conditioning receipt of federal funds on compliance with
statutory directives, as in the Medicaid program. However,
the power is not unlimited and ``must be in pursuit of the
`general welfare.' '' South Dakota v. Dole, 483 U.S. 203, 207
(1987). In Dole the Supreme Court stated, ``that conditions
on federal grants might be illegitimate if they are unrelated
to the federal interest in particular national projects or
programs.'' Id. at 207. It seems axiomatic that the federal
interest in H.R. 3590 is not simply requiring universal
health care, but also ensuring that the states share with the
federal government the cost of providing such care to their
citizens. This federal interest is evident from the fact this
legislation would require every state, except Nebraska, to
shoulder its fair share of the increased Medicaid costs the
bill will generate. The provision of the bill that relieves a
single state from this cost-sharing program appears to be not
only unrelated, but also antithetical to the legitimate
federal interests in the bill.
The fundamental unfairness of H.R. 3590 may also give rise
to claims under the due process, equal protection, privileges
and immunities clauses and other provisions of the
Constitution. As a practical matter, the deal struck by the
United States Senate on the ``Nebraska Compromise'' is a
disadvantage to the citizens of 49 states. Every state's tax
dollars, except Nebraska's, will be devoted to cost-sharing
required by the bill, and will be therefore unavailable for
other essential state programs. Only the citizens of Nebraska
will be freed from this diminution in state resources for
critical state services. Since the only basis for the
Nebraska preference is arbitrary and unrelated to the
substance of the legislation, it is unlikely that the
difference would survive even minimal scrutiny.
We ask that Congress delete the Nebraska provision from the
pending legislation, as we prefer to avoid litigation.
Because this provision has serious implications for the
country and the future of our nation's legislative process,
we urge you to take appropriate steps to protect the
Constitution and the rights of the citizens of our nation. We
believe this issue is readily resolved by removing the
provision in question from the bill, and we ask that you do
so.
By singling out the particular provision relating to
special treatment of Nebraska, we do not suggest there are no
other legal or constitutional issues in the proposed health
care legislation.
Please let us know if we can be of assistance as you
consider this matter.
Sincerely,
Henry McMaster, Attorney General, South Carolina; Rob
McKenna, Attorney General, Washington; Mike Cox, Attorney
General, Michigan; Greg Abbott, Attorney General, Texas; John
Suthers, Attorney General, Colorado; Troy King, Attorney
General, Alabama; Wayne Stenehjem, Attorney General, North
Dakota; Bill Mims, Attorney General, Virginia; Tom Corbett,
Attorney General, Pennsylvania; Mark Shurtleff, Attorney
General, Utah; Bill McCollum, Attorney General, Florida;
Lawrence Wasden, Attorney General, Idaho; Marty Jackley,
Attorney General, South Dakota.

Mr. NADLER. Mr. Speaker, for seven years, the Republicans have tried
and failed to repeal the Affordable Care Act. So now, with a
Republican-controlled House, a Republican-controlled Senate, and a
Republican in the White House, what have they presented us to vote on
today? Republicans complained that premiums were skyrocketing, so they
offer a bill that raises premiums. They complained that deductibles
were too high, so they propose allowing insurance companies to charge
more. They complained that too many people were losing their insurance,
so they have embraced a plan that will take away health care from 24
million Americans.
This bill imposes a devastating age tax on older Americans and does
next to nothing to protect Americans with pre-existing conditions. It
gives nearly $900 billion in tax cuts to the insurance companies and
the wealthy, while refusing coverage for services as basic as
hospitalization. It's simple: Americans will pay more and get less
under this bill.
In New York, 2.7 million people will lose insurance and the state
will lose $4.6 billion in Medicaid funding. Compounding those cuts is a
cynical so-called deal several upstate Members made to secure their
votes on this bill. Under the bill, New York State, and ONLY New York
State, will no longer be allowed to ask counties to provide a portion
of state Medicaid funding.
Don't be fooled--this is no deal at all for New York and will
actually gut the State's Medicaid program, forcing hundreds of
hospitals to close and rationing health care for millions of New
Yorkers.
But my colleagues who have traded their vote for this provision have
made an empty bargain. This provision is flatly unconstitutional and
will never be enacted. They are giving away health insurance for
millions of New Yorkers for an empty promise.
My Republican colleagues claim we need to pass this bill to give
people ``freedom'' to buy health insurance. Let me tell you, freedom to
buy health insurance and actually being able to afford health insurance
are two very different things.
They keep talking about ``access'' to health care. Access is not
coverage. When they talk about access and freedom, they are conceding
that this bill does nothing to ensure that Americans have affordable,
comprehensive health insurance to cover them no matter what their
health care needs are.
The Republicans so clearly believe that Americans just need freedom
to buy insurance, that when asked what a pregnant woman should do if
her state no longer requires insurance companies to cover maternity
care, OMB Director Mick Mulvaney said she can ``figure out a way to
change the state [she] lives in.'' How callous are my Republican
colleagues to believe that is a real option for Americans?
This bill is a cowardly, cynical effort to lower taxes on the rich
and dismantle Medicare and Medicaid as we know it. I urge my colleagues
to oppose this bill.

The SPEAKER pro tempore. Pursuant to clause 1(c) of rule XIX, further
consideration of H.R. 1628 is postponed.

____________________