Congressional Record, Volume 163 Issue 77 (Thursday, May 4, 2017)

[Congressional Record Volume 163, Number 77 (Thursday, May 4, 2017)]
[House]
[Pages H4114-H4138]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

PROVIDING FOR CONSIDERATION OF H.R. 2192, PUBLIC HEALTH SERVICE ACT
AMENDMENT, AND PROVIDING FOR FURTHER CONSIDERATION OF H.R. 1628,
AMERICAN HEALTH CARE ACT OF 2017

Mr. COLLINS of Georgia. Mr. Speaker, by direction of the Committee on
Rules, I call up House Resolution 308 and ask for its immediate
consideration.
The Clerk read the resolution, as follows:

H. Res. 308

Resolved, That upon adoption of this resolution it shall be
in order to consider in the House the bill (H.R. 2192) to
amend the Public Health Service Act to eliminate the non-
application of certain State waiver provisions to Members of
Congress and congressional staff. All points of order against
consideration of the bill are waived. The bill

[[Page H4115]]

shall be considered as read. All points of order against
provisions in the bill are waived. The previous question
shall be considered as ordered on the bill and on any
amendment thereto to final passage without intervening motion
except: (1) one hour of debate equally divided and controlled
by the chair and ranking minority member of the Committee on
Energy and Commerce; and (2) one motion to recommit.
Sec. 2. During further consideration of the bill (H.R.
1628) to provide for reconciliation pursuant to title II of
the concurrent resolution on the budget for fiscal year 2017,
as amended, pursuant to House Resolution 228, the further
amendments printed in the report of the Committee on Rules
accompanying this resolution shall be considered as adopted.

The SPEAKER pro tempore (Mr. Poe of Texas). The gentleman from
Georgia is recognized for 1 hour.
Mr. COLLINS of Georgia. Mr. Speaker, for the purpose of debate only,
I yield the customary 30 minutes to the gentleman from Massachusetts
(Mr. McGovern), pending which I yield myself such time as I may
consume. During consideration of this resolution, all time yielded is
for the purpose of debate only.

General Leave

Mr. COLLINS of Georgia. Mr. Speaker, I ask unanimous consent that all
Members have 5 legislative days to revise and extend their remarks and
include extraneous materials on House Resolution 308, currently under
consideration.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from Georgia?
There was no objection.
Mr. COLLINS of Georgia. Mr. Speaker, I am pleased today to bring
forward this rule on behalf of the Rules Committee.
Over the past few weeks, the Rules Committee has had the opportunity
to hear from numerous stakeholders, from the chairs and ranking members
of committees of jurisdiction to the Members who have offered
amendments.
Most recently, last night we heard testimony from Mr. MacArthur and
Mr. Upton to explain their amendments and address any questions from
the committee members, and from Ms. McSally to explain her legislation.

{time} 0915

This rule provides for further consideration of H.R. 1628, the
American Health Care Act, and incorporates three amendments--the
Palmer-Schweikert amendment, the MacArthur amendment, and the Upton
amendment--that strengthen the underlying bill.
It also provides for consideration of H.R. 2192, legislation authored
by Representative McSally, with 1 hour of debate equally divided and
controlled by the chair and ranking member of the Committee on Energy
and Commerce.
Mr. Speaker, all across our country, the Affordable Care Act
continues to strip hardworking Americans and families of access to
affordable, quality medical care and offer them skyrocketing premiums
and anemic provider networks in return.
Democrats smuggled ObamaCare through with little regard for the
procedure, left lofty and empty promises that benefit simply a
bureaucratic machine. Seven years later, we have seen these promises
evaporate as ObamaCare patients lose access to their doctors and lose
the very insurance plans they were promised would remain intact.
Our friends across the aisle claim that coverage has been expanded
and individuals who never had quality health care before now have
access. Mr. Speaker, I wish that were true, but it is not. I wish my
colleagues and I didn't hear from neighbor after neighbor who can't
find a doctor to accept ACA insurance or who avoids medical care
altogether because their deductibles reach higher than the clouds. But
we do hear from them because Americans are suffering as insurance
providers flee from the not-so-free market.
You see, coverage doesn't mean access to care. Unfortunately, we have
heard all too often that individuals may have health coverage, but they
can't use it because their premiums and deductibles are too high for
them to actually afford the care.
What good does the coverage do a woman who earns $22,000 a year and
has a $5,000 deductible?
What good does it do a young family to have insurance that no
provider in their community accepts?
What good does it do to say we want to grow the economy and create
jobs when American businesses are struggling to keep their doors open
due to the ObamaCare mandate?
We have witnessed insurers dropping out of the exchanges and seen
premiums climbing while consumers are left with less and less choice.
Five States have one option and no choice for health insurance, and
nothing guarantees that their residents will keep that much.
ObamaCare has hijacked the free market, and it has taken some
Americans' liberties with it. We must remember that exchanging freedom,
choice, self-determination for securities at the hands of Big Brother
too often leaves us with neither liberty nor security.
We know that ObamaCare was designed to make a single-payer system
inevitable. And to the extent that a single-payer system means a zero-
choice system, the prophecy has already come true.
Families can no longer choose to save for retirement or pay their
mortgages because premiums suck up all the oxygen in their budget.
Individuals who want to purchase a PPO cannot because their county only
offers HMO plans. Disabled Americans who depend on Medicare find that
ObamaCare has given more Federal funding to able-bodied Americans than
our more vulnerable neighbors.
In my district, a young mother who wants to take her young son to the
family doctor post-ObamaCare can't because she can't find a physician
who accepts her new insurance.
Brittany Ivey and her husband have struggled under the consequences
of the Affordable Care Act. Mrs. Ivey was working part-time at a small
business that provided her family with health insurance until the
effects of ObamaCare on the insurance market raised her premiums
sharply. This drove the Ivey family into the individual market, where a
midlevel plan took 65 percent of her monthly gross income, even after a
small Federal subsidy. Unable to afford insurance through her employer,
Mrs. Ivey turned to the Federal exchange, where she obtained a plan
that neither she nor her children's doctor would accept.
The Affordable Care Act robbed Americans of the ability to choose
health care that worked for them, and the Affordable Care Act destroyed
the insurance market along with the benefits that competition and
innovation offer all of us. The American people deserve better.
ObamaCare replaced our doctors with bureaucrats because that is what
socialized medicine does.
The American Health Care Act is our last chance to get off the
Federal ferris wheel before we are locked into a healthcare system that
takes us nowhere and offers neighbors nothing but heartburn.
The American Health Care Act guts the most egregious provisions of
ObamaCare, rolls back the law's taxes, restores flexibility to the
States, and helps to make quality care more accessible and affordable.
Mr. Speaker, one of the reasons I came to Congress is to repeal and
replace ObamaCare and rein in our Nation's bloated, ballooning
entitlement system. The American Health Care Act does that by, for the
first time, making major reforms to an entitlement program--Medicaid.
It rolls back the Medicaid expansion under ObamaCare, one of the
fundamental pillars, and it makes structural changes to the program to
ensure it only goes to the individuals it was intended to help.
The American Health Care Act allows States to establish work
requirements for able-bodied adult Medicaid enrollees. It lets States
choose between the per capita cap and a flexible Medicare block grant,
and it increases the growth rate to cover disabled and elderly Medicaid
populations.
The bill enacts patient-centered reforms, increases access to
healthcare savings accounts, and creates a Patient and State Stability
Fund to help stabilize insurance markets that have contracted during
ObamaCare.
Over the course of the last several weeks, we have worked in this
House to strengthen the bill. We have listened to feedback from
constituents, neighbors, stakeholders, and each other.

Importantly, coverage for individuals with preexisting conditions is
maintained as a baseline within the bill. An

[[Page H4116]]

amendment from Mr. MacArthur further protects individuals' preexisting
conditions from being denied coverage.
While the amendment provides States with additional flexibility by
allowing them to seek a waiver, individuals with preexisting conditions
will not be left out to dry. In fact, there are conditions attached to
the waiver that ensure States use funds provided by the bill, should
they receive a waiver, to set up high-risk pools for those very
individuals. With the addition of the Upton amendment, the bill
provides $108 billion to help States fund programs such as high-risk
pools.
Mr. Speaker, my home State of Georgia has very different needs than
California. That is why I think it makes sense to give States more say
in what works for their populations. Our plan does this, but it does so
in a way that ensures protections exist for vulnerable populations like
the elderly, disabled, and children.
The rule also provides for Representative McSally's legislation to
ensure that Members of Congress are treated the same as all Americans.
I fully support this bill and firmly believe elected officials should
be required to live under the same laws as those they were elected to
represent.
President Trump has made his support of the American Health Care Act
and its strengthening amendments clear, and I stand with him in
supporting this legislation to gut ObamaCare and rescue the American
people.
Mr. Speaker, average premiums rose by 40 percent or more in 11 States
just this year. The statistics and the stories speak for themselves. We
must act to dismantle ObamaCare, and the Affordable Care Act does that.
I support the rule before us today to provide for further
improvements to the bill and look forward to supporting both the rule
and the underlying bill.
I reserve the balance of my time.
Mr. McGOVERN. Mr. Speaker, I yield myself such time as I may consume.
(Mr. McGOVERN asked and was given permission to revise and extend his
remarks.)
Mr. McGOVERN. I thank the gentleman from Georgia (Mr. Collins) for
the customary 30 minutes.
Mr. Speaker, pathetic, that is the word to describe this process and
this bill. If the American people could sue Congress for malpractice,
my Republican friends would be in deep trouble.
How could you do this? How could you do this to the American people?
How can you do this to the people you represent?
You are taking away essential healthcare protections. You are
allowing insurance companies to discriminate against people with
preexisting conditions. You are supporting a bill that will throw 24
million people off of their health care and cut Medicaid by $880
billion to give a $1 trillion tax break to the wealthiest people in
this country.
What is wrong with you guys?
Today's rule self-executes three of the newest Republican amendments
to the Republican health plan. This means, without any sort of debate
or discussion whatsoever, the Palmer, MacArthur, and Upton amendments
will magically pass the House.
What I find so hard to believe about this latest backroom deal is
that they actually make this bill worse. I didn't think that was
possible, Mr. Speaker.
To shore up support amongst this Chamber's most conservative faction,
Representative MacArthur and others made a deal with President Trump to
gut protections for individuals with preexisting conditions and to
eliminate essential health benefits like maternity care, mental health
treatment, and prescription drug coverage, just to name a few. These
are among the most popular provisions of the Affordable Care Act.
The American people were justifiably outraged, and they showed up by
the thousands to townhalls to express their anger. And there were some
on the Republican side who actually got it. They listened to their
constituents and they had the courage to stand up and say no.
But when Republican leaders came up short in their whip count,
Representative Upton ran to the White House and concocted a deal with
President Trump to try to win back votes. His amendment adds a measly
$8 billion spread out over 5 years in a futile attempt to soften the
devastating effect that this bill will have on millions and millions of
Americans with preexisting conditions.
Now, $8 billion over 5 years sounds like a lot, but when we are
talking about an entire country, it really isn't. Don't take it from
me. Robert Graboyes from the conservative Mercatus Center said:
``The $8 billion amount is a pittance. Spread over 5 years, it's a
fifth of a pittance.''
This is not a leftwing organization. This is an organization funded
by Koch Industries, the Koch brothers. My friends love the Koch
brothers.
What's more, some analysts have already estimated that an additional
$200 billion will be needed over a decade to adequately fund high-risk
pools. So this amendment is billions upon billions upon billions of
dollars short. And as the Center for American Progress points out, the
Upton amendment ``will have almost no effect.''
Now, my colleagues who have been won over by this should be ashamed
of themselves. We are supposed to fix problems and help people, not
merely settle for political cover that can be used in a press release.
$8 billion to cover a $200 billion shortfall? Back where I come from,
we call that being a cheap date. I guarantee you, your constituents are
going to figure this out, and they will not be happy.
So to so-called moderate Republicans who have contorted themselves
this week to try to find a fix to the damage being done to the people
with preexisting conditions, I have breaking news: I have a magic
bullet fix if Republicans really want to protect people with
preexisting conditions. Are you ready? Brace yourselves. Don't change
the law. Everyone is already protected by the Affordable Care Act,
including people with preexisting conditions and those who struggle to
find affordable care. Let me say to my colleagues that to claim or
imply that this Republican plan covers preexisting conditions is a lie,
plain and simple.

Now, let me say a few words about the process that has been used to
bring this bill to the floor. It has been a disaster from start to
finish, with secret negotiations, backroom deals, and bribes to buy off
factions within the Republican Conference. There have been no hearings
on this bill whatsoever. And the Republican leadership couldn't even
slow down long enough to receive a score from the CBO.
I have one simple question: What is the rush? Wait a week and get a
CBO score. Why is that such a radical idea?
Mr. Speaker, are Republican leaders jamming this bill through to
appease Donald Trump?
Are they concerned that a new CBO score will confirm what we already
know is true, that this bill will be devastating to the people of this
country, force even more people to lose their health care, especially
to older, sick, and low-income Americans.
Or maybe, Mr. Speaker, Republican leaders are worried that their
colleagues will go home over this weeklong break and actually hear from
their constituents who overwhelmingly oppose this effort to repeal the
Affordable Care Act.
Honestly, I don't know how my Republicans friends can defend this
terrible, closed, authoritarian process. It is an absolute disgrace.
I urge my colleagues to vote ``no'' on this bill, or, better yet, I
urge my Republicans colleagues to do what they did a couple of weeks
ago and pull this disastrous bill.
I reserve the balance of my time.
Mr. COLLINS of Georgia. Mr. Speaker, I reserve the balance of my
time.
Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentleman from
Kentucky (Mr. Yarmuth), the distinguished ranking member of the
Committee on the Budget.
Mr. YARMUTH. Mr. Speaker, the question every Member of Congress
should be asking themselves today is: Who in the world is better off
because of today's bill?
It is not the 24 million people the CBO says will lose their health
coverage if this bill becomes law.
It is not the seniors who will be priced out of the market by an age
tax or the millions of families who will see their health care gutted
by the more than $800 billion in cuts to Medicaid.
It is not the 881,000 non-elderly adults in Kentucky with preexisting
conditions who would, once again, face

[[Page H4117]]

staggering health costs with reduced care.
So who is better off? Well, certainly corporations and millionaires
who will see nearly $1 trillion in tax cuts from this bill.
And at least, in their minds, a few Republican Members are so
desperate for some type of political victory they are willing to risk
the health and well-being of their constituents to ram through a bill
without hearings, analysis, or, most alarmingly, any sense of morality.
That is the cruel tradeoff my Republican colleagues have decided to
make.
Our families deserve far better. I urge my colleagues to exercise
better judgment and vote ``no'' on this bill.
Mr. COLLINS of Georgia. Mr. Speaker, I reserve the balance of my
time.

{time} 0930

Mr. McGOVERN. Mr. Speaker, I am not sure if my colleagues are aware
of this since we are moving so quickly here, but I want to flag for
everyone an important op-ed in The Hill by the executive director of
the Boston Area Rape Crisis Center. She points out that in the latest
version of this legislation, rape can once again be categorized as a
preexisting condition as it often was before the Affordable Care Act.
I include her column, entitled ``Health `reform' will make sexual
assault survivors sick,'' in the Record.

Health `Reform' Will Make Sexual Assault Survivors Sick

(By Gina Scaramella)

So far, we know that about 24 million Americans stand to
lose their health insurance coverage if the Affordable Care
Act (ACA) is replaced with the American Health Care Act
(AHCA). We know that most of those 24 million people will be
low-income.
We also know that groups of people who experience
significant health care disparities, such as lesbian, gay,
bisexual and transgender (LGBT) people, and Black and Latino
people, will be among those who risk losing the most if the
ACA is repealed. To that list, we must add survivors of
sexual violence.
Before passage of the ACA in 2010, sexual assault survivors
who had sought medical care for their injuries could be
denied health insurance coverage at a later date. The reason?
Health insurers often categorized rape as a pre-existing
health condition.
In one widely reported case, a 45-year-old woman met two
men at a bar in Florida who bought her a drink. Hours later,
she found herself lying by the side of the road with injuries
indicating that she had been raped and that the men had
spiked her drink. Her doctor prescribed a treatment of anti-
viral, post-HIV exposure drugs to protect against HIV
transmission.
When the woman lost her health insurance several months
after the attack, she was unable to obtain new insurance due
to the health care treatment she had received for the
assault. She went without health insurance for three years.
Stories like these prompted the National Women's Law Center
to launch a campaign called ``Being a Woman Is Not a Pre-
Existing Condition.'' It was so popular that then-House
Speaker Nancy Pelosi adopted the phrase in her pro-health
reform talking points with media, and the New York Times ran
an explainer on the ways in which health insurers treated
women as if they were just one giant pre-existing condition.
The AHCA initially retained the ACA's ban on discrimination
against people with pre-existing conditions. But an amendment
to the AHCA bill offered last week by New Jersey Congressman
Tom MacArthur and North Carolina Congressman Mark Meadows
would make it easier for health insurers to deny coverage to
people with pre-existing conditions.
By letting states waive the ACA prohibition on charging
people with pre-existing health conditions higher premiums,
protections for those who've previously been medically
treated for sexual assault would be gutted.
Perhaps more alarming, though, is the MacArthur-Meadows
amendment's provision allowing states to also seek waivers
from the ACA's requirement that essential health benefits be
covered by health insurance plans. Essential health benefits
include preventive health care services that most of us take
for granted. These include tests for blood pressure and
cholesterol, mammograms, and vaccinations. Essential health
benefits also include coverage for mental health care and
substance abuse treatment.
Sexual violence survivors face acute treatment needs in the
aftermath of an assault such as care for gynecological
injuries, other physical trauma, sexually-transmitted
diseases, and pregnancy. But sexual violence takes many
forms: incest: ongoing sexual abuse outside of the family,
sexual assault, sexual harassment or exploitation, and rape.
Each of these types of assault puts the survivor at risk for
various potential negative physical health and mental health
outcomes.
For example, an adult survivor of childhood sexual abuse is
at a higher risk for psychiatric disorders. Women and men who
have survived rape as adults are at higher risk of post-
traumatic stress disorder, depression, anxiety, and substance
abuse--any of which can significantly interfere with daily
living. No one can deny that there is a direct line between
having survived sexual violence, and an increased risk of
physical and mental health problems.
The mental health impacts of sexual violence are deep and
often longstanding. Survivors need long-term access to
nonjudgmental health and mental health services to reduce
their suffering and mitigate as much as possible the stress
that recovery from sexual violence puts on intimate family
relationships, and obligations related to school and work.
It is hard to see any good coming from this latest attempt
to repeal the ACA and all of the care it has brought to
survivors of sexual violence.
Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentlewoman from
Washington (Ms. DelBene).
Ms. DelBENE. Mr. Speaker, this destructive legislation hurts middle
class families and threatens massive disruption to our healthcare
system. And it has only gone from bad to worse.
Stripping protections from 133 million Americans with preexisting
conditions isn't just wrong, it is inhumane. Nobody in this country
should go bankrupt trying to afford the medical care they need to stay
alive.
This isn't about politics; it is about human decency and who we are
as Americans. It is about people like Jackie, a cancer survivor from
Snohomish who says the Affordable Care Act saved her life.
She wrote to me saying: ``My cancer recurred, but I was covered. I
was able to complete my treatments without having to worry about how to
put food on the table. Or being left to die. Because of the ACA, I
survived.''
We all have stories like this in our districts, but some of my
colleagues aren't listening. I hope they find the courage and the
wisdom to vote ``no'' on this dangerous legislation.
Mr. COLLINS of Georgia. Mr. Speaker, I reserve the balance of my
time.
Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentleman from
Texas (Mr. Castro).
Mr. CASTRO of Texas. Mr. Speaker, Republicans, over the last few
months, have said that they would fundamentally change health care in
the United States, and it is clear today that they have. They have made
it much worse.
I want to highlight one provision that allows for States to permit
insurers to get rid of essential healthcare benefits and charge people
more who have preexisting conditions. Think about that for a second.
In my home State of Texas, the Governor and other State leaders have
already turned their back on so many people, allowing foster care
children to sleep in State offices, allowing sex trafficking and human
trafficking victims to go to jail because there is nowhere else to put
them.
You should ask yourselves: What will your leaders do? Will they allow
insurers to charge you more for preexisting conditions like diabetes
and hypertension and cancer and asthma?
Do you think, and do you trust, that they are going to do the right
thing by you? Because today, this plan allows them to abandon you.
Mr. COLLINS of Georgia. Mr. Speaker, I yield myself such time as I
may consume.
At this time, I think one of the interesting things is, as discussed,
the criticism of this. I think it was just a reminder, Mr. Speaker, of
what happened 7 years ago when our healthcare market, which could have
been helped by many good ideas, was decided to be taken on a very
unhealthy bent. We are now paying the price for that. We are going to
continue to see that unless we change it. We are changing that for the
better.
One of the strongest voices that we have had in this body is someone
who has actually taken it as his living to take care of people. Dr.
Burgess not only came to this Congress with a strong voice of not only
what doctors and the medical profession have, but I think it gives us
an insight into what patients need as well. He has been a clarion voice
through this whole process, before ObamaCare, during the disaster of
ObamaCare, and now as we look to fix the problems that have existed.
I yield as much time as he may consume to the gentleman from Texas
(Mr. Burgess).
Mr. BURGESS. Mr. Speaker, how did we get to this point?

[[Page H4118]]

The Affordable Care Act is simply not working for the American
people. It is limiting choices. It is raising costs. It is leaving
millions without access to care. And unfortunately, these are not just
talking points but very real issues affecting very real Americans.
The Affordable Care Act has left the individual market in shambles
and has driven insurers away from offering coverage. Now, we are seeing
one-third of all counties in the United States of America with only a
single insurer. And among the plans that have chosen to remain in these
markets, there have been widespread, double-digit premium increases. In
Texas, premiums have jumped 29 percent a year, on average, from 2014 to
2017.
The markets are in difficulty. They are failing to live up to the
promise made 7 years ago, that Americans would be able to receive
``affordable care.''
As we knew then, and we still know now, this was an empty promise and
has priced over 19 million Americans out of the market. What is worse,
these individuals are forced to pay the individual mandate penalty or
seek a hardship exemption because of the cost to purchase and use their
health insurance.
Mr. Speaker, 11 months ago, Speaker Ryan released the Better Way plan
to save the Nation's healthcare system and to bring relief to the
American people. This plan, which served as the blueprint for the
American Health Care Act, laid out policies to stabilize the markets
damaged by the Affordable Care Act, repeal the burdensome Affordable
Care Act taxes and mandates that have hindered innovation and limited
access to care. So let's take a look at what the American Health Care
Act does.
First and foremost, the American Health Care Act provides immediate
relief to the State insurance markets. As Republicans, we know that
one-size-fits-all works for no one, and certainly did not work for the
individual markets. The States should have the flexibility to support
their insurance markets and ensure that plans can continue to provide
options for coverage.
To do this, we relax two of the more egregious market regulations
that were imposed under the Affordable Care Act: the mandate that
premiums cannot vary for younger and older Americans by more than a 3-
to-1 ratio and the mandate creating fixed actuarial values for plans.
The mandate limiting a plan's ability to set premiums by age has
driven up the cost of coverage for younger and healthier Americans and,
subsequently, pushed them away from seeking coverage by the millions.
Of the over 19 million Americans who have sidestepped the individual
market, it is estimated that as many as 45 percent of these individuals
are under the age of 35. Without these younger Americans seeking
coverage, the markets have plunged, as insurers have hiked up premiums
year after year to compensate for unhealthy risk pools.

To change this, there is relaxation of the 5-to-1 ratio. It will
lower premium costs and provide necessary opportunities to stabilize
markets. We also give States the option, the choice to go higher or go
lower, which honors the spirit of federalism.
Additionally, we are repealing the actuarial values mandate to
provide insurers with additional flexibility to offer more coverage
options. The requirement for insurers to offer specified Bronze,
Silver, and Gold level tiers has limited consumer choice, driving even
more individuals away from seeking coverage and further contributing to
the collapse of the healthcare markets.
To further supplement these efforts, we are establishing the Patient
and State Stability Fund. This fund provides States access to a total
of over $140 billion over 10 years to promote innovative solutions to
lower costs and increase access to health care for their unique patient
populations.
Mr. Speaker, the goal is simple, to provide States with maximum
flexibility in how they address the cost of care for their citizens.
The American Health Care Act provides States with options for how to
use funds, including providing financial assistance for high-cost
individuals, incentivizing insurer participation in those markets,
reducing the cost of insurance, promoting access to preventive
services, and reducing out-of-pocket costs for patients.
The Congressional Budget Office estimated that a combination of the
Stability Fund and other proconsumer changes would reduce premiums by
10 percent below current projections of 2026.
We want patients to have access to high-quality, affordably priced
health coverage. The Patient and State Stability Fund can help States
lower costs and can increase access to high quality health care for
their citizens.
In addition to supporting the insurance markets, the American Health
Care Act creates needed reforms to the Medicaid program itself. Without
any changes, the current Medicaid expansion is expected to cost $1
trillion in 10 years' time--$1 trillion a year in 10 years' time.
Medicaid needs reform so that States can continue to provide coverage
to children, people with disabilities, and other vulnerable groups, the
very populations that this safety net program was created to serve.
To address these concerns, the American Health Care Act first phases
out the Medicaid expansion, not traditional Medicaid but Medicaid
expansion. The expansion has hurt State budgets and limited States'
abilities to ensure that resources will continue to be available for
the vulnerable populations for which Medicaid was designed. By phasing
out expansion, we are providing States with greater budget autonomy.
Additionally, our bill helps further bend the Medicaid cost curve by
shifting the program toward a per beneficiary allotment. Per
beneficiary allotments set limits on the annual growth for per capita
expenditures for which the States will receive matching funds from the
Federal Government. Per beneficiary allotments create greater fiscal
accountability and ensure that the program can continue to exist for
years to come.
This is not a new idea. This was an idea put forward by President
Bill Clinton and, at one time, supported by every Democratic Member of
the Senate in 1995.
Second, the American Health Care Act increases the amount of
flexibility that States have in managing their Medicaid program. The
bill scales back the Affordable Care Act mandates that have limited a
State's ability to tailor plans toward the needs of beneficiaries.
States can and States should be trusted to effectively manage the needs
of their Medicaid beneficiaries. The American Health Care Act will
allow them to do so.
Additionally, the American Health Care Act furthers the goal of
providing the States with greater flexibility in managing their
Medicaid programs by providing States with the option to implement two
additional opportunities: work requirements and block grants for
Medicaid.
When the Affordable Care Act was being debated, some of the most
consistent complaints that we heard throughout the discussion came from
Governors and State representatives expressing concerns about the
negative consequences that they saw on the horizon.
This time around, we chose to engage our State counterparts in the
discussion and listen to their input as we designed the bill; and at
the top of their list was a desire to see the work requirements built
into the Medicaid and the expansion populations, and the opportunity to
work with Medicaid as a block grant.

Republicans trust that States know what works for their respective
populations, and we are not going to stand in the way of States seeking
to design Medicaid programs that work for them.
Finally, the American Health Care Act provides additional resources
to bolster State safety net providers. The bill provides increases to
the Community Health Center Fund, offers enhanced funding to support
the safety net providers in States that did not expand Medicaid, and
ends the cuts to Disproportionate Share Hospital payments, cuts that
are going to occur under current law on October 1 of this year.
We are committed to ensuring that our local providers can continue to
deliver lifesaving care and that the American Health Care Act turns
this commitment into action. For the millions of Americans in rural and
medically underserved areas, these actions

[[Page H4119]]

will provide needed relief that was undercut by the Affordable Care Act
and will allow these Americans to continue to have access to care.
Moving forward, together, these efforts will provide meaningful
reform and relief for the States and for the individuals seeking health
care. We are stabilizing the markets, reforming Medicaid in the most
substantive and consequential way in its 52-year history, and ensuring
that all Americans can maintain access to care through local safety net
providers.
We do recognize there is still more work to be done in health care,
and that is why we only consider the American Health Care Act to be the
beginning. It is the key that gets us through the door into additional
health reform. From here, we will work with Secretary Price at the
Department of Health and Human Services to further deregulate the
marketplace and increase consumer choice in the healthcare markets, and
we will enhance the American Health Care Act with additional
legislative efforts to further the goal of lowering healthcare costs.
Mr. Speaker, this should be a very exciting time in health care. With
all of the knowledge that has been gained over the years in the
practice of medicine, I am humbled to be here today speaking in support
of this legislation.
It will begin the much-awaited process of unwinding the Affordable
Care Act and will finally return patients to the center of health care.

{time} 0945

Mr. McGOVERN. Mr. Speaker, wow. I yield myself such time as I may
consume, and to rebut the gentleman from Texas, let me include in the
Record a letter from the American Cancer Society, the American Diabetes
Association, the American Heart Association, the American Lung
Association, the Cystic Fibrosis Foundation, the Juvenile Diabetes
Foundation, the March of Dimes, the National Multiple Sclerosis
Society, the National Organization for Rare Disorders, and the National
Coalition for Women with Heart Disease.

Leading Patient Advocacy Groups Remain Opposed to the American Health
Care Act

Eight Organizations Issue Statement Criticizing Upton Agreement

Washington, May 3, 2017.--Earlier today, House Energy and
Commerce Committee Chairman Greg Walden (R-OR) issued a press
release stating that an amendment proposed by Representative
Fred Upton (R-MI) to the American Health Care Act (AHCA)
provides ``protection and certainty for patients with pre-
existing conditions.'' Eight leading patient groups, listed
below, issued the following statement in response:
Despite the Upton amendment, we remain strongly opposed to
the American Health Care Act and urge Congress to consider
the people at the heart of this decision. The various
patchwork solutions offered by lawmakers would still leave
the millions of patients we represent, who have serious and
chronic health conditions, at risk of not being able to
access life-saving treatments and care.
There is no substitute for fundamental, unequivocal
protections for people with pre-existing conditions.
The AHCA, including the potential amendment, would
undermine vital safeguards against being charged more for
insurance based on health status. Increasing funding for risk
sharing programs and consumer financial assistance does not
address the legitimate challenges built into these proposals.
The other equally important problems with the AHCA remain,
including:
Allowing states to waive the guarantee of essential health
benefits, which would:
Segment the market into plans for sick people and plans for
healthy people, driving up the cost of plans for people with
serious health care needs
Undermine the protection against annual and lifetime
coverage caps, a critical safeguard for patients
Eliminating Medicaid expansion coverage for millions of
Americans and altering the program's financing structure in a
way that jeopardizes coverage of new and innovative
treatments
Increasing out-of-pocket costs for many Americans,
including some of the sickest and elderly among us
Given the numerous shortcomings of the American Health Care
Act in serving the patients we represent, our organizations
have no choice but to oppose this legislation and urge all
Representatives to vote against it, with or without the Upton
and MacArthur amendments.

Patient Advocacy Groups

American Cancer Society Cancer Action Network
American Heart Association
American Lung Association
Cystic Fibrosis Foundation
March of Dimes
National Organization for Rare Disorders
National MS Society
WomenHeart: The National Coalition for Women with Heart
Disease

Media Contacts

American Cancer Society Cancer Action Network, Alissa
Crispino.
American Heart Association, Abbey Dively.
American Lung Association, Allison MacMunn.
Cystic Fibrosis Foundation, Jessica Rowlands.
March of Dimes, Cindy Pellegrini.
National Organization for Rare Disorders, Jennifer Huron.
National MS Society, Eileen Curran.
WomenHeart: The National Coalition for Women with Heart
Disease, Tom Murphy.

Mr. McGOVERN. Mr. Speaker, I also include in the Record a statement
from the American Medical Association in opposition to this bill.

[From the American Medical Association, May 3, 2017]

AMA Warns that Proposed Changes to the American Health Care Act Do Not
Remedy Bill's Shortcomings

Despite amendments to bill, millions of Americans would still lose
health insurance coverage

Chicago.--American Medical Association (AMA) President
Andrew W. Gurman, M.D., issued the following statement today
about proposed changes to the American Health Care Act
(AHCA):
``None of the legislative tweaks under consideration
changes the serious harm to patients and the health care
delivery system if AHCA passes. Proposed changes to the bill
tinker at the edges without remedying the fundamental failing
of the bill--that millions of Americans will lose their
health insurance as a direct result of this proposal.
``High-risk pools are not a new idea. Prior to the
enactment of the Affordable Care Act, 35 states operated
high-risk pools, and they were not a panacea for Americans
with pre-existing medical conditions. The history of high-
risk pools demonstrates that Americans with pre-existing
conditions will be stuck in second-class health care
coverage--if they are able to obtain coverage at all.
``Not only would the AHCA eliminate health insurance
coverage for millions of Americans, the legislation would, in
many cases, eliminate the ban against charging those with
underlying medical conditions vastly more for their
coverage.''
``America should not go backward to the time when our
fellow citizens with pre-existing health conditions faced
high costs for limited coverage, if they were able to obtain
coverage at all. The AMA urges congressional leaders and the
Administration to pursue a bipartisan dialogue on alternative
policies that provide patients with access and coverage to
high quality care and preserve the safety net for vulnerable
populations.''

Background on high-risk pools

A January report from the American Academy of Actuaries
notes that ``enrollment has generally been low, coverage has
been limited and expensive, they require external funding,
and they have typically operated at a loss . . . Removing
high-risk individuals from the insured risk pools reduces
costs in the private market only temporarily. Over time, even
lower-cost individuals in the individual market can incur
high health care costs, which would put upward pressure on
premiums.''
According to the Kaiser Family Foundation:
State high-risk pools featured premiums above standard non-
group market rates--with most states capping them at 150%-
200% of standard rates. Many also featured high deductibles,
some $5,000 or more.
Despite the fact that many individuals were forced into
high-risk pools because of a pre-existing condition, nearly
all states excluded coverage for these conditions for 6-12
months.
Almost all high-risk pools imposed lifetime limits on
covered services, and some imposed annual limits.
Some states capped or closed enrollment.
Combined net losses for the state high-risk pools totaled
more than $1.2 billion for 2011, or $5,510 per enrollee, on
average.
Furthermore, a 2010 paper by James Capretta and Tom Miller
that appeared in National Affairs estimated that the cost of
adequately funded high risk pools would be $15 billion to $20
billion per year.

Mr. McGOVERN. Mr. Speaker, I also include in the Record a letter from
the American Academy of Family Physicians in opposition to this bill.

American Academy of

Family Physicians,

May 3, 2017.
Jim McGovern,
Representative, House of Representatives, Washington, DC.
Dear Rep. Jim McGovern: Despite recent activities and
amendments, the American Health Care Act (H.R. 1628) remains
a highly flawed proposal that will destabilize our health
care system, cause significant loss of coverage, and allow
for the discrimination against patients based on their
gender, age, and health status. For these reasons, the
American Academy of Family Physicians (AAFP) continues to
oppose the AHCA and

[[Page H4120]]

encourages the House of Representatives to reject this failed
policy.
The fact remains that the AHCA will:
Cause more than 24 million people to lose their health care
coverage, including more than 7 million with employer-
sponsored coverage.
Destabilize the individual health insurance market.
Create a race to the bottom by eliminating any standards
with respect to minimum insurance benefits.
Enact draconian cuts in the Medicaid program that will have
an immediate negative impact on low-income individuals,
children, and millions of senior citizens who rely on the
program.
Eliminate community rating and return to medical
underwriting, thus allowing insurers to discriminate against
individuals based on their gender, age, and health status.
Deny individuals protection against annual and lifetime
spending caps, thus threatening the financial stability of
millions of individuals and families in the future.
Over the past few days there has been an effort to advance
policies that seek to protect individuals with pre-existing
conditions from facing discrimination in insurance
underwriting as a result of their health status. Despite a
willingness to spend more money on these proposals, the
current efforts on pre-existing conditions fail to accomplish
their goal. High-risk pools are inherently flawed and
expensive. The proposals under consideration provide
inadequate funding for an inadequate period of time, thus
creating an under-funded and temporary solution for the
millions of Americans with pre-existing conditions. We find
it regrettable that Congress would seek to relegate
individuals with high health care needs to a program that has
a questionable history and would face uncertain financial
stability in the future.
By removing critical consumer protections that collectively
ensure that the millions of individuals with pre-existing
conditions can continue to purchase affordable health care
coverage, the AHCA would result in higher premiums and higher
deductibles for millions. Additionally, the negative impact
of the AHCA is not limited to the individual insurance
market. These policies also may impact the more than 130
million people with employer-sponsored insurance.
Thank you.

Mr. McGOVERN. Mr. Speaker, I also include in the Record a statement
from the AARP in strong opposition to this bill.

AARP,

May 3, 2017.
Dear Representative: Older Americans care deeply about
access to and affordability of health care. With the addition
of the Upton Amendment, as reported, we once again write to
share our opposition to the American Health Care Act (AHCA)
and urge you to vote NO. Changes under consideration that
would allow states to waive important consumer protections--
allowing insurance companies to once again charge Americans
with pre-existing conditions more because they've had cancer,
diabetes or heart disease--would make a bad bill even worse.
This would be devastating for the 25 million Americans 50-64
who have a deniable pre-existing condition. The Upton
amendment would do little to reduce the massive premium
increases for those with pre-existing conditions.
Throughout consideration of the AHCA, we have been
expressing serious concerns about the impact that this
legislation will have on older Americans. The Congressional
Budget Office (CBO)'s last estimate further demonstrates the
harmful impact of this bill on older Americans and some of
our most vulnerable. Specifically, the American Health Care
Act will weaken the fiscal sustainability of Medicare;
dramatically increase premium and out-of-pocket costs for 50-
64 year olds purchasing coverage on the individual insurance
market; allow insurance companies to once again discriminate
against those with pre-existing conditions; substantially
increase the number of Americans without insurance; and put
at risk millions of children and adults with disabilities and
poor seniors who depend on the Medicaid program to access
long-term services and supports and other benefits.
Our members and others 50 years of age and older care
deeply about health care and want to know where their elected
leaders stand. Recognizing the importance of the upcoming
vote on the American Health Care Act, AARP intends to inform
our members, and others over age 50, how their elected
officials voted. We'll communicate the results of the vote in
our widely-circulated publications, in e-mail alerts, in our
online channels, and through the media. Again, we urge all
Representatives to vote NO on the American Health Care Act in
its current form.

Medicare

The American Health Care Act repeals provisions in current
law that have strengthened Medicare's fiscal outlook,
specifically, the repeal of the additional 0.9 percent
payroll tax on higher-income workers. Repealing this
provision would remove billions from the Hospital Insurance
trust fund, hasten the insolvency of Medicare, and diminish
Medicare's ability to pay for services in the future.

Individual Private Insurance Market

Currently, about 25 million Americans age 50-64 have a pre-
existing condition, about 6.1 million purchase insurance in
the non-group market, and nearly 3.2 million are currently
eligible to receive subsidies for health insurance coverage
through either the federal health benefits exchange or a
state-based exchange (exchange). Since passage of the ACA,
the number of 50-64 year old Americans who are uninsured has
dropped by half. We are deeply concerned that the AHCA would
be a significant step backwards and result in millions of
older Americans who cannot afford their health care,
including many simply losing their health care. Based on CBO
estimates, approximately 14 million Americans will lose
coverage next year, while a total of 24 million Americans
would lose coverage over the next 10 years.
Affordability of both premiums and cost-sharing is critical
to older Americans and their ability to obtain and access
health care. A typical 50-64 year old seeking coverage
through an exchange has a median annual income of under
$25,000 and already pays significant out-of-pocket costs for
health care. We have serious concerns--reinforced by the CBO
estimate--that the bill under consideration will dramatically
increase health care costs for 50-64 year olds who purchase
health care through an exchange due both to the changes in
age rating from 3:1 (already a compromise that requires
uninsured older Americans to pay three times more than
younger individuals) to 5:1 (or more) and reductions in
current tax credits for older Americans. CBO concluded that
the bill will substantially raise premiums for older people
and force many into lower quality plans.
Age rating plus reduced tax credits equal an unaffordable
age tax. Our previous estimates on the age-rating change
showed that premiums for current coverage could increase by
up to $3,200 for a 64 year old. In addition, the bill reduced
the tax credits available for older Americans to help
purchase insurance. We estimate that the bill's changes to
current law's tax credits alone could increase premium costs
by more than $5,800 for a 64-year old earning $15,000.
Overall, both the bill's tax credit changes and 5:1 age
rating would result in skyrocketing cost increases for older
Americans. In their analysis, CBO found that a 64 year old
earning $26,500 a year would see their premiums increase by
$12,900--758 percent--from $1,700 to $14,600 a year.
Current law prohibits insurance companies from
discriminating against individuals due to a pre-existing
condition. The bill would repeal pre-existing condition
protections and would once again allow insurance companies to
charge Americans more--we estimate up to $25,000 more--due to
a pre-existing condition. As a result, the 40 percent of 50-
to 64-year-olds (about 25 million people) who have a deniable
pre-existing condition risk losing access to affordable
coverage. The Upton Amendment, which would add funds to
address the impact of premium increases for those with
pre-existing conditions, would do little to mitigate the
massive premium increase for some of the most vulnerable
Americans. AARP strongly opposes any weakening of the
law's pre-existing condition protections which benefit
millions of Americans.

Medicaid and Long-Term Services and Supports

AARP opposes the provisions of the American Health Care Act
that create a per capita cap financing structure in the
Medicaid program. We are concerned that these provisions
could endanger the health, safety, and care of millions of
individuals who depend on the essential services provided
through Medicaid. CBO found that the bill would cut Medicaid
funding by $880 billion over 2017-2026, about 25 percent less
than what it projects under current law. Medicaid is a vital
safety net and intergenerational lifeline for millions of
individuals, including over 17.4 million low-income seniors
and children and adults with disabilities who rely on the
program for critical health care and long-term services and
supports (LTSS, i.e., assistance with daily activities such
as eating, bathing, dressing, managing medications, and
transportation). Older adults and people with disabilities
now account for over sixty percent of Medicaid spending, and
cuts of this magnitude will result in loss of benefits and
services for this vulnerable population.
Of these 17.4 million individuals: 6.9 million are ages 65
and older (which equals more than 1 in every 7 elderly
Medicare beneficiaries); 10.5 million are children and adults
living with disabilities; and about 10.8 million are so poor
or have a disability that they qualify for both Medicare and
Medicaid (dual eligibles). Dual eligibles account for almost
33 percent of Medicaid spending. While they comprise a
relatively small percentage of enrollees, they account for a
disproportionate share of total Medicare and Medicaid
spending.
Individuals with disabilities of all ages and older adults
rely on critical Medicaid services, including home and
community-based services (HCBS) for assistance with daily
activities such as eating, bathing, dressing, and home
modifications; nursing home care; and other benefits such as
hearing aids and eyeglasses.
In providing a fixed amount of federal funding per person,
this approach to financing would likely result in
overwhelming cost shifts to states, state taxpayers, and
families unable to shoulder the costs of care without
sufficient federal support. This would result in cuts to
program eligibility, services, or both--ultimately harming
some of our nation's most vulnerable citizens.

[[Page H4121]]

The bill also repeals the six percent enhanced federal
Medicaid match for states that take up the Community First
Choice (CFC) Option. CFC provides states with a financial
incentive to offer HCBS to help older adults and people with
disabilities live in their homes and communities where they
want to be. About 90 percent of older adults want to remain
in their own homes and communities for as long as possible.
HCBS are also cost effective. On average, in Medicaid, the
cost of HCBS per person is one-third the cost of
institutional care. Taking away the enhanced match could
disrupt services for older adults and people with
disabilities in the states that are already providing
services under CFC and would result in a loss of about $12
billion for HCBS over ten years.

Prescription Drugs

The AHCA would repeal the fee on manufacturers and
importers of branded prescription drugs, which currently is
projected to add $24.8 billion to the Medicare Part B trust
fund between 2017 and 2026. Rather than repeal this fee for
Medicare, AARP believes Congress must do more to reduce the
burden of high prescription drug costs on consumers and
taxpayers, and we urge action on bipartisan solutions.
AARP remains willing to work with you to ensure that we
maintain a strong health care system that ensures robust
insurance market protections, controls costs, improves
quality, and provides affordable coverage to all Americans.
However, the AHCA does not accomplish these goals, and we
continue to urge you to vote NO.
Sincerely,
Nancy A. LeaMond,
Executive Vice President and Chief
Advocacy and Engagement Officer.

Mr. McGOVERN. Mr. Speaker, if this bill were so great, these
organizations would be supporting the Republican bill, not opposing it;
and they are strongly opposing it.
Mr. Speaker, I yield 1 minute to the gentleman from Texas (Mr.
Doggett).
Mr. DOGGETT. Mr. Speaker, the harsh indifference of these Republicans
to the well-being of so many Americans is startling. Trump may
temporarily bury the lies central to this plan with a tweet storm--with
fake news. But these Republicans who follow him will not be able to
find an excuse as one family after another suffers.
Today's surprise attack on American health care has been widely
condemned by healthcare professionals across the country and those who
represent the disabled and sick, like the American Cancer Society and
the March of Dimes.
Jimmy Kimmel, know that your baby was fortunate, but others born with
a disability will face the barrier of preexisting conditions.
They didn't listen to the AARP, which knows that those Americans too
young for Medicare by a few years will get socked with unaffordable
premiums. They don't know what this monstrosity of a bill costs to the
taxpayer. They don't know how many families will lose coverage or how
many jobs will be lost. They don't really know what is in this bill.
They know only that the Pied Piper of Trump Tower is playing a tune
today and they must dance.
There is much talk about high-risk pools. The real high-risk pool is
the one that everyone who votes for this outrageous proposal is about
to plunge into.
Mr. McGOVERN. Mr. Speaker, I yield 3 minutes to the distinguished
gentlewoman from New York (Ms. Slaughter), the ranking member of the
Rules Committee.
Ms. SLAUGHTER. Mr. Speaker, I certainly thank my colleague for
yielding to me.
Mr. Speaker, I was fortunate enough to bring the ACA to the floor
after years of working on it and experts writing it. It had such
incredible things in it. I think it would behoove us this morning to
talk about what every one of us who has health insurance is going to
lose because the benefits of the ACA accrued to all of us.
Now, you need to know first that we are going to lose the fact that
85 cents of every premium dollar will go for health care. It will go
back to insurance profits. We are also going to lose the fact that
families could no longer go bankrupt because of health care.
The largest cause of bankruptcy are families with medical bills, and
the ACA took care of that. Nobody ever talks about that much, but if a
single person spent $4,500 a year on health care, a family $12,500, the
insurance companies picked up the rest of it.
How about that? That is a pretty good loss that we are going to face.
So why in the world are we rushing into this thing?
Well, the President of the United States, Donald Trump, verified as
recently as last Saturday evening in Pennsylvania that we have to do
this first because $800 billion has to come out of health care so that
they could do the tax bill with great corporate tax relief for the 1
percent. So as you lose your health care, your ability to go to the
doctor, and your preexisting conditions because risk pools don't work,
be comforted by the fact that we are in the hands of people who put the
needs of corporations and wealthy people ahead of the citizens of the
United States.
Just in case you think people aren't paying any attention, for the
first time in my life, my office has 185 applications for six seats as
interns in the summertime. It is unheard of. Calls in my office have
gone from about 10 a day to 80, all of them talking about this. I have
never seen political suicide in my life like I am seeing today. I think
our leader put it so succinctly: you are tattooing that on your
foreheads.
Now, those people out there who have really gotten sort of used to
this, all we have heard all the way through is that this is going to
fall apart. The problems going on with the ACA right now are that the
insurance companies have uncertainty because of what has been going on
here.
I need to bring up one of the greatest hoaxes in America in any
institution that passes laws. For over 60 times, you brought to the
floor of this House and we debated bills to do away with the health
care. ``Repeal and replace,'' you shouted. Millions and millions of
dollars' worth of time on this floor were spent on what was absolutely
a hoax because you had no repeal-and-replace plan. It was simply all
talk, and now you have got to rush through this so you can do your big
tax bill.
I am sorry to see this happen. It is a sad day for the United States.
Mr. McGOVERN. Mr. Speaker, I feel bad for the gentleman because it
appears as if he only has one speaker supporting this rule and the
bill, and nearly our entire caucus wants to speak on this against the
Republican healthcare repeal bill. So I was wondering whether the
gentleman might consider sharing some time with us?
Mr. COLLINS of Georgia. Will the gentleman yield?
Mr. McGOVERN. I yield to the gentleman from Georgia.
Mr. COLLINS of Georgia. I thank the gentleman for yielding. As a
wonderful manager of time, he will be able to parse the time as best he
may see fit. I have other speakers who probably will be coming by, so I
will just encourage the manager to manage his time well.
Mr. McGOVERN. It looks kind of lonely over there. It speaks volumes
about how much support there is for this bill.
Mr. Speaker, I yield 1 minute to the gentleman from New Jersey (Mr.
Pascrell).
Mr. PASCRELL. Mr. Speaker, now I have to say to my friends on the
other side: You sold out cheap--as we say in New Jersey--all to give a
tax cut to insurance companies and the most well off. The Upton
amendment is, of course, an admission.
After 7 years, you came up with this?
You have got to be kidding me. This is worse than a Fellini movie. At
least he didn't take 7 years to distinguish between fantasy and
reality.
For a New Jerseyan with asthma, this will mean a $4,340 premium
surcharge; for autism, $5,510. The list goes on and on--60, $70,000 if
you have cancer.
But less discussed is their attempt to rid the essential health
benefits which removes yet another ACA protection for everyone. So now
the Republicans have hit for the cycle.
You hit for the cycle. You jeopardized the health care of nearly
every single American--those on Medicare, those on Medicaid, those in
the ACA exchanges, and now 150 million people with employer coverage.
You sold out. It is a shame. I like most of you, but you are on the
wrong path.
It took you 7 years for this?
I will never yield. I will never yield.
The SPEAKER pro tempore. Members are reminded to direct their remarks
to the Chair, not to each other.
Mr. COLLINS of Georgia. Mr. Speaker, I reserve the balance of my
time.
Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the

[[Page H4122]]

American College of Physicians in opposition to the bill.

American College of Physicians,

April 24, 2017.
Hon. Paul Ryan,
Speaker, House of Representatives,
Washington, DC.
Hon. Nancy Pelosi,
Minority Leader, House of Representatives,
Washington, DC.
Hon. Mitch McConnell,
Majority Leader, Washington, DC.
Hon. Charles Schumer,
Minority Leader, U.S. Senate,
Washington, DC.
Dear Speaker Ryan, Minority Leader Pelosi, Majority Leader
McConnell, and Minority Leader Schumer: On behalf of the
American College of Physicians (ACP), I am writing to urge
Congress to move away from the harmful changes to patient
care that would occur if the American Health Care Act (AHCA)
were to become law, and to instead work for bipartisan
solutions to improve the Affordable Care Act (ACA) rather
than repealing and replacing it. We believe that the AHCA,
which would repeal and replace the most important coverage
and consumer protections created by the ACA, is so
fundamentally flawed that it cannot be made acceptable. We
understand that the leadership in the House of
Representatives continues to explore ways to bring a modified
version of the AHCA to a vote, based on a draft amendment
reportedly being developed by Representatives MacArthur and
Meadows, a summary of which was made available to the public
through news organizations. This amendment would make the
harmful AHCA even worse by creating new coverage barriers for
patients with pre-existing conditions and weakening
requirements that insurers cover essential benefits.
The American College of Physicians is the largest medical
specialty organization and the second-largest physician group
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.
The draft MacArthur-Meadows amendment would create what is
known as the ``Limited Waiver Option'' that would allow
states to eliminate or severely weaken vital ACA Title I
consumer protections--specifically, community rating and
essential health benefits (EHBs)--returning the country to
the pre-ACA days when persons with pre-existing
``declinable'' medical conditions in most states were priced
out of the market and the insurance products available in the
individual market did not cover medically necessary services.
Specifically:
The MacArthur-Meadows amendment would create an option for
states to obtain Limited Waivers from certain federal
standards that would gut existing law consumer protections.
Based on a summary of the draft amendment, states could seek
Limited Waivers for:
Essential Health Benefits (EHBs)
Community-rating rules, except for the following
categories, which are not waivable: Gender or Age (except for
reductions of the 5:1 age ratio previously established) or
Health Status (unless the state has established a high-risk
pool or is participating in a federal high-risk pool)
To obtain the waiver, states would only need to ``attest
that the purpose of their requested waiver is to reduce
premium costs, increase the number of persons with healthcare
coverage, or advance another benefit to the public interest
in the state, including the guarantee of coverage for persons
with preexisting medical conditions. The Secretary shall
approve applications within 90 days of determining that an
application is complete.'' [Emphasis added in italics].
In other words, as long as a state attested that there was
a ``benefit to the public,'' insurers would be once again
allowed to charge more to people with pre-existing
conditions, or decline to cover needed benefits like
physician and hospital visits, maternity care and
contraception, mental health and substance use disorder
treatments, preventive services, and prescription drugs.
This would take us back to the days when people had to fill
out intrusive insurance company applications to document
their previous health history, even before being advised what
the premium would be based on their individual health risk.
Unlike community rating, which bases premiums based on the
expected costs associated with all persons in the insurance
pool (adjusted only by age, tobacco use, and family size),
the Limited Waiver would again allow insurers in states that
obtain a waiver to again charge people exorbitant and
unaffordable premiums for their pre-existing conditions.
Before the ACA, insurance plans sold in the individual
insurance market in all but five states typically maintained
lists of so-called ``declinable'' medical conditions
including asthma, diabetes, arthritis, obesity, stroke, or
pregnancy, or having been diagnosed with cancer in the past
10 years. Even if a revised bill would not explicitly repeal
the current law's guaranteed-issue requirement which requires
insurers to offer coverage to persons with pre-existing
conditions like these guaranteed issue without community
rating allows insurers to charge as much as they believe a
patient's treatment will cost. The result would be that many
patients with pre-existing conditions would be offered
coverage that costs them thousands of dollars more for the
care that they need, and in the case of patients with
expensive conditions like cancer, even hundreds of thousands
more.
An amendment to the AHCA reported out of the Rules
Committee on April 6th to establish a ``Federal Invisible
Risk Sharing Program,'' which would create a fund that states
could use to reimburse insurers for some of the costs
associated with insuring sicker patients, would not offset
the harm done to patients with pre-existing conditions by
allowing the Limited Waiver of community rating and essential
benefit protections. The pre-ACA experience with high-risk
pools was that many had long waiting lists, and offered
inadequate coverage with high deductibles and insufficient
benefits. Unless a national high-risk pool is supported with
a massive infusion of funding it will not be sufficient to
cover the millions of people with pre-existing conditions
that would be denied or charged more for coverage under
the AHCA. One paper estimates that a national high-risk
pool would cost $178.1 billion a year, roughly $176.4
billion more than the annual funding provided to the
Invisible Risk Sharing Program. Also, shifting people out
of the existing health insurance marketplace to a high-
risk pool would undermine the assurance that enrollees
could keep their existing coverage.
The Limited Waiver Option will also allow states to seek
waivers from the essential health benefits required of all
plans sold in the individual insurance market, with the
result that millions of patients will be at risk of losing
coverage for essential services like maternity care, cancer
screening tests and treatments, prescription drugs,
preventive services, mental health and substance use disorder
treatments, and even physician visits, prescription drugs and
hospitalizations.
Prior to passage of the ACA, 62% of individual market
enrollees did not have coverage of maternity services, 34 did
not have substance-use disorder-services, 18% did not have
mental-health services and 9% did not have coverage for
prescription drugs. A recent independent analysis found that
the AHCA's repeal of current law required benefits would
result in patients on average paying $1,952 more for cancer
drugs; $1,807 for drugs for heart disease; $1,127 for drugs
to treat lung diseases; $1,607 for drugs to treat mental
illnesses; $4,940 for inpatient admission for mental health;
$4,555 for inpatient admission for substance use treatment;
and $8,501 for maternity care. Such increased costs would
make it practically impossible for many patients to avail
themselves of the care they need. The result will be delays
in getting treatment until their illnesses present at a more
advanced, less treatable, and more expensive stage, or not
keeping up with life-saving medications prescribed by their
physicians.
Allowing states to eliminate the EHB will threaten our
nation's fight against the opioid epidemic. A study concluded
that with repeal of the ACA, ``approximately 1,253,000 people
with serious mental disorders and about 2.8 million Americans
with a substance use disorder, of whom about 222,000 have an
opioid disorder, would lose some or all of their insurance
coverage.'' Finally, allowing states to drop important
benefits like maternity, substance use disorder treatment,
and preventive services will do little to reduce premiums. A
report by Milliman found that the main drivers of premium
costs were ambulatory patient services, hospitalization, and
prescription drugs. These are crucial services that form the
core of any health insurance plan.
To be clear: while some younger and healthier persons might
be offered lower premiums in states that obtained a ``Limited
Waiver'' of community-rating and essential health benefits,
it would be at the expense of making coverage unaffordable
for those who need it most, older and sicker persons, and
result in skimpy ``bare-bones'' insurance for many others
that does not cover the medical care they would need if and
when they get sick.
Finally, even without the Limited Waiver Amendment, ACP
continues to believe that the AHCA has numerous other
provisions and policies that that will do great harm to
patients including:
The phase-out of the higher federal match in states that
have opted to expand Medicaid and the ban on non-expansion
states being able to access the higher federal contribution
if they choose to expand Medicaid;
Converting the shared federal-state financing structure for
Medicaid to one that would cap the federal contribution per
enrollee;
Providing states with a Medicaid block grant financing
option;
Eliminating EHBs for Medicaid expansion enrollees;
Imposing work or job search requirements on certain
Medicaid enrollees;
Regressive age-based tax credits, combined with changes
that will allow insurers to charge older people much higher
premiums than allowed under current law;
Continuous coverage requirements for patients with pre-
existing conditions;
Legislative or regulatory restrictions that would deny or
result in discrimination in the awarding of federal grant
funds and/or Medicaid and Children's Health Insurance Program
funding to women's health clinics that are qualified under
existing federal law for

[[Page H4123]]

the provision of evidence-based services including, but not
limited to, provision of contraception, preventive health
screenings, sexually transmitted infection testing and
treatment, vaccines, counseling, rehabilitation, and
referrals, and;
Elimination of the Prevention and Public Health Fund, which
provides billions in dollars to the Centers for Disease
Control and Prevention to prevent and control the spread of
infectious diseases.
The College strongly believes in the first, do no harm
principle. Therefore, we continue to urge that Congress move
away from the fundamentally flawed and harmful policies that
would result from the American Health Care Act and from the
changes under consideration--including the proposed ``Limited
Waiver'' amendment--that would make the bill even worse for
patients. We urge Congress to instead start over and seek
agreement on bipartisan ways to improve and build on the ACA.
The College welcomes the opportunity to share our ideas for
bipartisan solutions that would help make health care better,
more accessible, and more affordable for patients rather than
imposing great harm on them as the AHCA would do.
Sincerely,
Jack Ende, MD, MACP,
President.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the
Cancer Action Network against this bill.

Cancer Action Network,

American Cancer Society,

May 3, 2017.
Hon. Paul Ryan,
Speaker, House of Representatives,
Washington, DC.
Hon. Nancy Pelosi,
Minority Leader, House of Representatives,
Washington, DC.
Dear Speaker Ryan and Minority Leader Pelosi: The American
Cancer Society Cancer Action Network (ACS CAN) is deeply
concerned about the reports of additional amendments to the
American Health Care Act (AHCA), including one that would
allegedly add $8 billion in new spending for state high-risk
pools. This amendment is particularly egregious because it
would further incent states to apply for waivers from
current-law market rules that protect patients with pre-
existing conditions.
Historically, state high-risk pools have fallen short of
providing coverage of prevention, treatment and follow-up
care for cancer patients and survivors. Segmenting people
with cancer and other serious illnesses away from the private
marketplace and into high-risk pools absent an adequate and
permanent source of public funding has never been an adequate
solution.
Between 1976 and 2010, 35 states created high-risk pools to
cover individuals who could not otherwise purchase insurance
in the private market, usually because of a pre-existing
condition. Every one of those risk pools experienced net
operating losses year after year. Furthermore, high-risk
pools did not result in lower premiums. All of them set
premiums above the non-group market average or standard rate
in the state, usually by 150-200 percent. Only a few states
provided additional premium assistance for low-income
individuals, leaving many who could not afford premiums
priced out of the program. Most states also imposed waiting
periods before covering preexisting conditions. An individual
with a prior cancer diagnosis often had to wait 6-12 months
before the high-risk pool would cover the costs associated
with cancer treatment or follow-up survivorship care. Most
states imposed limitations on coverage with either lifetime
or annual limits. And most plans offered deductibles of
$1,000 or higher. Neither AHCA, nor the new amendment would
fully protect patients from any of those conditions.
Cancer patients and survivors need insurance coverage that
is affordable, readily accessible, and protects them from
pre-existing condition exclusions, annual and lifetime caps
on coverage and extraordinary out-of-pocket costs. Past
experience has shown that high-risk pools failed to meet
these basic needs, yet still were a drain on state budgets.
As we have indicated in our earlier letters, there are
reasonable fixes that could be made to the current law. We
stand ready to work with you to develop policies that improve
the law and encourage a robust health insurance market that
provides affordable and comprehensive coverage options.
Sincerely,
Christopher W. Hansen,
President.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the
American Society of Clinical Oncology against this bill.

American Society of

Clinical Oncology,

April 27, 2017.
Hon. Paul Ryan,
Speaker, House of Representatives,
Washington, DC.
Dear Speaker Ryan, On behalf of the American Society of
Clinical Oncology (ASCO), I write to express our strong
opposition to the American Health Care Act (AHCA), as
currently amended. As the leading professional society
representing more than 42,000 physicians worldwide who care
for people with cancer, ASCO has a unique perspective on the
law's potential impact on cancer patients. Our core mission
is to ensure every patient with cancer has meaningful access
to high quality care. We believe Congress shares this goal
and our comments today are in the spirit of advancing that
common purpose.
In January 2017, as Congress embarked upon the repeal and
replacement of the Affordable Care Act, ASCO shared a set of
guiding principles that support improvements to the current
health care system. We also put forth specific areas where
people with cancer need protections. Our principles rest on
the belief that any health system reform must ensure all
people affected by cancer receive high-quality care. ASCO's
first principle states, ``all Americans should have access to
affordable and sufficient healthcare coverage regardless of
their income or health status. To ensure protected access,
the current ban on preexisting condition limitations,
elimination of annual and lifetime coverage caps, and
maintenance of guaranteed renewability should be preserved.''
We take the position that ``any efforts to reform the
healthcare system at the national, state, or local levels
should ensure that individuals with healthcare insurance can
continue to access affordable insurance without
interruption.'' The amended AHCA violates these principles.
Studies show that when cancer patients do not have adequate
insurance they receive less care, receive it later, and have
worse outcomes than those with better insurance coverage.
Uninsured and under-insured families facing a cancer
diagnosis experience significant stress. They often are
unable to meet out-of-pocket expenses and even forgo cancer
care in order to pay for necessities of daily living. The
AHCA as currently constructed will create or worsen these
barriers to care. It will add costs to the system, decrease
access to appropriate treatment and increase existing
disparities in care.
We are especially concerned with provisions allowing state
waivers that could erode important protections for patients
with cancer, including pre-existing condition safeguards,
coverage of essential services, and access to affordable
health insurance. Removing these protections from current
federal law allows for a weakening of these critical
provisions in some states and establishes a system of
inequitable protections across state lines for cancer
patients. We urge policymakers to ensure that robust
requirements are in place to ensure that all insurance
products cover the full scope of services and therapies that
cancer patients require.
ASCO strongly opposes passage of the AHCA in its current
form. We welcome the opportunity to address these issues--and
to work toward a better proposal--with you and your staff.
Sincerely,
Daniel F. Hayes, MD, FASCO, FACP,
President, American Society of Clinical
Oncology.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the
American Congress of Rehabilitation Medicine against this bill.

American Congress of

Rehabilitation Medicine,

May 2, 2017.
Re Deep Concerns with the American Health Care Act and
Related Amendments.

Hon. Paul Ryan,
Speaker, House of Representatives,
Washington, DC.
Hon. Nancy Pelosi,
Democratic Leader, House of Representatives,
Washington, DC.
Dear Speaker Ryan and Leader Pelosi: The American Congress
of Rehabilitation Medicine (ACRM) writes in reference to the
American Health Care Act (AHCA), H.R. 1628, and the MacArthur
Amendment to the bill. ACRM is an organization of
rehabilitation professionals dedicated to serving people with
disabling conditions by supporting research and services that
promote health, independence, productivity, and quality of
life; and meet the needs of rehabilitation clinicians and
individuals with disabilities.
ACRM is seriously concerned that current House proposals
will undercut the federal coverage standard for
rehabilitation and habilitation services and devices
established under the Affordable Care Act (ACA). Access to
rehabilitation enables individuals experiencing injuries,
illnesses, and disabilities to maximize their quality of life
by enhancing their health, function, and independence. We
believe that any ACA repeal and replace bill that advances in
the House and Senate must maintain access to rehabilitation
and habilitation services and devices.
In particular, the AHCA (H.R. 1628, as amended) includes a
provision that would allow states to apply for waivers
exempting them from compliance with important patient
protections that are required by the Affordable Care Act
(ACA), including premium rating ratios based on age,
protections for consumers disallowing medical status
underwriting (i.e., community rating), and requirements for
insurers to cover a defined package of essential health
benefits (EHBs), which include rehabilitative and
habilitative services and devices. We are deeply concerned
these EHB changes will curtail access for both children and
adults in Medicaid expansion states, as well as private ACA
health plans. ACRM believes that these provisions will
significantly undermine the health insurance coverage that
patients need.
ACRM urges Congress to work in a bipartisan manner to
improve access to affordable, comprehensive care for all
Americans,

[[Page H4124]]

including those with disabilities and chronic conditions
needing rehabilitation and habilitation services and devices.
Douglas Katz, MD, FACRM, FAAN,
ACRM President.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the
Consortium for Citizens with Disabilities in strong opposition to this
bill.

Consortium for Citizens

With Disabilities,

April 28, 2017.
Dear Member of Congress: The Consortium for Citizens with
Disabilities (CCD) is strongly opposed to the amended
American Health Care Act. The amended American Health Care
Act retains the original bill's proposals to dramatically cut
Medicaid services that are vital to people with disabilities
and seniors through per capita caps, which CCD has opposed.
The new amendments--including permitting states to seek
waivers from the protections for people with pre-existing
conditions and from the requirement to provide essential
health benefits--makes the amended AHCA even more harmful to
people with disabilities. We urge you to oppose this
legislation.
Medicaid provides services and supports that maintain the
health, function, independence, and well-being of 10 million
enrollees living with disabilities. For many people with
disabilities, being able to access timely needed care is a
life or death matter. The American Health Care Act changes
the way that the Federal Government funds Medicaid--rather
than paying states based on the actual costs of healthcare
for people in Medicaid, it sets a cap on the amount of
federal support, a cap that is totally unrelated to the
actual costs of needed care for enrollees. This cap is
designed to cut Medicaid, and the bill uses those cuts to pay
for unrelated tax cuts. Slashing federal support for
Medicaid, which is already a lean program, will force states
to cut services and eligibility that put the health and
wellbeing of people with disabilities at significant risk.
The newest amendments to the American Health Care Act make
the bill even more harmful to people with disabilities. The
new amendments would allow states to easily obtain waivers
that would allow them to charge higher premiums to people
with pre-existing conditions, including people with
disabilities. They also would allow states to seek waivers
from the Affordable Care Act's requirement to provide
essential health benefits, including crucial services for
people with disabilities such as mental health and substance
use disorder services, prescription drugs, rehabilitative and
habilitative services and devices, preventative and wellness
services and chronic disease management, and pediatric
services. These waivers jeopardize the Affordable Care Act's
protections for people with pre-existing conditions,
including people with disabilities, and CCD opposes any roll-
back of those protections.
The ACA helped millions of people with disabilities and
others to gain access to affordable and comprehensive health
insurance. The amended American Health Care Act is
insufficient to help people with disabilities meet their
healthcare needs, and we urge you to oppose the bill should
it come to a vote.
Sincerely,
Health Task Force Co-chairs: Bethany Lilly, Bazelon Center
for Mental Health Law; Dave Machledt, National Health Law
Program; Peter Thomas, Brain Injury Association of America;
and Julie Ward, The Arc of the United States.
Long Term Services and Supports Co-chairs: Alison Barkoff,
Center for Public Representation; Nicole Jorwic, The Arc of
the United States; Sarah Meek, Lutheran Services in America
Disability Network; and Laura Weidner, National Multiple
Sclerosis Society.

Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentleman from
Massachusetts (Mr. Moulton.)
Mr. MOULTON. Mr. Speaker, there is only one reason this bill is on
the floor today: the President cares more about cutting a deal than
keeping his promises.
He promised we would lower costs. That turned out to be a lie. He
promised we would expand coverage. That turned out to be a lie. He
promised we would protect millions of Americans with preexisting
conditions. That, too, was a lie.
Back in Massachusetts at the Agawam Diner, I met a veteran named
Clif, who told me when I was on my way to Washington for the first time
to go to Washington as an American--not as a Democrat or a Republican,
but as an American.
To my Republican colleagues, heed Clif's advice today. Don't vote as
a Republican. Vote as an American. Don't throw away your credibility to
give a legislative victory to a President who will never stick his neck
out for anyone other than himself. For what? To betray the people who
trusted them?
I urge my Republican colleagues to put country before party. Vote
``no'' on this ridiculous bill.
The SPEAKER pro tempore. Members are reminded to refrain from
engaging in personalities toward the President.
Mr. COLLINS of Georgia. Mr. Speaker, I think it is interesting today
since we would not be here today if there was not the problems that
you, Mr. Speaker, and I have seen.
One-third of this country has one insurer, premiums with double-digit
increases, people who can afford--maybe even with subsidies the amount
of their plan can't afford the deductibles and co-pays. They go to
doctors who won't take their insurance.
We are not here by mistake, Mr. Speaker. We are here because
ObamaCare is an abject failure.
Mr. Speaker, I reserve the balance of my time.
Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from
Children's Leadership Council opposed to this bill.

Children's Leadership Council,

May 1, 2017.
Dear Representative: The Children's Leadership Council
opposes the American Health Care Act (AHCA) because it would
jeopardize health care for millions of babies, children,
youth and families. We urge you to vote NO on this
legislation.
The Children's Leadership Council (CLC) is a coalition of
organizations dedicated to improving the lives and
opportunities of America's children. Nationwide, CLC members
work to advance the health, education and well-being of
babies, children and youth in order to prepare them for
school, work, and life. The CLC is the only national
children's coalition solely dedicated to supporting
investments in our nation's children and youth; and
collectively, CLC's members have affiliates, partners, and
members in every state in the nation.
The Affordable Care Act and Medicaid play a crucial role in
the lives of children, including those facing the greatest
challenges such as children in poverty; children suffering
abuse and neglect; children in foster care, and children with
disabilities. Medicaid, for example, provides coverage for
approximately 37 million children, including children with
disabilities, children in foster care and children from low-
income families. Children are the largest group of Medicaid
recipients, and nearly 40 percent of all the nation's
children rely on Medicaid and CHIP for their healthcare.
Medicaid provides health care treatment and preventive
services, mental health care, case management and
transportation services to and from medical appointments for
children who are low-income or disabled. The AHCA's changes
to Medicaid would radically restructure a program that has
worked for more than 50 years to support children's health.
The Medicaid cap would shift $839 billion to stages, forcing
them to cut eligibility, benefits, or provider rates that
could have disastrous health consequences.
There is no question that the massive cuts to Medicaid,
increased premiums likely for millions of families, and
eliminating the Essential Health Benefits requirements under
current law will seriously harm children and families.
Maternity benefits would be among the many medical services
no longer guaranteed if this bill were to become law. The
massive Medicaid reductions in substance abuse treatment will
add to the increases nationwide in the need for child welfare
services because of the surge in opioid addiction. Families
caring for children with disabilities will find supports for
care at home jeopardized.
With a record 95% of children with health coverage in our
country, the AHCA would turn back the clock on progress for
children. And recent proposed changes to the bill would
further undermine consumer protections that make health care
out of reach for low-income children and their families--thus
making the already harmful bill worse for children. Polling
conducted by the Children's Leadership Council found 71
percent of parents, including 67 percent of Independent
parents (of children under the age of 18), want increased
investments in programs that help children in the areas of
education, health and nutrition, not less as proposed by the
AHCA.
Congress has a strong history of working on a bipartisan,
bicameral basis on issues, policies and programs important to
children. It is our hope and expectation that members of
Congress continue this history, as Congress works on
improving our nation's healthcare system. This legislation
would be a dangerous step backward. We strongly urge you to
vote NO.
Sincerely,

Randi Schmidt,

Executive Director, Children's
Leadership Council.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the
Paralyzed Veterans of America against this bill.

Paralyzed Veterans of America,

Washington, DC, May 3, 2017.
Hon. Paul Ryan,
Speaker, House of Representatives,
Washington, DC.
Hon. Nancy Pelosi,
Minority Leader, House of Representatives,
Washington, DC.
Dear Speaker Ryan and Leader Pelosi: Paralyzed Veterans of
America (PVA) urges

[[Page H4125]]

rejection of the latest version of the American Health Care
Act (AHCA). PVA is the nation's only Congressionally-
chartered veterans' service organization solely dedicated to
representing veterans with spinal cord injury and/or disease.
Consequently, we are very concerned about the conflicting
information circulating about this legislation and the
adverse impact it could have on our members and millions of
other people with disabilities.
As we understand it, the AHCA cuts $880 billion out of the
Medicaid program in order to finance tax cuts that will
explode the deficit and largely assist upper income
individuals, corporations, and providers. The Medicaid
changes are particularly devastating to people with
disabilities. Under the cap and cut proposal, the federal
government would no longer share in the costs of providing
health care services and community services beyond the capped
amount. This would eliminate the enhanced federal match for
the Community First Choice Option under Medicaid that
provides attendant care services in the community. Thanks to
this program, many poor veterans with serious non-service-
connected disabilities have been able to move from nursing
homes into their communities. The AHCA also weakens Medicaid
by ending the Medicaid expansion earlier and offering
Medicaid block grants to states. Data from the Robert Wood
Johnson Foundation shows expansion has helped thousands of
veterans and their caregivers.
For veterans and PVA members in particular, the AHCA
continues several problematic policies of the ACA as well as
troubling new provisions that could affect the ability of
many veterans and their family members to afford health
insurance in the private market. The underlying AHCA bill:
Continues to exclude CHAMPVA beneficiaries--dependents of
the most catastrophically disabled veterans--from the
dependents' coverage policy up to age 26.
Fails to remove the prohibition on enrollment into the VA
health care system for Priority Group 8 veterans, thus
denying these veterans access to the principal health care
system for veterans.
Denies access to tax credits making health insurance
affordable to anyone eligible for a host of other federal
health programs, including those ``eligible'' for coverage
under Title 38 health care programs. This would prevent many
veterans who may be ``eligible for'' but not enrolled in the
VA health care system from accessing these tax credits
intended to help people buy insurance.
Not only do the changes made to the original version of the
AHCA continue its failure to protect veterans and people with
disabilities, they make these circumstances worse. The latest
changes would allow states to seek waivers that would allow
insurers to charge higher premiums to people with pre-
existing conditions, including people with disabilities. The
new amendments also would allow states to seek waivers from
the ACA's requirement that certain essential health benefits
must be provided, including crucial services for people with
disabilities such as prescription drugs, rehabilitative and
habilitative services and devices, preventative and wellness
services and chronic disease management. The combination of
these changes would make it nearly impossible for people with
pre-existing conditions to find affordable plans that cover
basic health care services.
Throughout these past few months, the American people have
been calling for a bipartisan effort to improve the nation's
health care system. Congress should heed these voices, stop
its pursuit of the flawed American Health Care Act and work
together through regular order to strengthen all Americans'
access to affordable, high quality health care.
Sincerely,
Carl Blake,
Associate Executive Director.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the
March of Dimes opposed to this bill.

[From the march of dimes]

Under AHCA, Over 6 Million Women of Childbearing Age Will Lose Health
Coverage

Dear Representative: Prior to 2010, low-income adult women
could generally only obtain Medicaid coverage after they were
pregnant. By the time they enrolled in this coverage, many of
the best opportunities for guaranteeing a healthy pregnancy
and healthy baby had already been missed.
Today, states that have expanded Medicaid can extend
Medicaid coverage to low-income women of childbearing age,
giving them the chance to get healthy before they get
pregnant. The March of Dimes estimates that approximately 6.5
million low income women of childbearing age are currently
covered under Medicaid expansion, giving them access to
treatment for tobacco use, obesity, substance abuse, and
other conditions that can have a major impact on future
pregnancies. Between 2012 and 2015, the rate of uninsurance
among women of childbearing age dropped by 40%, with much of
that decline attributable to Medicaid expansion.
The American Health Care Act (AHCA) would do away with
these advances by rolling back Medicaid expansion. Its
fundamental restructuring of the traditional Medicaid program
would also likely lead to significant coverage losses or
restriction of services to beneficiaries, including pregnant
women. These changes do a serious disservice to low-income
women and families by denying them access to the care they
need to lead healthy lives and, ultimately, have healthy
pregnancies and give birth to healthy infants.
The MacArthur amendment and other proposed changes to the
AHCA do not address these issues. Women, infants, families,
and communities will bear the longterm cost if health care
for women of childbearing age and pregnant women is
shortchanged and more babies are born sick as a result. The
March of Dimes urges all Representatives to oppose the
American Health Care Act.
Sincerely,
Stacey D. Stewart,
President.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from
AFSCME in strong opposition to this bill.

AFSCME,

May 3, 2017.
U.S. House of Representatives,
Washington, DC.
Dear Representative: On behalf of the 1.6 million working
and retiree members of the American Federation of State,
County and Municipal Employees (AFSCME), I am writing to
express our continuing opposition to the American Health Care
Act (AHCA), notwithstanding the addition of the Upton
amendment.
The harm that AHCA will impose on ordinary Americans is
breathtaking in scope. As the Congressional Budget Office has
detailed, 24 million will lose their health care coverage.
The Medicaid program will be cut by $839 billion and
restructured, ending the guarantee that the federal
government will fund a specified share of state Medicaid
costs. The bill makes coverage more expensive, especially for
lower-income families and older workers and it undermines the
financial strength of Medicare. And the MacArthur amendment
makes a very bad bill worse by allowing states to opt out of
Affordable Care Act protections that ensure that people with
pre-existing conditions will be able to obtain comprehensive,
affordable health care. Moreover, the MacArthur amendment
would allow insurance companies to re-impose caps on annual
and lifetime limits, even in employer-sponsored coverage,
putting the health care of those with catastrophic illnesses
or injuries at risk.
Under the Upton amendment, grants to states that could be
used for high-risk pools will be increased by 6% or $8
billion over five years. This is a paltry increase. Even the
conservative Mercatus Center described the increase as a
``pittance.'' High-risk pools would still be grossly
underfunded, even if states put all of the $138 billion in
grant funding into them. We urge the Congress not to ignore
the previous experience with state high-risk pools. By
segregating those with pre-existing conditions into separate
coverage we know they will face higher premiums, benefit
exclusions, annual and lifetime limits on coverage and
waiting lists.
It is unacceptable that this bill eliminates $500 billion
in taxes on the wealthiest 2%, health insurers,
pharmaceutical manufacturers and medical device makers, while
taking health care away from millions. Moreover, the bill
retains the 40% tax on high cost health plans, which will
undermine employer-sponsored insurance for working families
by hollowing out coverage and increasing out-of-pocket
expenses, although it delays the implementation for six
years.
The bottom line is that this bill would cause millions to
lose their health coverage. Most of those with pre-existing
conditions would return to the days when even inadequate
coverage was unaffordable. The bill would drive up costs for
those who are older and lower-income, shift costs to states,
fail to protect employer-sponsored coverage, weaken public
health and undermine the solvency of the Medicare trust
fund--all the while providing tax cuts for the wealthy and
well-connected.
The priorities demonstrated by this bill are upside down.
We urge you to oppose this bill.
Sincerely,
Scott Frey,
Director of Federal Government Affairs.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the
National Farmers Union in strong opposition to this bill.

National Farmers Union,

May 3, 2017.
Dear Member of Congress: I write on behalf of nearly
200,000 members of the National Farmers Union (NFU) who are
engaged in all forms of farming and ranching. NFU has already
spoken in opposition of the American Health Care Act (AHCA)
because of the estimated 24 million Americans who would lose
coverage as a result. The most recent amendment to the AHCA
only moves further away from NFU's member-driven policy of
affirming ``the right of all Americans to have access to
affordable, quality health care.''
Farming is a dangerous occupation, ranking 6th in
occupational fatality rates. The injury rate for agricultural
workers is also 40% higher than the rate of all workers.
Finally, the average age of farmers in the United States is
over 58 years. U.S. health care policy must take into account
the unique needs of the men and women who provide food and
fiber for our country and much of the world.
Our current health care system is not without its problems,
but progress has been

[[Page H4126]]

made since the passage of the Affordable Care Act (ACA). The
current structure of tax credits and premium subsidies help
farmers maintain consistent coverage, especially during
downturns in the farm economy. The expansion of Medicaid has
proven beneficial to rural communities, where the rate of
enrollment is higher than in urban America. The Health
Insurance Marketplace, while certainly in need of stabilizing
measures, makes coverage more accessible for many farm
families.
The correlation between a strong Medicaid program and the
success of rural hospitals has become evident during the
influx of rural hospital closures over the last six years.
Seventy-eight rural hospitals have closed since 2010 with
over 80% of those located in states that opted out of the
Medicaid expansion. With another 673 hospitals at risk of
closure, the AHCA's proposed Medicaid cap could have
devastating consequences for rural communities.
In 2012, 75 percent of farms sold less than $50,000 in
agricultural products and 57% had sales less than $10,000.
Young farm families that don't receive additional income or
health benefits from off-farm jobs would find it extremely
difficult to purchase health insurance. The proposed
legislation would also hurt older farmers. Easing
restrictions on what insurance companies can charge older
customers will leave older farmers facing increased premiums
of thousands of dollars, despite the larger subsidies some
would receive.
The modified AHCA bill also has a significant negative
impact on those with pre-existing conditions. It's estimated
that 40 percent of 50- to 64-year-olds would be denied
coverage in the individual market without the Affordable Care
Act's protections for those with preexisting conditions. The
waiver option would mean that a large number of farmers in
many states would be forced into high-risk pools. This
legislation is woefully short in funding for those high-risk
pools, leaving individuals with preexisting conditions to
contend with increased premiums, higher deductibles and
longer waiting periods for coverage.
Affordable access to quality health coverage is a high
priority for all Americans. As you consider how to best
improve our health care system, we ask that you give serious
consideration to the needs of farmers and ranchers. While
there is certainly room for improvement in current policy,
the American Health Care Act will only hurt family farmers
and rural communities across the country. NFU requests that
you oppose the proposed legislation.
We appreciate your efforts to provide all Americans with
high-quality comprehensive health insurance. Thank you for
your consideration.
Sincerely,
Roger Johnson,
President.

Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the distinguished
gentleman from Massachusetts (Mr. Neal), the distinguished ranking
member of the Committee on Ways and Means.
Mr. NEAL. Mr. Speaker, this procedure that we are witnessing here
this morning, based on what happened at the White House for the last 48
hours, has all the charm of a ransom note.
The idea that this is put in front of us so that they can provide a
tax cut at the expense of middle class Americans is really what we are
voting on today. So that child who is born with diabetes across America
can no longer be guaranteed health insurance if we turn this option
over to the States. Anybody who comes from local or State government
knows this: that money will be used to balance the budgets in economic
downturns at the expense of those who need it for health care.
Another essential point here as I think we go forward, the other
side--by the way, there are only two on the other side. What is amazing
about this is--when you consider that argument that they had with us
yesterday about national defense, understand this: real national
defense also includes providing health care for members of the American
family. That is a very important consideration. They are about to
subtract from guaranteed benefits to the American family for the
purpose of offering a tax cut to people at the very top, again, at the
expense of middle class Americans.
Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentleman from New
York (Mr. Crowley), the chairman of the Democratic Caucus.
Mr. CROWLEY. Mr. Speaker, here we go again. The majority thinks they
have finally found the right combination of political giveaways to pass
their bill, a bill that we have to remember still kicks 24 million
Americans off their healthcare coverage. It still charges seniors more.
It still takes away some of the most basic protections of your health
plan that it should cover. Despite what you hear, this latest Band-Aid
amendment is not going to change any of that.
That is just what we know so far. Since this bill was built by
backroom deals and haphazard guesses, we don't even know how much this
bill will cost America--not just dollars added to the deficit, but the
human cost of how much more damaging this bill will be.
It is the height of irresponsible governing, not just rushing
something through without full and fair consideration. Frankly, we are
getting used to that on our side of the aisle. But to force through a
bill that you know is going to hurt 24 million Americans is more than
irresponsible; it is just plain wrong.

{time} 1000

Mr. COLLINS of Georgia. Mr. Speaker, I reserve the balance of my
time.
Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the
National Education Association in strong opposition to this bill.

May 3, 2017.
Hon. James P. McGovern,
House of Representatives, House Office Building, Washington,
DC.
Dear Congressman McGovern: On behalf of our three million
members and the 50 million students they serve, we strongly
urge you to oppose H.R. 1628, the American Health Care Act as
amended. The Congressional Budget Office (CBO) found that by
2026, the original bill would provide $883 billion in tax
cuts while taking health coverage away from 24 million
people, including some of the most vulnerable among us--the
poor, the sick, the elderly, and the children who constitute
more than half the current Medicaid enrollment. Votes on this
issue may be included in NEA's Report Card for the 15th
Congress.
The April 25 amendment made the original bill even worse.
It allows states to jettison existing essential health
benefit requirements, thereby permitting health plans
covering millions of people once again to exclude coverage
for maternity and newborn care, pediatric dental and vision
services, mental health and substance use services, and other
crucial benefits. The May 3 amendment is the equivalent of a
tiny bandage on a gaping wound. The cost of setting up
separate pools or premium assistance programs for people with
pre-existing conditions far exceeds the $8 billion spread
over five years the amendment provides--nationwide, at least
$25 billion per year would be required, according to the
Kaiser Family Foundation.
Both the original and amended American Health Care Act
threaten to return this country to the days when annual and
lifetime dollar-based limits on the use of essential health
benefits shifted tremendous financial and health risks to
working families. Insurance companies could charge people
with pre-existing conditions many times more than they charge
healthy people--just as they did before the Affordable Care
Act. Millions of Americans with pre-existing conditions would
be at risk of losing health coverage or face premiums so high
only the very wealthy could afford them--the same people who
benefit from the massive tax cuts in the original bill.
Specifically, we are concerned that this legislation will:
Lead to drastic cuts in Medicaid benefits and eligible
beneficiaries. The American Health Care Act radically
restructures how Medicaid is funded. Instead of the federal
government paying a percentage of actual Medicaid spending,
each state will get a set amount. States will choose between
a block grant, a lump sum payment, and a ``per capita cap,''
a flat amount for certain Medicaid beneficiaries. Either way,
state budgets will take a big hit: the share of revenue spent
on Medicaid will rise from 24.5 percent in 2017 to 28 percent
by 2025, according to Moody's Investors Service. To
compensate for the loss of federal support, states are likely
to divert money from education to health care as well as
limit the number of Medicaid beneficiaries, the scope of
Medicaid benefits, or both.
Hit the students most in need the hardest. Under the
Individuals with Disabilities Education Act (IDEA), Medicaid
reimburses schools for mental health care, vision and hearing
screenings, diabetes and asthma management, wheelchairs and
hearing aids, and more. Federal support is substantial--for
example, in 2015 California schools received about $90
million from Medicaid, Florida schools about $63 million, New
York schools about $137 million, Pennsylvania schools about
$131 million, and Texas schools about $250 million (Source:
Centers for Medicare and Medicaid, compilation of 2017 data).
Capping federal support for Medicaid will shift costs to the
states, jeopardizing services essential for students to learn
and thrive, especially those with disabilities.
Increase the cost of health care for those least able to
afford it. The American Health Care Act provides largely age-
based tax credits ranging from $2,000 to $4,000 per year--far
less than today's subsidies. For example, according to Kaiser
Family Foundation calculations, a 60-year-old earning $20,000
a year in Lincoln, Nebraska, now gets $18,470 to help buy
insurance and additional subsidies to help with deductibles
and co-payments. Under the American Health Care Act, she
would get a $4,000 tax credit for the premium and nothing for
other out-of-pocket health

[[Page H4127]]

care costs. By 2026, the average subsidy under the American
Health Care Act would be half the average subsidy under the
Affordable Care Act, according to CBO.
Tax ``high cost'' employer-sponsored health coverage. We
recognize that the American Health Care Act postpones the
effective date of the 40 percent excise tax on such plans
until 2026. But this tax--a back-door pay cut for millions of
working families--needs to be fully repealed.
Enhance tax breaks for the rich. The American Health Care
Act nearly doubles the amount of money that can be socked
away in tax-free health savings accounts--at least $6,550 for
individuals and at least $13,100 for families in 2018. It
also repeals a 3.8 percent investment tax and 0.9 percent
surcharge on wages above $250,000--a savings of about
$195,000 per year for the top 0.1 percent of earners,
according to the independent Tax Policy Center.
Weaken the individual insurance market and employment-based
coverage. The American Health Care Act eliminates penalties
for individuals not buying--and large employers not
providing--health coverage. But premiums go up 30 percent if
coverage lapses for more than 63 days--for example, when
someone loses her job and cannot afford to buy health
insurance until she gets another one. Overall, CBO predicts
substantial increases in out-of-pocket costs for low- and
moderate-income people due to the decline in subsidies and
increase in deductibles and other cost-sharing. Some
employers may gut their health plans or stop offering
coverage altogether, since they will no longer be penalized
for doing so.
The American Health Care Act plays Robin Hood in reverse.
It reneges on the promise to deliver better, cheaper health
coverage for all Americans, giving the richest among us
massive tax cuts while causing the number of people without
insurance to rise from 28 million today to an estimated 52
million in 2026, according to CBO.
We strongly urge you to oppose the amended American Health
Care Act--deeply flawed legislation that is even worse than
the original bill.
Sincerely,

Marc Egan,

Director of Government Relations,
National Education Association.

Mr. McGOVERN. Mr. Speaker, I include a letter from the American
Academy of Pediatrics, American College of Nurse-Midwives, American
College of Physicians, American Congress of Obstetricians and
Gynecologists, National Association of Nurse Practitioners in Women's
Health, National Partnership for Women & Families, and Planned
Parenthood Federation of America.
May 1, 2017.
Hon. Paul Ryan,
Speaker, House of Representatives,
Washington, DC.
Hon. Nancy Pelosi,
Minority Leader, House of Representatives,
Washington, DC.
Dear Speaker Ryan and Leader Pelosi: On behalf of
physicians, certified nurse-midwives/certified midwives, and
nurse practitioners who provide care for the women of
America, along with our patient partners, we stand together
for women and families and against House passage of the
MacArthur (R-NJ) Amendment to the American Health Care Act
(AHCA, H.R. 1628). Rather than support recent gains in
women's access to healthcare and coverage, the MacArthur
Amendment and AHCA turn back the clock and reverse hard-won
progress. We stand ready to continue work with Congress to
advance legislation that promotes women's health, healthcare
and coverage.
In our letter of March 22, 2017, we expressed opposition to
the AHCA because it threatened women's access to care
protected by Essential Health Benefits (EHBs) requirements,
eliminated the Medicaid expansion, cut qualified providers at
Planned Parenthood from the Medicaid program, and made severe
reductions to Medicaid and other programs critical to women
and newborns. We said that important health initiatives for
women and newborns should be built upon and improved--not
rolled back.
However, the MacArthur Amendment to AHCA places women's
health and coverage at even greater risk. The MacArthur
Amendment would enable states to waive EHBs including those
for maternity and newborn care, preventive services, and
services for mental health and substance use disorders; to
waive community rating rules; and to shunt patients with
costly healthcare conditions or illnesses into unproven
government high risk pools. Supporters of the bill claim this
bill maintains protections for those with preexisting
conditions, but allowing states to waive coverage of EHB and
charge people more based on their health status renders the
promise of coverage for preexisting conditions to be
meaningless. If all that the Secretary may require of a state
waiver application is an un-validated attestation that the
purpose of their requested waiver is to reduce premium costs,
increase the number of persons with healthcare coverage, or
advance another benefit to the public interest in the state,
including the guarantee of coverage for persons with pre-
existing medical conditions, it is meaningless in protecting
health, quality healthcare and coverage. Women and families
must not be made to suffer, lose access to care and coverage,
and pay higher healthcare costs.
EHB is a critical protection that ensures women have
guaranteed access to a robust set of health care services.
Making certain categories of coverage optional--such as
maternity care--would not substantially lower the premiums
that people pay for health coverage. For example, the
requirement for maternity care as an EHB is not a source of
health cost growth. Rather, by sharing risk across a broad
population of beneficiaries it provides vital protection for
women and families from the risk of tens of thousands of
dollars of out-of-pocket costs associated with normal
physiologic labor and delivery, cesarean section, and birth
complications. In exchange for monthly premium costs of just
$8-14 according to one recent analysis, the maternity care
EHB provides significant security for people wishing to grow
their families in the U.S. Furthermore, since everyone is at
some point a newborn, childbirth affects all of us. Enabling
exclusion of maternity care from health coverage denies
people access to the care that everyone deserves for the best
start in life.
Congress should move to protect and advance health, quality
care and coverage, particularly for women and newborns, and
not to endanger them as the AHCA and the MacArthur Amendment
would do. Americans of both parties agree. A recent Kaiser
Family Foundation poll found ``relatively few Americans want
to see the president and Congress decrease funding for a
variety of different health priorities--including spending
for reproductive health services for lower-income women (21
percent).''
When women have access to quality, evidence-based,
affordable care throughout their lives, they enrich our
workforce, achieve higher levels of education, reach their
goals, and actively contribute to the success of their
families and their communities. We urge the U.S. House in the
strongest possible terms to get it right, not fast. The AHCA
and the MacArthur Amendment turn the clock back on women's
health and should not move forward.
We stand ready to continue assisting Congress in advancing
health policy that supports women's access to high quality
healthcare and coverage, and is effective at controlling and
reducing the costs that people pay for their healthcare.
Sincerely,
American Academy of Pediatrics, American College of Nurse-
Midwives, American College of Physicians, American Congress
of Obstetricians and Gynecologists, National Association of
Nurse Practitioners in Women's Health, National Partnership
for Women & Families, Planned Parenthood Federation of
America.

Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentlewoman from
Texas (Ms. Jackson Lee).
Ms. JACKSON LEE. Mr. Speaker, I want you to look and keep your eyes
on who will feel the TrumpCare's mother of all bombs of health care
dropped on the American people. God have mercy on your soul.
I am a person living with a preexisting disease. I am a breast cancer
survivor. This heartless and callous bill, with 24 million-plus people
being thrown off of health care and the reverse Robin Hood of stealing
from the poor and the seniors laying in their beds, and you are doing
an age tax that is five times more than any other young person has to
pay, is disgraceful, as well as the pittance that you have given for
preexisting conditions, which is $8 billion. They say you need $25
billion.
Then you are telling the States to get a waiver. They are going to
celebrate. And then you are saying to Trump, the king, that we have the
votes to drop that mother of all bombs of health care.
Let me just simply say: I want to stand with the people. I want her
to live in dignity and to be able to get well. I want to make sure that
Medicaid is provided for working families. I don't want the poor to
sleep under bridges, to beg in the streets, to steal bread from the
market because they can't get any health insurance.
God have mercy on your soul.
Mr. Speaker, as a member of the Budget Committee and the
representative of a congressional district that has benefitted
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.''
I oppose this third and latest reincarnation of Trumpcare for several
compelling reasons:
1. Trumpcare forces families to pay higher premiums and deductibles,
increasing out-of-pocket costs.
2. Trumpcare will take away health care from 24 million hardworking
Americans.
3. Trumpcare would gut Essential Health Benefits and protections for
Americans with pre-existing conditions.
4. Trumpcare forces Americans aged 50-64 to pay premiums five times
higher than what others pay for health coverage, no matter how healthy
they are.

[[Page H4128]]

5. Trumpcare shortens the life of the Medicare Trust Fund and
ransacks funds that seniors depend on to get the long-term care they
need.
Mr. Speaker, 85 months ago, on March 23, 2010, redeemed a promise
that had been unfulfilled for nearly a 100 years, when he 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.
As reflected in the most recent public opinion polls, 61% of
Americans approve of ObamaCare and oppose efforts to repeal it, the
highest approval rates on record to date and continuing an inexorable
upward trend over the past several years.
Mr. Speaker, the reason Americans are adamantly opposed to Republican
repeal efforts, including the third iteration of Trumpcare now before
us is that Obamacare is no longer a bogey cooked up in Republican
talking points but a life-saving and life affirming measure that they
experienced in their own lives.
Americans think it is beyond crazy to repeal a law that has brought
to more than 20 million Americans the peace of mind and security that
comes with 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.
With all of this progress, and the prospect for more through further
refinements, who in their right mind would want to go back to how it
used to be?
The answer seems to be only the President and House Republicans who
call the Affordable Care Act and its enviable record of success a
``disaster.''
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, get less,
decimate the Medicare and Medicaid programs, and give a massive tax cut
for top 1 percent.
Americans are right to be alarmed and angered by what the Trump
Republicans are trying to do by rushing to vote on a Trumpcare bill
before it can be scored by highly respected and nonpartisan
Congressional Budget Office.
What we do know for sure is that this Trumpcare 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.
Trump gave the game away on March 20, 2017 in one of his trademark
pep rallies:
``We want a very big tax cut, but cannot do that until we keep our
promise to repeal and replace the disaster known as Obamacare.''
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.
When they were forced to pull Trumpcare 1.0 from the floor because
they lacked the votes to pass, House Republican leaders responded by
adding an amendment (Trumpcare 2.0) that made the original bill even
worse.
Trumpcare 2.0 would allow states to jettison existing essential
health benefit requirements, thereby permitting health plans covering
millions of people once again to exclude coverage for maternity and
newborn care, pediatric dental and vision services, mental health and
substance use services, and other crucial benefits.
All this accomplished was a hemorrhaging of support from the moderate
wing of the Republican Conference who feared the repercussions of
leaving millions of Americans with preexisting conditions without
health insurance so the Trump Republicans invented Trumpcare 3.0 to
provide $8 billion over five years to offset the cost of setting up
separate pools or premium assistance programs for people with pre-
existing conditions.
This pittance is not designed or intended to help real people with
preexisting conditions, but to provide cover for House Republicans to
walk the plank.
According to the Kaiser Family Foundation, at least $25 billion per
year would be required, not $8 billion spread out over five years as
provided for in Trumpcare 3.0.
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.''

[[Page H4129]]

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 $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.
Community health centers employ nearly 100,000, people and generate
over $45 billion in total economic activity in some of the nation's
most distressed communities.
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.
What the Affordable Care Act, and its repeal means in the lives of
real people:
At the end of the day, Mr. Speaker, the powerful and compelling
reasons to reject Trumpcare lie 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 infection 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.''
Brain 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 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.''
Like a horror film of yore with monsters and vampires, both the
original Trumpcare and its sequels threaten to return this country to
the days when annual and lifetime dollar-based limits on the use of
essential health benefits shifted tremendous financial and health risks
to working families.
Insurance companies could charge people with pre-existing conditions
many times more than they charge healthy people--just as they did
before the Affordable Care Act.
Millions of Americans with pre-existing conditions would be at risk
of losing health coverage or face premiums so high only the very
wealthy could afford them--the same people who benefit from the massive
tax cuts in the original bill.
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.''
Mr. COLLINS of Georgia. Mr. Speaker, I yield myself such time as I
may consume.
Mr. Speaker, if I had to defend ObamaCare, I would go into hysterics,
too.

Since ObamaCare went into effect, the insurance choices and
coverage have gotten lower and the costs have gotten higher.
Virtually no doctors take the marketplace insurance so I'm
left to change doctors who I've seen for over 30 years and
switch to ``new'' doctors who I don't trust, and who cannot
provide the same healthcare benefits I've received in the
past. I have a brain tumor that I have monitored by a very
skilled neuro-oncologist. Not anymore. The three choices I
was given via healthcare.gov aren't even honored forms of
insurance for this doctor.

[[Page H4130]]

Yes, it left them out again.
Mr. Speaker, I yield 2\1/2\ minutes to the gentleman from Indiana
(Mr. Messer).
Mr. MESSER. Mr. Speaker, despite the rhetoric on the other side of
the aisle, today is an exciting day for those of us who have been
working and fighting to end ObamaCare's reign over this country.
It is race month in Indiana, and I want to remind my colleagues that,
as exciting as today is, today's vote is a green flag, not a checkered
flag. It is the beginning of the race, not the end.
Today, the House will vote to move legislation forward that will
repeal ObamaCare and replace it with something far better. The bill
will surely undergo more changes as we continue this process in the
Senate, but it is on its way to the finish line.
There are some really strong policies in this bill. It cut taxes by a
trillion dollars on the American people, and government spending by
hundreds of billions, too. Despite the rhetoric, it keeps preexisting
condition prohibitions. No one with a preexisting condition will be
denied coverage because of the policies in this bill. Insurance
companies cannot raise premiums on individuals with preexisting
conditions as long as they maintain coverage.
The bill will also make sure 26-year-olds continue to stay on their
parents' healthcare plans as they enter the workforce. Most
importantly, though, the bill unshackles American families from the
mandates, taxes, and penalties that are costing these families
thousands of dollars each year.
Though ObamaCare helped some, we have to remember that ObamaCare made
things worse for millions of America, and that is where the national
anger has come from. I have heard from countless Hoosiers who tell me
the stories of their premiums going from $500 a month to $1,500 a
month, with deductibles that are through the roof, at $10,000-plus a
month. They have to spend $30,000 out of pocket before they even get to
their insurance. For a middle class family, that means they have no
meaningful insurance at all.
We can do better, and we will. That starts today.
Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the
National Rural Health Association opposed to this bill.

[From the National Rural Health Association]

Vote NO to the American Health Care Act

The National Rural Health Association urges a NO vote on
the American Health Care Act (AHCA).
Rural Americans are older, poorer and sicker than other
populations. In fact, a January 2017 CDC report pronounced
that life expectancies for rural Americans have declined and
the top five chronic diseases are worse in rural America. The
AHCA does nothing to improve the health care crisis in rural
America, and will lead to poorer rural health outcomes, more
uninsured and an increase in the rural hospital closure
crisis.
Though some provisions in the modified AHCA bill improve
the base bill, NRHA is concerned that the bill still falls
woefully short in making health care affordable and
accessible to rural Americans. For example, the modified bill
contains a decrease in the Medical Expense Deduction
threshold from 10% to 5.8% in an attempt to assist Americans
between the ages of 50 and 64 who would see their premiums
skyrocket under the current plan. However, this deduction is
not a credit and therefore would be of little use to low
income seniors that are in very low tax brackets or do not
pay income tax at all. Additionally, the new amendments to
freeze Medicaid expansion enrollment as of Jan. 1, 2018, and
reduce the Medicaid per-capita growth rate will
disproportionately harm rural Americans.
The AHCA will hurt vulnerable populations in rural
Americans, leaving millions of the sickest, most underserved
populations in our nation without coverage, and further
escalating the rural hospital closure crisis. According to
the Wall Street Journal, the ``GOP health plan would hit
rural areas hard . . . Poor, older Americans would see the
largest increase in insurance-coverage costs.'' The LA Times
reports ``Americans who swept President Trump to victory--
lower-income, older voters in conservative, rural parts of
the country--stand to lose the most in federal healthcare aid
under a Republican plan to repeal and replace the Affordable
Care Act.'' Let's be clear--many provisions in the ACA failed
rural America. The lack of plan competition in rural markets,
exorbitant premiums, deductibles and co-pays, the co-op
collapses, lack of Medicaid expansion, and devastating
Medicare cuts to rural providers--all collided to create a
health care crisis in rural America. However, it's beyond
frustrating that an opportunity to fix these problems is
squandered, and instead, a greater health care crisis will be
created in rural America.
Congress has long recognized the importance of the rural
health care safety net and has steadfastly worked to protect
it. And now, much of the protections created to maintain
access to care for the 62 million who live in rural America
are in jeopardy. We implore Congress to continue its fight to
protect rural patients' access to care. Three improvements
are critical for rural patients and providers:
1. Medicaid--Though most rural residents are in non-
expansion states, a higher proportion of rural residents are
covered by Medicaid (21% vs. 16%).
Congress and the states have long recognized that rural is
different and thus requires different programs to succeed.
Rural payment programs for hospitals and providers are not
`bonus' payments, but rather alternative, cost-effective and
targeted payment formulas that maintain access to care for
millions of rural patients and financial stability for
thousands of rural providers across the country. Any federal
health care reform must protect a state's ability to protect
its rural safety net providers. The federal government must
not abdicate its moral, legal, and financial responsibilities
to rural, Medicaid eligible populations by ensuring access to
care.
Any federal health care reform proposal must protect access
to care in Rural America, and must provide an option to a
state to receive an enhanced reimbursement included in a
matching rate or a per capita cap, specifically targeted to
create stability among rural providers to maintain access to
care for rural communities. Enhancements must be equivalent
to the cost of providing care for rural safety net providers,
a safeguard that ensures the enhanced reimbursement is
provided to the safety net provider to allow for continued
access to care. Rural safety net providers include, but not
limited to, Critical Access Hospitals, Rural Prospective
Payment Hospitals, Rural Health Clinics, Indian Health.
Service providers, and individual rural providers.
2. Market Reform--Forty-one percent of rural marketplace
enrollees have only a single option of insurer, representing
70 percent of counties that have only one option. This lack
of competition in the marketplace means higher premiums.
Rural residents average per month cost exceeds urban ($569.34
for small town rural vs. $415.85 for metropolitan).
Rural Americans are more likely to have obesity, diabetes,
cancer, and traumatic injury; they are more likely to
participate in high risk health behaviors including smoking,
poor diet, physical inactivity, and substance abuse. Rural
Americans are more likely to be uninsured or underinsured and
less likely to receive employer sponsored health insurance.
Rural communities have fewer health care providers for
insurers to contract with to provide an adequate network to
serve the community.
Any federal health care reform proposal must address the
fact that insurance providers are withdrawing from rural
markets. Despite record profit levels, insurance companies
are permitted to cherry pick profitable markets for
participation and are currently not obliged to provide
service to markets with less advantageous risk pools.
Demographic realities of the rural population make the market
less profitable, and thus less desirable for an insurance
company with no incentive to take on such exposure. In the
same way that financial service institutions are required to
provide services to underserved neighborhoods, profitable
insurance companies should be required to provide services in
underserved communities.
3. Stop Bad Debt Cuts to Rural Hospitals--Rural hospitals
serve more Medicare patients (46% rural vs. 40.9% urban),
thus across-the-board Medicare cuts do not have across the
board impacts. A goal of the ACA was to have hospital bad
debt decrease significantly. However, because of unaffordable
health plans in rural areas, rural patients still cannot
afford health care. Bad debt among rural hospitals has
actually increased 50% since the ACA was passed. According to
MedPAC ``Average Medicare margins are negative, and under
current law they are expected to decline in 2016'' has led to
7% gains in median profit margins for urban providers while
rural providers have experienced a median loss of 6%.
If Congress does not act, all the decades of efforts to
protect rural patients' access to care, could rapidly be
undone. The National Rural Health Association implores
Congress to act now to protect rural health care across the
nation.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the
American Thoracic Society opposed to this bill.

American Thoracic Society,

April 27, 2017.
Dear Representative: On behalf of the 16,000 members of the
American Thoracic Society (ATS), I want to voice my grave
concerns with the latest legislative proposal developed to
repeal and replace the Affordable Care Act (ACA). While CBO
estimates are not yet available for the most recent
legislation proposal being considered in the House, we remain
concerned that the bill, if enacted, will result in a loss of
health insurance for millions of Americans. Should the
proposal come up for a vote in the near future, we urge you
to vote ``NO'' on the American Health Care Act.
The ATS opposes any legislation that does not ensure
affordable health insurance coverage for Americans currently
insured under

[[Page H4131]]

the ACA. We are concerned that allowing states to waive
important insurance reforms in the Affordable Care Act will
lead to reduced coverage for many Americans and significant
price increases for patients with pre-existing conditions.
Further, we are concerned that reliance on ``high risk
pools'' will not adequately meet the health insurance needs
of many Americans with pre-existing conditions. We note that
previous attempts at implementing state-based high risk pools
have been largely unsuccessful. Members of the ATS serve a
large and diverse patient population, including patients with
respiratory diseases, critical illnesses and sleep disorders
such as asthma, COPD, pneumonia, sepsis and obstructive sleep
apnea. Our patients cannot afford to lose affordable health
insurance coverage for any period of time.
The ATS looks forward to working with Congress to improve
our health care system and ensure health insurance coverage
for all Americans. If you have questions or need additional
information, please contact Nuala S. Moore, Associate
Director of Government Relations.
Sincerely,
David Gozal, MD, MBA,
President.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the
Academy of Nutrition and Dietetics opposed to this bill.

Academy of Nutrition

and Dietetics,

Washington, DC, May 2, 2017.
Hon. Paul Ryan,
Speaker, House of Representatives,
Washington, DC.
Hon. Nancy Pelosi,
Democratic Leader, House of Representatives,
Washington, DC.
Dear Speaker Ryan and Leader Pelosi: Nutrition services
save money, improve chronic disease outcomes and save lives.
For this reason, the Academy of Nutrition and Dietetics, the
nation's largest organization of food and nutrition
professionals, remains opposed to H.R. 1628, the American
Health Care Act (AHCA) as amended by the MacArthur amendment.
The Academy and our 75,000-plus members believe that all
Americans should have both coverage and access to high-
quality health care. The Academy urges Congress to support
measures that include nutrition services and prevention that
reduces the cost of health care and improve patients' lives.
The new proposal set forth in the AHCA not only fails to
improve the health of all Americans, but it will worsen
patient care and public health by removing vital resources
that are currently effective in improving health across the
country.
This legislation continues to eliminate investments in
prevention and public health, reverse advancements made in
disease prevention and chronic care management, and according
to the Congressional Budget Office, would result in the loss
of health care coverage for at least 24 million Americans
Allowing states to waive pre-existing conditions and
essential health benefits will lead to decreased coverage and
utilization of vital nutrition services.
Individuals with chronic disease such as diabetes and
hypertension benefit from medical nutrition therapy and
nutrition services to lower their blood sugar and blood
pressure, while reducing reliance on expensive medications.
The cost of these services is inexpensive and replaces more
costly interventions that are necessary as chronic disease
progresses with many complications.
The Academy holds five key tenets for analyzing any
legislation to reform health care:
1. The health of all Americans should improve as a result
of our health policy choices. Sufficient resources must be
made available to ensure optimal health.
2. Access to quality health care is a right that must be
extended to all Americans.
3. Nutrition services, from pre-conception through end of
life, are an essential component of comprehensive health
care.
4. Stable, sufficient and reliable funding is necessary for
our health care system to provide everyone access to a core
package of benefits.
5. Health care must be patient-centered.
Affordable access to care is an ongoing challenge that any
reform legislation should address. Although this legislation
purports to provide access, it fails to make coverage more
affordable; unaffordable access to coverage is really not
coverage at all. The proposal fails to maintain a core
package of benefits that improve the health of Americans, by
removing a basic floor of services that should be provided
without cost-sharing to the Medicaid population.
Additionally, the new proposal would allow states to opt
out of requiring that health plans cover the Essential Health
Benefits which help reduce longer term health care costs,
allow insurers to charge people higher premiums based on pre-
existing conditions like nutrition related diseases like
diabetes and heart disease and increase out-of-pocket costs
for vulnerable older adults.
By repealing the Prevention and Public Health Fund, the
proposal eliminates the sole federal investment in
prevention, which will harm our state and local communities
that depend on these effective public-private partnerships to
improve the health of their communities.
The AHCA as currently drafted fails to meet the Academy's
five tenets, and therefore we cannot support the passage of
these proposals.
The Academy urges Congress to not hold future votes without
an evaluation of the proposed amendments from the
Congressional Budget Office estimating the budgetary impact
of the amended legislation and the anticipated effect on
coverage for Americans. We look forward to continued
collaboration to improve the health and nutrition for all
Americans.
Sincerely,
Lucille Beseler,
President.

Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from The
Jewish Federations of North America opposed to this bill.

The Jewish Federations

of North America,

Washington, DC, May 2, 2017.
Hon. Paul Ryan,
Speaker, House of Representatives,
Washington, DC.
Hon. Nancy Pelosi,
Minority Leader, House of Representatives,
Washington, DC.
Dear Speaker Ryan and Leader Pelosi: The Jewish Federations
of North America (JFNA) remains staunchly opposed to the
American Health Care Act of 2017 (AHCA), even with the
recently released amendment proposed by Representative Tom
MacArthur (R-NJ). We are disappointed that AHCA retains the
devastating cuts to Medicaid included in the earlier version
of the legislation, cuts which are the result of the
legislation's proposal to dramatically restructure Medicaid's
federal financing structure and roll back coverage for 14
million people covered by the state Medicaid expansions. The
amendment does nothing to alleviate these concerns.
JFNA represents 148 Jewish federations and 300 network
communities that together support 15 leading academic medical
centers/health systems, 100 Jewish nursing homes, and 125
Jewish family & children's agencies, providing health care
for more than one million clients, Jewish and non-Jewish
alike. Medicaid is a lifeline for more than 80 million
people, including low-income children, older adults, and
people with disabilities nationwide. Medicaid is a vital
program for Jewish federations throughout the country and
particularly for our communal health and long-term care
partners that care for the most vulnerable in our
communities.
JFNA is deeply troubled by the findings of the
Congressional Budget Office (CBO) that AHCA will cause $839
billion in reductions--about 25 percent--to federal Medicaid
funding and a loss in coverage for more than 14 million
Medicaid beneficiaries. We believe that converting Medicaid
to a block grant or per capita cap will cause irreparable
harm not only to the millions who depend on the program, but
also to our large network of providers who care for them.
AHCA would convert the long-standing and fundamental
federal-state partnership of the Medicaid program to a block
grant or per capita cap system. Under either approach, states
would receive a limited amount of federal money for their
Medicaid programs. As CBO found, even under a per capita cap
system, the federal share is lower than the average annual
increase in Medicaid spending and will not be sufficiently
flexible to address a variety of key factors affecting
Medicaid spending, including major disasters, economic
downturns, unexpected health care cost increases, and
demographic changes, such as the rapidly aging baby boomer
generation. CBO projected that AHCA's $839 billion cut in
federal Medicaid funding will shift substantial costs to
state and local governments, our providers, and our patients,
thus exacerbating the existing strain on the program. We
agree with CBO's conclusion that, due to these reductions in
funding, states will be left with no choice but to reduce
Medicaid enrollment, eligibility for Medicaid benefits, and
payment rates. Many people who now qualify for Medicaid could
end up uninsured or losing access to critical health and
long-term care services.
JFNA is concerned by many of the unintended consequences of
this legislation, such as:
People who desperately need Medicaid and who are currently
eligible will become uninsured;
States will be forced to cut back on crucial Medicaid
services, such as home and community-based services,
effectively forcing people who are capable of living in the
community with proper home and community-based services into
nursing homes;
States will be forced to reduce already low provider
payment rates, thus further decreasing the pool of providers
serving Medicaid beneficiaries and increasing waiting times
for services; and,
Health care providers and entities that care for these
vulnerable populations will suffer additional financial
strain. As a result, these agencies will be forced to lay off
staff or close their doors altogether, resulting in
significant job losses and further hurting state economies.
For these reasons, we must oppose the legislation as
currently written and urge the House of Representatives to
reconsider moving forward with it. We stand ready to work
with you, in tandem with our Jewish communal health and long-
term care providers, to promote more targeted ways to reduce
Medicaid spending and develop a new framework of policies to
improve Medicaid quality, efficiency, and sustainability.
Sincerely,
William C. Daroff,

[[Page H4132]]

Senior Vice President for Public Policy & Director of the
Washington Office.

Mr. McGOVERN. Mr. Speaker, I include in the Record an article in The
Wall Street Journal today stating: ``. . . employers looking to lower
their costs could impose lifetime limits and eliminate the out-of-
pocket cost cap from their plans under the GOP legislation.''

[From the Wall Street Journal]

Little-Noted Provision of GOP Health Bill Could Alter Employer Plans

Last-minute amendment would allow states to obtain waivers from
certain Affordable Care Act requirements

(By Stephanie Armour and Michelle Hackman)

Many people who obtain health insurance through their
employers--about half of the country--could be at risk of
losing protections that limit out-of-pocket costs for
catastrophic illnesses, due to a little-noticed provision of
the House Republican health-care bill to be considered
Thursday, health-policy experts say.
The provision, part of a last-minute amendment, lets states
obtain waivers from certain Affordable Care Act insurance
regulations. Insurers in states that obtain the waivers could
be freed from a regulation mandating that they cover 10
particular types of health services, among them maternity
care, prescription drugs, mental health treatment and
hospitalization.
That could also affect plans offered by large employers,
health analysts said.
The ACA prevents employer plans from putting annual limits
on the amount of care they will cover, and it bars lifetime
limits on the 10 essential benefits. But in 2011, the Obama
administration issued guidance stating that employers aren't
bound by the benefits mandated by their state and can pick
from another state's list of required benefits. That guidance
was mostly meaningless because the ACA established a national
set of essential benefits.
Under the House bill, large employers could choose the
benefit requirements from any state--including those that are
allowed to lower their benchmarks under a waiver, health
analysts said. By choosing a waiver state, employers looking
to lower their costs could impose lifetime limits and
eliminate the out-of-pocket cost cap from their plans under
the GOP legislation.
The measure would give employers added flexibility to take
steps that could lower costs by limiting more-expensive
coverage areas. And it would lessen the federal regulation of
insurers, a goal of GOP lawmakers who believe the ACA is an
example of government overreach.
The impact on employer plans expands the scope of the
health bill to affect, potentially, everyone not insured by
Medicare or small-business plans, since the bill also
includes cuts to Medicaid and changes to the individual
market. Employer health plans are the single largest source
of health insurance in the country, with about 159 million
Americans receiving coverage through their jobs.
``It's huge,'' said Andy Slavitt, former acting
administrator of the Centers for Medicare and Medicaid
Services under President Barack Obama. ``They're creating a
backdoor way to gut employer plans, too.''
But some experts say the impact could be less.
``The real question is, would employers do this? Many
wouldn't,'' said Larry Levitt, a senior vice president at the
Kaiser Family Foundation. ``Many employers offer quality
benefits to attract employees. But employers are always
looking for ways to lower costs.''
Fifty-nine percent of employers had a lifetime limit on how
much their insurance plans would cover before the ACA, Mr.
Levitt said.
The potential impact on large-employer plans was picked up
on by health analysts including Matthew Fiedler, a fellow at
the Brookings Institution. It is possible the Trump
administration could minimize the impact by barring employers
from picking plans across state lines, he said, but there is
no sign that that would occur.
``The core goal of insurance is to ensure that people are
protected if the worst happens, and these protections are
crucial to achieving that goal,'' Mr. Fiedler said.
Potentially, the new provision could play out this way: If
a state did away with a requirement to provide mental health
and substance abuse services, employer plans using that
benchmark could impose lifetime caps on the amount of mental
health coverage they are willing to pay for.
One trade group representing employers said the amendment's
effects on people with employer-sponsored health coverage
would be minimal. Most large employers didn't impose annual
or lifetime limits before the ACA was implemented, according
to James Gelfand, senior vice president of health policy at
the Erisa Industry Committee.
``Even if self-insured health plans are no longer banned
from imposing annual or lifetime limits, they're unlikely to
attempt to squeeze the toothpaste back into the tube,'' he
said. ``The benefits of reimposing limits are questionable.''

Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the distinguished
gentleman from Michigan (Mr. Levin).
(Mr. LEVIN asked and was given permission to revise and extend his
remarks.)
Mr. LEVIN. Mr. Speaker, it has just been said that no one with a
preexisting condition will be denied treatment. That is a cruel
falsehood. Roughly 129 million Americans today have a preexisting
condition.
Here is what the AMA says to refute what was just said: ``The history
of high-risk pools demonstrates that Americans with preexisting
conditions will be stuck in second class health coverage, if they are
able to obtain coverage at all.''
Now we have a proposal for $8 billion. That is a deceitful fraud. I
intend going back home to travel the State of Michigan and elsewhere
and tell the American people that although those who have said that are
simply not being truthful, they essentially are turning their backs on
129 million Americans. We Democrats will never turn our back on the
people of the United States of America. When it comes to health care,
it is a vital need.
Mr. COLLINS of Georgia. Mr. Speaker, I yield myself such time as I
may consume.
Mr. Speaker, even with, again, the muddled hysterics, there is
nothing in this bill, even if you have preexisting coverage now, there
is nothing that says you lose it. Let's at least get the facts
straight.
Also, let's talk about families and why we are here.

Despite Obama's promises, my plan was canceled at an
affordable $450 a month when ObamaCare was implemented. My
new plan has gone up every year and for 2017 will be over
$1,300 a month. My husband and I cannot keep up with these
increases. Soon it will be a choice between food and housing
or health care.

Virginia from Florida.
Mr. Speaker, I yield 1 minute to the gentleman from Michigan (Mr.
Mitchell).
Mr. MITCHELL. Mr. Speaker, my question today is: How long will the
opposition try to hold on to the failing Affordable Care Act? How long
will they desperately try to hold on with their fingernails, screaming
and thrashing at something that is failing so miserably?
Just this week, it was announced that 94 of 99 counties of Iowa will
not have a carrier at all. In Michigan this year, individual policy
premiums went up 20 percent, never mind deductibles and copays.
While currently 26 million Americans do not have coverage, 19.2
million either claim a waiver or pay a penalty that last year was $3
billion. Yet somehow the other side claims the Affordable Care Act is
some form of nirvana.
The American Health Care Act guarantees issuance of coverage and
targets assistance to those who have health challenges, in contrast to
the Affordable Care Act that just thinks we should throw money at it.
What amazes me, in my first few months here in Congress, if there is a
problem, we will just throw money. The opposition wants a blank check,
which will not work in this country. It is going to kill this country.
Let me suggest to my colleague from Michigan, my neighbor, that if he
wants to schedule to go around the State and talk about the benefits of
this program, the Affordable Care Act, I will go with him. We will go
anywhere he would like to go.
Mr. McGOVERN. Mr. Speaker, I include in the Record a statement from
the Children's Hospital Association in opposition to this bill.

[From Children's Hospital Association,

Apr. 27, 2017]

Children's Hospitals Urge House to Vote Against Amended AHCA

Lawmakers should know bill is bad for kids

Washington, DC.--On behalf of our nation's children's
hospitals and the patients and families they serve,
Children's Hospital Association (CHA) continues to oppose the
newly modified American Health Care Act (AHCA) and strongly
urges the House of Representatives to reject the bill.
Recently adopted changes only worsen the AHCA by putting
children with preexisting conditions at increased risk of
losing health care coverage and failing to correct the
Medicaid cuts that would impact over 30 million kids.
The legislation the House might consider for a vote as
early as the weekend would impose over $800 billion in cuts
on states by fundamentally changing Medicaid--a program over
40 percent of the children across the country depend on for
their health care coverage and access to medical care. Under

[[Page H4133]]

the bill, Medicaid would no longer be able to flex with the
needs of enrollees, instead becoming a severely restricted
system of per capita caps or block grants.
The block grant option in particular would be devastating
to children as it eliminates Medicaid's EPSDT (Early and
Periodic Screening, Diagnostic, and Treatment) benefit which
ensures children receive immunizations, mental health
assessments and vision, eye and hearing exams as well as
other medical services they might need. A block grant would
also remove cost-sharing protections for children,
essentially creating new barriers to care for low-income,
working families.
CHA urgently asks members of Congress to vote against the
AHCA. Medicaid must be maintained to ensure children receive
the coverage and medical care that return lifelong benefits
into adulthood. Investing in children's health advances a
better future for our nation.

Mr. McGOVERN. Mr. Speaker, I include a statement from Families USA in
opposition to this bill.

[From FAMILIESUSA]

Latest House GOP Proposal--``Upton Amendment''--Still Leaves People
with Pre-Existing Conditions Out in the Cold

Washington, DC.--Republicans in the House today are
discussing a so-called compromise that ostensibly adds $8
billion to their Affordable Care Act (ACA) repeal bill in an
attempt to appease members worried that the bill strips
coverage guarantees for people with pre-existing conditions.
Below is a statement from Families USA Executive Director
Frederick Isasi.
``Despite today's wheeling and dealing, the GOP repeal bill
still drops the coverage guarantee for people with pre-
existing conditions, strips coverage from millions, and
drives up costs for millions more. A measly $8 billion
handout isn't going to change that. The bill also decimates
Medicaid--more than $800 billion in cuts. That hurts seniors,
people with disabilities, and children like Jimmy Kimmel's
son who he so eloquently spoke of Monday night. Remember,
half of the births in America are reimbursed through
Medicaid.
``The Upton $8 billion is a non-solution--money thrown at
`high-risk pools' that experts on both sides of the aisle
have warned lead to higher costs, fewer benefits, and waiting
lists rationing care for those with pre-existing conditions.
``Republicans in the House can do all the backroom vote-
trading they want; their bill will still harm millions and
millions of people in America and breaks President Trump's
promise to cover everybody and protect people with pre-
existing conditions. This isn't what people in America want.
It is time for the GOP to drop this deeply flawed legislation
and move on to efforts that will help, and not hurt,
America's families.''

Mr. McGOVERN. Mr. Speaker, I include a statement from the Association
of American Medical Colleges in opposition to this bill.

[From AAMC, May 2, 2017]

AAMC Statement on the MacArthur Amendment to the American Health Care
Act

AAMC (Association of American Medical Colleges) President
and CEO Darrell G. Kirch, MD, issued the following statement
regarding the amendment to the American Health Care Act
(AHCA) introduced by Rep. Tom MacArthur (R-N.J.):
``This week, the House could vote on a new version of the
American Health Care Act that includes the MacArthur
amendment. Unfortunately, the amendment does not address the
limitations in the original measure, such as making high-
quality, affordable health insurance available to all, and
maintaining programs to support the health care safety net--
at least at current levels--until other comparable coverage
expansions are available.
The amendment's treatment of essential health benefits and
health status underwriting dilutes protections for many
Americans and would leave individuals with preexisting
conditions facing higher premiums and reduced access to vital
care.
The shortcomings in the underlying bill remain the same.
The original analysis from the Congressional Budget Office
indicated that 14 million Americans would lose their health
insurance coverage as early as next year, and as many as 24
million by 2024. Nothing in the bill has changed that alters
the fact that this legislation would lead to fewer Americans
with quality insurance, less affordable coverage for those
who have it, and the destabilization of the current Medicaid
program.
We continue to urge members of Congress to engage with the
nation's medical schools and teaching hospitals and other
stakeholders to find ways to achieve high quality health care
for all Americans.''

Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentlewoman from
California (Ms. Sanchez), the vice chair of the Democratic Caucus.
Ms. SANCHEZ. Mr. Speaker, I can't believe we are here again to vote,
or not, on the Republicans so-called healthcare bill.
Let me remind my colleagues that we are finally here only after
Republicans failed to even hold a vote on March 24, and then offered
extreme, multiple amendments to appease the furthest right of their
party.
But I have to give it to them: it takes real cojones to stand here
and vote on a bill that they know provides nearly zero healthcare
benefits for the American people. It takes real fortitude and
conviction to stand up for a bill that cuts coverage for 24 million
Americans, guts Medicaid, reduces the solvency of Medicare, and
segregates the sickest.
The truth is, Republicans lack the bravery to call this bill what it
really is: a massive tax cut for the rich on the backs of working moms
and dads and the sick. They lack the integrity to do the hard work that
it takes to craft an actual healthcare bill that would build upon
current law and improve the health of Americans.
I implore my colleagues to come to their senses, vote against this
terrible bill, and work with us to continue to improve health care in
this country for all Americans.
Mr. COLLINS of Georgia. Mr. Speaker, I yield myself such time as I
may consume.
Mr. Speaker, I have been waiting also for my friends across the aisle
to stand up and say that ObamaCare is a failure. I guess they can't.
For the last 7 years, the voters have.
Small business owners and American entrepreneurs:

As an entrepreneur with two special needs children, the ACA
is an expensive nightmare. Both my husband and I are small-
business owners and must pay for individual insurance. We are
on the highest deductible plan offered to us, a monthly
premium over $1,000, and outstanding medical bills that we
are struggling to pay off. We have seen our premium go up at
least 14 percent and the expenses of care, lab, et cetera.
With all exceptions, to the President, he is offering to his
corporate friends. We are the ones who get ignored.

That is the true face of ObamaCare.
Mr. Speaker, I yield 1 minute to the gentleman from Texas (Mr.
Barton).
(Mr. BARTON asked and was given permission to revise and extend his
remarks.)
Mr. BARTON. Mr. Speaker, mandates seldom work. Markets do work.
My friends on the Democratic side of the aisle haven't pointed out
that 19 million Americans have chosen to pay the tax penalty to the
IRS, rather than be forced into one of these ObamaCare plans.
They talk about all the people who have gotten coverage. Most of them
got coverage when the bill that is now called ObamaCare expanded
Medicaid to healthy adults and paid 100 percent of the cost to cover
those individuals at a cost right now of about $70 billion a year.
Mandates don't work; markets do. I choose less government mandate,
more personal freedom.
Vote for the rule; vote for the bill. Let's restore markets and
freedom to health care in America.
Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentlewoman from
California (Ms. Judy Chu of California.)
Ms. JUDY CHU of California. Mr. Speaker, yesterday, Kate called my
office, worried for her son who is 1-year-old and was born with
muscular dystrophy. He will need care for the rest of his life.
Without the ban on preexisting conditions, the cost of insurance for
her son will be astronomical. She is paralyzed with fear about how she
is going to be able to care for him for the rest of his life. Under
TrumpCare, the healthcare bill written for Donald Trump and not the
American people, insurance companies will be able to charge Kate's son
more because he has a preexisting condition.
Imagine that. Her son's health care will be out of reach, his
precious life endangered. That is unimaginably cruel, especially when
we have a system in place right now that gets Kate's son the treatment
he deserves.
That is why I am opposing this bill today. I cannot support a measure
that we know will cost sick people more money, will force families to
pay higher premiums and deductibles, will force 24 million people off
their insurance, and guts essential health benefits.
I urge my colleagues to vote ``no'' on this horrific bill today.

{time} 1015

Mr. COLLINS of Georgia. Mr. Speaker, I believe probably the reason
they won't vote for it is they don't understand it, because preexisting
conditions

[[Page H4134]]

are covered. If you have coverage now, nothing in our bill, no matter
what would come from the State or anyone else, would lose the
preexisting conditions. I guess it is just easier to talk your talking
points and have your poster and go from there.
Mr. Speaker, I yield 1 minute to the gentleman from Florida (Mr.
Mast).
Mr. MAST. Mr. Speaker, I, too, am a person with preexisting
conditions, and I believe it is not just something that I should do; it
is a responsibility for me to be the staunchest advocate for people out
there who have preexisting conditions. That is why I am such an ardent
supporter of this bill.
I think every American and every person out there with preexisting
conditions should be asking themselves: How is it that they have
coverage if every single insurance provider has pulled out of the
market? If there is no entity to go to out there and provide insurance,
how is it that preexisting conditions could possibly be covered?
I have had the question constantly: How is it so difficult for
Republicans to get this bill passed, to get this through the floor? The
answer is this, and this is again the question that every American
should be asking themselves: Who is going out there and saying that
preexisting conditions won't be covered? It is the exact same group of
people that went out there and lied to the face of every single
American, telling them that if they liked their plan, they would keep
their plan; if they liked their doctor, they would keep their doctor;
that the average American family was going to save $2,500 or more on
health insurance.
That was a bold-faced lie. It was orchestrated by architects who
specifically went out with the intention to prey on the American
people. That is who is going out there selling these lies against my
party. I resent that completely because we have come up with a plan,
with a strategy to go out there and save health care for the American
people, and I couldn't be more proud of that.
Mr. McGOVERN. Mr. Speaker, maybe the gentleman hasn't been listening
to all the organizations and healthcare advocates who have come out
strongly opposed to the Republican bill, that I have read into the
Record, who know a lot more about health care than anybody in this
House, who spend their lives protecting people and protecting people's
healthcare rights. They are all in strong opposition to the Republican
bill because you take away the protections for preexisting conditions,
plain and simple.
Mr. Speaker, I yield 1 minute to the gentleman from Oregon (Mr.
Blumenauer).
Mr. BLUMENAUER. Mr. Speaker, we began this debate listening to my
friend from Texas talk about how he was humbled to be here today
supporting the Republican bill. Well, frankly, I think he should be
embarrassed, embarrassed that my Republican colleagues are afraid to
have a full, open, lengthy debate about these impacts. We are taking a
consequential piece of legislation, and Republicans are jamming it
through without a CBO score so they don't know the impacts, and we
don't have the confidence.
We do know, however, my friend from Massachusetts has read into the
Record item after item, the medical association, disease advocacy
groups, the American Association of Retired People, it is an honor roll
of people who know about health care, who fought to preserve and
protect and enhance, and the Republicans have no answer to refute this
litany of experts who are independent, who are professional, who care.
Who are opposed. That is something that I think Republicans should be
ashamed of.
They have had 7 years chipping away at the Affordable Care Act to try
to make it worse, yet it still is supported by people who know. The
Republican approach should be rejected.
Mr. COLLINS of Georgia. Mr. Speaker, I reserve the balance of my
time.
Mr. McGOVERN. Mr. Speaker, I include in the Record a letter from the
American Public Health Association in strong opposition to the
Republican bill.
American Public Health Association,
May 4, 2017.
House of Representatives,
Washington, DC.
Dear Representative: On behalf of the American Public
Health Association, a diverse community of public health
professionals who champion the health of all people and
communities, I write to express our continued strong
opposition to H.R. 1628, the American Health Care Act of
2017, legislation to repeal the Affordable Care Act. The
amended bill would be even worse for the nation's health than
the original proposal and does nothing to improve the health
of the American public. Additionally, the bill would have the
greatest negative impact on the health of the most vulnerable
Americans.
According to the March Congressional Budget Office
analysis, the legislation would result in 14 million
Americans losing health insurance coverage in 2018. By 2026,
CBO estimates 24 million individuals would lose coverage,
taking the uninsured rate up to a staggering 52 million,
nearly double the number of Americans who would lack
insurance under existing law. The bill would cut critical
premium subsidies for low- and middle-income families and
phase out the ACA's Medicaid expansion. Under the proposal,
many, especially low-income and older Americans, would pay
higher premiums, receive lower subsidies and be subject to
higher out of pocket costs, including higher deductibles and
co-pays for plans that provide less coverage. Health
insurance coverage is critical to preventing disease,
ensuring health and well-being and driving down the use of
costlier providers of care. Unfortunately, this proposal will
result in a greater number of people losing coverage than the
number of people who have gained coverage under the
Affordable Care Act, putting many at risk of premature death
due to the lack of access to critical health services.
The amended bill would be even worse for public health than
the original bill that was pulled from the House floor in
late March. The amended bill would allow states to opt-out of
requiring health plans to cover the 10 essential health
benefits such as maternity care, mental health and substance
abuse disorder services and prescription drug coverage. It
would also allow insurers to charge significantly higher
premiums for people with pre-existing conditions and possibly
allow insurers to charge older adults even higher premiums.
The inclusion of a mere $8 billion over five years will do
little to help people with pre-existing conditions who could
see drastically higher premiums leaving millions in the
individual and small group market with no protections from
insurer discrimination.
The bill would also eliminate the Prevention and Public
Health Fund, the first and only mandatory funding stream
specifically dedicated to public health and prevention
activities. The fund has already provided more than $6
billion to support a variety of public health activities in
every state including tracking and preventing infectious
diseases like the Ebola and Zika viruses, community and
clinical prevention programs, preventing childhood lead
poisoning and expanding access to childhood immunizations.
Eliminating the fund would devastate the budget of the
Centers for Disease Control and Prevention. The fund
currently makes up 12 percent of CDC's budget and eliminating
this funding stream would force Congress to replace the
funding through the regular appropriations process where
resources for nondefense discretionary programs are already
too low.
Not only would the bill phase out the Medicaid expansion
under the ACA, it would also make other troubling changes to
the Medicaid program, converting it to a per capita program.
The most recent CBO analysis estimated the bill would cut
federal spending on Medicaid by $839 billion over the next
decade, drastically cutting resources to states, many of
which are already struggling with tight budgets. The bill
would also block Medicaid reimbursements to Planned
Parenthood for one year--which CBO estimates will lead to
less access to care, more unintended births and more costs
for the Medicaid program.
While the Affordable Care Act is not perfect, the law has
made progress in addressing the biggest challenges facing our
health system including the rising costs associated with our
health care system, uneven quality of care, deaths due to
medical errors, discriminatory practices by health insurance
providers and the shrinking ranks of the nation's primary
care providers. The ACA has made progress in shifting our
health system from one that focuses on treating the sick to
one that focuses on keeping people healthy. We ask you to
oppose this and future efforts to repeal or weaken the ACA.
Instead, we urge you to work on a bipartisan basis to improve
and build upon the successes of the ACA and to work to
provide health insurance coverage to the more than 28 million
who still lack coverage. We look forward to working with you
to create the healthiest nation in one generation.
Sincerely,
Georges C. Benjamin, MD,
Executive Director.
Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the gentlewoman from
Connecticut (Ms. DeLauro).
Ms. DeLAURO. Mr. Speaker, the Republican healthcare bill is reckless
and heartless:
It increases the cost of premiums and deductibles;
It imposes an age tax on older Americans;
It unravels protections for patients with preexisting conditions;

[[Page H4135]]

It eliminates maternity care, substance abuse treatment, and
prescription drug coverage;
It does away with lifetime limits and annual caps.
President Trump's claim that people with preexisting conditions will
be covered is false, and it is a betrayal. It will have threatening
consequences for millions of Americans. It will cost lives.
If this passes today, the American people should be in the street to
call out the immorality of this legislation. They should decry this
offense against humanity and this offense against the American people.
I call on the American people: Do not let them get away with it.
Mr. COLLINS of Georgia. Mr. Speaker, I reserve the balance of my
time.
Mr. McGOVERN. Mr. Speaker, I yield 1 minute to the distinguished
gentleman from Rhode Island (Mr. Langevin).
Mr. LANGEVIN. Mr. Speaker, I rise today in strong opposition to the
Republicans' latest plan to dismantle the Affordable Care Act. After
Republicans failed to earn the votes to pass their American Health Care
Act in March, I thought that we could finally move forward to find
bipartisan solutions to improving health care in America. Instead,
Republicans have revived their partisan goal of ACA repeal by adding
provisions that have made a bad bill even worse.
Mr. Speaker, make no mistake about it; the bill before us today will
make Americans' health care worse in this country:
This legislation will cause 24 million people to lose coverage, while
drastically increasing healthcare costs on everyday families;
It eliminates Federal safeguards that prevent insurers from charging
older Americans higher premiums;
It guts essential health benefits, like maternity care and
prescription drugs;
Further, it removes crucial patient protections that prevent
discrimination against people with preexisting conditions, leaving our
most vulnerable populations with a false promise of sufficient coverage
through these failed high-risk pools.
Mr. Speaker, I am saddened that so many Republicans appear willing to
place hollow partisan victories above the health of their constituents.
I oppose the Republican AHCA in the strongest possible terms and urge
all of my colleagues to put the health of Americans first.
Mr. COLLINS of Georgia. Mr. Speaker, 7 years ago, our friends across
the aisle put partisan interests above the health of the American
people, and we are seeing the results of that today. In fact, a small-
business owner from Missouri says:

I recall the days before the ACA when we would receive a 2-
inch notebook that contained multiple quotes from different
health insurance companies. Now our options are listed on a
single legal-sized sheet of paper. We only received three
quotes for 2017, and just two of them were adequate for our
region. In 2013, our insurance cost $180,000 for 92 lives
with a $2,000 deductible. In 2016, we paid $252,000 for just
61 lives who face a $5,000 deductible. Our options are
dwindling, our costs are skyrocketing, and our employees are
ultimately suffering because of the ACA.

Again, a defense of the defenseless or a positive solution for
America; that is what we are offering.
Mr. Speaker, I reserve the balance of my time.
Mr. McGOVERN. Mr. Speaker, I yield 30 seconds to the gentlewoman from
Wisconsin (Ms. Moore).
Ms. MOORE. Mr. Speaker, analysis of health insurance coverage for the
past 30 years, analysis of data from the New England Journal of
Medicine shows that, for every 455 people who are insured, one life
will be saved. With the repeal of the Affordable Care Act, it is
estimated that 43,956 people a year will die.
Long live the Republican Party.
Mr. COLLINS of Georgia. Mr. Speaker, I reserve the balance of my
time.
Mr. McGOVERN. Mr. Speaker, I yield 30 seconds to the gentleman from
Vermont (Mr. Welch).
Mr. WELCH. Mr. Speaker, President Trump was elected by rural America.
This bill betrays rural America three ways:
Health care, 24 million-plus are going to lose their health care,
many of them in rural America;
Second, it takes healthcare dollars and it turns them into a $7
million tax cut for the wealthiest 400 families in this country;
Third, the tenet of rural America is: we are in it together. That
means if you are born with a preexisting condition, you have a
preexisting condition, we are going to be there for you.
This bill turns its back on rural America, the people who stand up
for one another and believe we are in it together, you are not on your
own.
Mr. COLLINS of Georgia. Mr. Speaker, I appreciate it, but it is
amazing the concern for rural health care now under ObamaCare when much
of rural America has been down to one provider. That is not a choice.
Mr. Speaker, I yield 45 seconds to the gentleman from Pennsylvania
(Mr. Rothfus).
Mr. ROTHFUS. Mr. Speaker, I am listening to this debate and I am
hearing a lot of demagoguery and no solutions, no solutions for people
who have seen skyrocketing premiums, no solutions for people who have
lost their healthcare plans, no solutions for people who have lost
their doctors, no solutions for people with preexisting conditions who
are subject to the same skyrocketing premiums as everybody else, no
solutions for people with preexisting conditions who don't even have an
insurer in their exchanges.
I, too, have a preexisting condition. I am a cancer survivor. I am in
the individual market. I am seeing the same skyrocketing premiums as
everybody else. We are moving legislation today that will not only
protect those with preexisting conditions, but will work to bring down
premiums.
Importantly, those defending the Affordable Care Act had a goal:
single-payer, socialized medicine, and this legislation will stop it.
Vote for this legislation, save our healthcare system, and have a
much better result for the American people.
Mr. McGOVERN. May I inquire of the gentleman how many more speakers
he has?
Mr. COLLINS of Georgia. Mr. Speaker, I am still waiting on a couple
more speakers, but I am ready to close whenever the gentleman is.
Mr. McGOVERN. Well, I am not really prepared to close because my side
has a ton more to say, but I am out of time.
Mr. COLLINS of Georgia. Mr. Speaker, I will tell Mr. McGovern, it is
his time to manage.
Mr. McGOVERN. Mr. Speaker, I yield myself the balance of my time, and
given the fact there were no hearings or anything else, it would have
been nice to have a little bit more time.
Mr. Speaker, if we defeat the previous question, I will offer an
amendment to the rule that would change the rules of the House to
prevent this bill or any other healthcare-related legislation from
being considered if it does not have a CBO cost estimate or if it would
deny health coverage or require higher premiums due to preexisting
conditions; impose lifetime limits on health coverage; prevent
individuals under age 26 from being covered under their parents' plan;
reduce the number of people receiving health care under the Affordable
Care Act; increase costs to seniors by reopening the doughnut hole and
raising prescription drug costs; require people to pay for preventive
services, including cancer screenings; reduce Medicare solvency or
change the Medicare guarantee; or reduce Federal taxes on the 1 percent
of the population with the highest incomes or increase taxes on the 80
percent of hardworking Americans earning moderate to low incomes.
Mr. Speaker, I ask unanimous consent to insert the text of my
amendment in the Record, along with extraneous materials, immediately
prior to the vote on the previous question.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from Massachusetts?
There was no objection.
Mr. McGOVERN. Mr. Speaker, none of us on this side are claiming that
the Affordable Care Act is perfect. In fact, for 7 years, we have been
prepared to work with our Republican colleagues in a bipartisan way to
make it even better, to cover more people, to find ways to lower costs;
but for 7 years, my Republican colleagues had no interest in doing
that. All they wanted to do was repeal the bill, repeal the bill,
repeal the bill and offer no alternative.
Now we see their alternative, and it is an awful alternative. It is a
disaster. It is an alternative that came not out

[[Page H4136]]

of a deliberative process, but out of some back room somewhere. People
haven't even read this bill. They don't even know what it does because
we are not even waiting for a CBO score. This is a pathetic process
that everybody should be ashamed of.
Let me just say, to claim or to imply that the Republican plan covers
people with preexisting conditions, it is a lie. It is a lie. Let's be
honest about it. This does not cover people with preexisting
conditions. To come on the floor and say it does, to try to fool
people, well, you may get away with it in the short term, you may get a
headline, but I will tell you, people will figure out soon enough when
they are denied healthcare coverage, when they see their costs rise and
rise and rise.
To have a healthcare bill that throws 24 million Americans off of
health insurance, you should be ashamed.
To have a healthcare bill that cuts Medicaid by $880 billion to give
a tax cut to the wealthiest people in this country, you should be
ashamed.
I spent a good deal of my time reading letters from organizations
like the National Farmers Union, the AARP, the Cystic Fibrosis
Foundation, Paralyzed Veterans of America, March of Dimes, the American
Medical Association, on and on and on, organizations that have
dedicated their lives to helping people in this country that know
something about this subject.

{time} 1030

And when it comes down to who do I trust, them or you, on whether or
not your bill covers people with preexisting conditions, there is no
contest. I trust them. They see what you are trying to do. They
understand that this bill is a fraud.
It is unconscionable to not only me and to people on our side, but to
people who are watching this debate--Democrats, Republicans, and
independents alike--that we would be spending time debating a
healthcare bill that will make life worse for people in this country.
Any kind of healthcare bill that came to this floor ought to be about
expanding coverage and lowering cost. We want to work with you on that.
Instead, you come to a bill that is going to rip health care away from
tens of millions of people.
How can you do this? How can you do this to the American people? How
can you do this to your constituents?
This is a terrible bill. You should vote ``no'' on it or, better yet,
pull it.
Mr. Speaker, I yield back the balance of my time.
Mr. COLLINS of Georgia. Mr. Speaker, I yield myself such time as I
may consume.
What we have seen for the last few minutes, I would probably get up
and cheer, too. Because now you look at it this way. What they want to
claim as a disaster or recognize as a disaster, they didn't recognize 7
years ago. They chose to cram it down America's throat, and for 7 years
the American people have said: No. Stop it. We don't want a healthcare
system from government that takes freedom away from us and that removes
it from us.
We have been presented with a list of letters from folks who are
against this bill. Well, it is just a quick reminder to those, Mr.
Speaker, who may be wanting to remember. Some of these same folks were
the same folks who said ObamaCare was great, and who gave letters of
support. I guess they are trying to cover up for 7 years of their first
mistake.
When we understand this--let's go to some experts. I will just
clarify them as experts, Mr. Speaker.
President Bill Clinton calling ObamaCare, last year, the craziest
thing in the world. He summed it up pretty well. Because what summed up
here is they forgot the American people.
Republicans have decided that we are going to put the American people
back in control. We are not going to continue to hear from Pam in
Nebraska, who is self-employed and lost her insurance four times under
ObamaCare and twice because of the Nebraska failed startup.
If we are going to talk about misleading the American people, it
started 7 years ago, and it ends today. It ends today. The American
people deserve better. They have been thrown under the bus for 7 years.
They deserve an insurance market that is open, that is accessible, and
that does cover preexisting conditions.
If you want the deception, follow the other side. If you want the
truth, follow this side.
Mr. Speaker, if I had to defend the last 7 years and offer nothing
into the faces of these, yeah, I would have been hysterical on the
floor this morning, too. And that is exactly what we have seen.
So for those who may be, it is time to vote ``yes'' on the rule,
``yes'' on this bill, and start giving back to America the liberty and
freedom for a healthcare system that is the best in the world and has
been attacked for 7 years. Again, that ends today.
The material previously referred to by Mr. McGovern is as follows:

An Amendment To H. Res. 308 Offered by Mr. McGovern

At the end of the resolution, add the following new
section:
Sec. 3. Rule XXI of the Rules of the House of
Representatives is amended by adding at the end the following
new clause:

RESTRICTIONS ON CONSIDERATION OF CERTAIN LEGISLATIVE PROVISIONS
RELATING TO HEALTHCARE

13.(a) It shall not be in order to consider a bill, joint
resolution, amendment, or conference report which includes
any provision described in paragraph (b).''
(b) A provision referred to in paragraph (a) is a provision
which, if enacted into law, would result in any of the
following:
(1) The denial of health insurance coverage to individuals
on the basis that such individuals have a pre-existing
condition or a requirement for individuals with a preexisting
condition to pay more for premiums on the basis of such
individuals having such a preexisting condition.
(2) The elimination of the prohibition on life time limits
on the dollar value of health insurance coverage benefits.
(3) The termination of the ability of individuals under 26
years of age to be included on their parent's employer or
individual health coverage.
(4) The reduction in the number of people receiving health
plan coverage pursuant to the Patient Protection and
Affordable Care Act (PL 111-148) and Education Affordability
Reconciliation Act of 2010 (PL 111-152).
(5) An increased cost to seniors for prescription drug
coverage pursuant to any changes to provisions closing the
Medicare prescription drug `donuthole'.
(6) The requirement that individuals pay for preventive
services, such as for mammography, health screening, and
contraceptive services.
(7) The reduction of Medicare solvency or any changes to
the Medicare guarantee.
(8) The reduction of Federal taxes on the 1 percent of the
population with the highest income or increase the tax burden
(expressed as a percent of aggregate Federal taxes) on the 80
percent of the population with the lowest income.
c) It shall not be in order to consider a measure or matter
proposing to repeal or amend the Patient Protection and
Affordable Care Act (PL 111-148) and the HealthCare and
Education Affordability Reconciliation Act of 2010 (PL 111-
152), or part thereof, in the House or in the Committee of
the Whole House on the state of the Union unless an easily
searchable electronic estimate and comparison prepared by the
Director of the Congressional Budget Office is made available
on a publicly available website of the House.
(d) It shall not be in order to consider a measure or
matter proposing to repeal or amend the Patient Protection
and Affordable Care Act (PL 111-148) and the Health Care and
Education Affordability Reconciliation Act of 2010 (PL 111-
152), or part thereof, in the House or in the Committee of
the Whole House on the state of the Union, that is called up
pursuant to a rule or order that makes an amendment in order
or considers such an amendment to be adopted, unless an
easily searchable updated electronic estimate and comparison
prepared by the Director of the Congressional Budget Office
reflecting such amendment is made available on a publicly
available website of the House.
(e) It shall not be in order to consider a rule or order
that waives the application of paragraph (a), paragraph (b),
paragraph (c), or paragraph (d). As disposition of any point
of order under paragraphs (c) through (e), the Chair shall
put the question of consideration with respect to the order,
conference report, or rule as applicable. The question of
consideration shall be debatable for 10 minutes bythe Member
initiating the point of order and for 10 minutes by an
opponent, but shall otherwise be decided without intervening
motion except one that the House adjourn.

The Vote on the Previous Question: What It Really Means

This vote, the vote on whether to order the previous
question on a special rule, is not merely a procedural vote.
A vote against ordering the previous question is a vote
against the Republican majority agenda and a vote to allow
the Democratic minority to offer an alternative plan. It is a
vote about what the House should be debating.
Mr. Clarence Cannon's Precedents of the House of
Representatives (VI, 308-311), describes the vote on the
previous question on the rule as ``a motion to direct or
control the

[[Page H4137]]

consideration of the subject before the House being made by
the Member in charge.'' To defeat the previous question is to
give the opposition a chance to decide the subject before the
House. Cannon cites the Speaker's ruling of January 13, 1920,
to the effect that ``the refusal of the House to sustain the
demand for the previous question passes the control of the
resolution to the opposition'' in order to offer an
amendment. On March 15, 1909, a member of the majority party
offered a rule resolution. The House defeated the previous
question and a member of the opposition rose to a
parliamentary inquiry, asking who was entitled to
recognition. Speaker Joseph G. Cannon (R.-Illinois) said:
``The previous question having been refused, the gentleman
from New York, Mr. Fitzgerald, who had asked the gentleman to
yield to him for an amendment, is entitled to the first
recognition.''
The Republican majority may say ``the vote on the previous
question is simply a vote on whether to proceed to an
immediate vote on adopting the resolution . . . [and] has no
substantive legislative or policy implications whatsoever.''
But that is not what they have always said. Listen to the
Republican Leadership Manual on the Legislative Process in
the United States House of Representatives, (6th edition,
page 135). Here's how the Republicans describe the previous
question vote in their own manual: ``Although it is generally
not possible to amend the rule because the majority Member
controlling the time will not yield for the purpose of
offering an amendment, the same result may be achieved by
voting down the previous question on the rule . . . When the
motion for the previous question is defeated, control of the
time passes to the Member who led the opposition to ordering
the previous question. That Member, because he then controls
the time, may offer an amendment to the rule, or yield for
the purpose of amendment.''
In Deschler's Procedure in the U.S. House of
Representatives, the subchapter titled ``Amending Special
Rules'' states: ``a refusal to order the previous question on
such a rule [a special rule reported from the Committee on
Rules] opens the resolution to amendment and further
debate.'' (Chapter 21, section 21.2) Section 21.3 continues:
``Upon rejection of the motion for the previous question on a
resolution reported from the Committee on Rules, control
shifts to the Member leading the opposition to the previous
question, who may offer a proper amendment or motion and who
controls the time for debate thereon.''
Clearly, the vote on the previous question on a rule does
have substantive policy implications. It is one of the only
available tools for those who oppose the Republican
majority's agenda and allows those with alternative views the
opportunity to offer an alternative plan.
Mr. COLLINS. Mr. Speaker, I yield back the balance of my time, and I
move the previous question on the resolution.
The SPEAKER pro tempore. The question is on ordering the previous
question.
The question was taken; and the Speaker pro tempore announced that
the ayes appeared to have it.
Mr. McGOVERN. Mr. Speaker, on that I demand the yeas and nays.
The yeas and nays were ordered.
The SPEAKER pro tempore. Pursuant to clause 8 and clause 9 of rule
XX, this 15-minute vote on ordering the previous question will be
followed by 5-minute votes on:
Adopting the resolution, if ordered; and
Agreeing to the Speaker's approval of the Journal.
The vote was taken by electronic device, and there were--yeas 235,
nays 193, not voting 2, as follows:

[Roll No. 252]

YEAS--235

Abraham
Aderholt
Allen
Amash
Amodei
Arrington
Babin
Bacon
Banks (IN)
Barletta
Barr
Barton
Bergman
Biggs
Bilirakis
Bishop (MI)
Bishop (UT)
Black
Blackburn
Blum
Bost
Brady (TX)
Brat
Bridenstine
Brooks (AL)
Brooks (IN)
Buchanan
Buck
Bucshon
Budd
Burgess
Byrne
Calvert
Carter (GA)
Carter (TX)
Chabot
Chaffetz
Cheney
Coffman
Cole
Collins (GA)
Collins (NY)
Comer
Comstock
Conaway
Cook
Costello (PA)
Cramer
Crawford
Culberson
Curbelo (FL)
Davidson
Davis, Rodney
Denham
Dent
DeSantis
DesJarlais
Diaz-Balart
Donovan
Duffy
Duncan (SC)
Duncan (TN)
Dunn
Emmer
Estes (KS)
Farenthold
Faso
Ferguson
Fitzpatrick
Fleischmann
Flores
Fortenberry
Foxx
Franks (AZ)
Frelinghuysen
Gaetz
Gallagher
Garrett
Gibbs
Gohmert
Goodlatte
Gosar
Gowdy
Granger
Graves (GA)
Graves (LA)
Graves (MO)
Griffith
Grothman
Guthrie
Harper
Harris
Hartzler
Hensarling
Herrera Beutler
Hice, Jody B.
Higgins (LA)
Hill
Holding
Hollingsworth
Hudson
Huizenga
Hultgren
Hunter
Hurd
Issa
Jenkins (KS)
Jenkins (WV)
Johnson (LA)
Johnson (OH)
Johnson, Sam
Jordan
Joyce (OH)
Katko
Kelly (MS)
Kelly (PA)
King (IA)
King (NY)
Kinzinger
Knight
Kustoff (TN)
Labrador
LaHood
LaMalfa
Lamborn
Lance
Latta
Lewis (MN)
LoBiondo
Long
Loudermilk
Love
Lucas
Luetkemeyer
MacArthur
Marchant
Marino
Marshall
Massie
Mast
McCarthy
McCaul
McClintock
McHenry
McKinley
McMorris Rodgers
McSally
Meadows
Meehan
Messer
Mitchell
Moolenaar
Mooney (WV)
Mullin
Murphy (PA)
Noem
Nunes
Olson
Palazzo
Palmer
Paulsen
Pearce
Perry
Pittenger
Poe (TX)
Poliquin
Posey
Ratcliffe
Reed
Reichert
Renacci
Rice (SC)
Roby
Roe (TN)
Rogers (AL)
Rogers (KY)
Rohrabacher
Rokita
Rooney, Francis
Rooney, Thomas J.
Ros-Lehtinen
Roskam
Ross
Rothfus
Rouzer
Royce (CA)
Russell
Rutherford
Sanford
Scalise
Schweikert
Scott, Austin
Sensenbrenner
Sessions
Shimkus
Shuster
Simpson
Smith (MO)
Smith (NE)
Smith (NJ)
Smith (TX)
Smucker
Stefanik
Stewart
Stivers
Taylor
Tenney
Thompson (PA)
Thornberry
Tiberi
Tipton
Trott
Turner
Upton
Valadao
Wagner
Walberg
Walden
Walker
Walorski
Walters, Mimi
Weber (TX)
Webster (FL)
Wenstrup
Westerman
Williams
Wilson (SC)
Wittman
Womack
Woodall
Yoder
Yoho
Young (AK)
Young (IA)
Zeldin

NAYS--193

Adams
Aguilar
Barragan
Bass
Beatty
Bera
Beyer
Bishop (GA)
Blumenauer
Blunt Rochester
Bonamici
Boyle, Brendan F.
Brady (PA)
Brown (MD)
Brownley (CA)
Bustos
Butterfield
Capuano
Carbajal
Cardenas
Carson (IN)
Cartwright
Castor (FL)
Castro (TX)
Chu, Judy
Cicilline
Clark (MA)
Clarke (NY)
Clay
Cleaver
Clyburn
Cohen
Connolly
Conyers
Cooper
Correa
Costa
Courtney
Crist
Crowley
Cuellar
Cummings
Davis (CA)
Davis, Danny
DeFazio
DeGette
Delaney
DeLauro
DelBene
Demings
DeSaulnier
Deutch
Dingell
Doggett
Doyle, Michael F.
Ellison
Eshoo
Espaillat
Esty (CT)
Evans
Foster
Frankel (FL)
Fudge
Gabbard
Gallego
Garamendi
Gonzalez (TX)
Gottheimer
Green, Al
Green, Gene
Grijalva
Gutierrez
Hanabusa
Hastings
Heck
Higgins (NY)
Himes
Hoyer
Huffman
Jackson Lee
Jayapal
Jeffries
Johnson (GA)
Johnson, E. B.
Jones
Kaptur
Keating
Kelly (IL)
Kennedy
Khanna
Kihuen
Kildee
Kilmer
Kind
Krishnamoorthi
Kuster (NH)
Langevin
Larsen (WA)
Larson (CT)
Lawrence
Lawson (FL)
Lee
Levin
Lewis (GA)
Lieu, Ted
Lipinski
Loebsack
Lofgren
Lowenthal
Lowey
Lujan Grisham, M.
Lujan, Ben Ray
Lynch
Maloney, Carolyn B.
Maloney, Sean
Matsui
McCollum
McEachin
McGovern
McNerney
Meeks
Meng
Moore
Moulton
Murphy (FL)
Nadler
Napolitano
Neal
Nolan
Norcross
O'Halleran
O'Rourke
Pallone
Panetta
Pascrell
Payne
Pelosi
Perlmutter
Peters
Peterson
Pingree
Pocan
Polis
Price (NC)
Quigley
Raskin
Rice (NY)
Richmond
Rosen
Roybal-Allard
Ruiz
Ruppersberger
Rush
Ryan (OH)
Sanchez
Sarbanes
Schakowsky
Schiff
Schneider
Schrader
Scott (VA)
Scott, David
Serrano
Sewell (AL)
Shea-Porter
Sherman
Sinema
Sires
Slaughter
Smith (WA)
Soto
Speier
Suozzi
Swalwell (CA)
Takano
Thompson (CA)
Thompson (MS)
Titus
Tonko
Torres
Tsongas
Vargas
Veasey
Vela
Velazquez
Visclosky
Walz
Wasserman Schultz
Waters, Maxine
Watson Coleman
Welch
Wilson (FL)
Yarmuth

NOT VOTING--2

Engel
Newhouse

{time} 1055

Messrs. LAWSON of Florida and FOSTER changed their vote from ``yea''
to ``nay.''
Messrs. AMODEI and DIAZ-BALART changed their vote from ``nay'' to
``yea.''
So the previous question was ordered.
The result of the vote was announced as above recorded.
The SPEAKER pro tempore. The question is on the resolution.
The question was taken; and the Speaker pro tempore announced that
the ayes appeared to have it.

Recorded Vote

Mr. McGOVERN. Mr. Speaker, I demand a recorded vote.
A recorded vote was ordered.
The SPEAKER pro tempore. This is a 5-minute vote.
The vote was taken by electronic device, and there were--ayes 235,
noes 192, not voting 3, as follows:

[[Page H4138]]

[Roll No. 253]

AYES--235

NOES--192

Adams
Aguilar
Barragan
Bass
Beatty
Bera
Beyer
Bishop (GA)
Blumenauer
Blunt Rochester
Bonamici
Boyle, Brendan F.
Brady (PA)
Brown (MD)
Brownley (CA)
Bustos
Butterfield
Capuano
Carbajal
Cardenas
Carson (IN)
Cartwright
Castor (FL)
Castro (TX)
Chu, Judy
Cicilline
Clark (MA)
Clarke (NY)
Clay
Cleaver
Clyburn
Cohen
Connolly
Conyers
Cooper
Correa
Costa
Courtney
Crist
Crowley
Cuellar
Cummings
Davis (CA)
Davis, Danny
DeFazio
DeGette
Delaney
DeLauro
DelBene
Demings
DeSaulnier
Deutch
Dingell
Doggett
Doyle, Michael F.
Ellison
Eshoo
Espaillat
Esty (CT)
Evans
Foster
Frankel (FL)
Fudge
Gabbard
Gallego
Garamendi
Gonzalez (TX)
Gottheimer
Green, Al
Green, Gene
Grijalva
Gutierrez
Hanabusa
Hastings
Heck
Higgins (NY)
Himes
Hoyer
Huffman
Jackson Lee
Jayapal
Jeffries
Johnson (GA)
Johnson, E. B.
Jones
Kaptur
Keating
Kelly (IL)
Kennedy
Khanna
Kihuen
Kildee
Kilmer
Kind
Krishnamoorthi
Kuster (NH)
Langevin
Larsen (WA)
Larson (CT)
Lawrence
Lawson (FL)
Lee
Levin
Lewis (GA)
Lieu, Ted
Lipinski
Loebsack
Lofgren
Lowenthal
Lowey
Lujan Grisham, M.
Lujan, Ben Ray
Lynch
Maloney, Carolyn B.
Maloney, Sean
Matsui
McCollum
McEachin
McGovern
McNerney
Meeks
Meng
Moore
Moulton
Murphy (FL)
Nadler
Napolitano
Neal
Nolan
Norcross
O'Halleran
O'Rourke
Pallone
Panetta
Pascrell
Payne
Perlmutter
Peters
Peterson
Pingree
Pocan
Polis
Price (NC)
Quigley
Raskin
Rice (NY)
Richmond
Rosen
Roybal-Allard
Ruiz
Ruppersberger
Rush
Ryan (OH)
Sanchez
Sarbanes
Schakowsky
Schiff
Schneider
Schrader
Scott (VA)
Scott, David
Serrano
Sewell (AL)
Shea-Porter
Sherman
Sinema
Sires
Slaughter
Smith (WA)
Soto
Speier
Suozzi
Swalwell (CA)
Takano
Thompson (CA)
Thompson (MS)
Titus
Tonko
Torres
Tsongas
Vargas
Veasey
Vela
Velazquez
Visclosky
Walz
Wasserman Schultz
Waters, Maxine
Watson Coleman
Welch
Wilson (FL)
Yarmuth

NOT VOTING--3

Engel
Newhouse
Pelosi

{time} 1103

Mr. SUOZZI changed his vote from ``aye'' to ``no.''
So the resolution was agreed to.
The result of the vote was announced as above recorded.
A motion to reconsider was laid on the table.

____________________